Idea Synthesis

The goal of a post-mortem is an opportunity for a team (or the broader organisation) to learn as much as they can, in a relatively short period of time, about how people normally perceive and perform their work. This is because the people involved were in their normal work when the incident happened. Questions should focus on the ways that the organization prevents this sort of event from happening all the time, not by asking what allowed this singular event to happen.

People pay attention to high value communication channels. These give them information about the job, hobby, etc. Since people pay attention to these channels, they get used more. Eventually they get used for something more borderline or inappropriate for the communication channel. When this happens people stop paying attention to the formerly high value channel and shift to new locations. Eventually the original channel is useless. Rinse and repeat for the new communication channel.