the autopsy you perform on a disaster while everyone insists they were following procedure.
means a structured after-the-fact analysis of what broke, why it broke, and how to stop it breaking the same way twice.
from grew out of aviation and nuclear safety culture in the mid-20th century, where a single missed step could kill hundreds, so engineers formalized blameless post-mortems that later spread into tech, medicine, and corporate risk management.
challenger disaster report — 1986 rogers commission exposed o-ring failure and nasa culture
three mile island review — 1979 nuclear near-meltdown rewrote us reactor safety standards
aws outage postmortems — amazon publishes detailed public root-cause reports after major cloud failures
boeing 737 max review — 2019 investigations traced crashes to software and oversight gaps