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De "Google Has an Official Process in Place for Learning From Failure--and It's Absolutely Brilliant":

"1. Identify the most important problems.
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"A postmortem is the process our team undertakes to reflect on the learnings from our most significant undesirable events,"
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2. Create a record.
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"Our next step is to work together to create a written record for what happened, why, its impact, how the issue was mitigated or resolved, and what we'll do to prevent the incident from recurring,"
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3. Promote growth. Not blame.
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"Removing blame from a postmortem can enable team members to feel greater psychological safety to escalate issues without fear,"
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The key is to encourage your people not to play "the blame game." Rather, you want them to focus on improvement and learning.
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Remember, everyone makes mistakes. The question is, not "what if," but instead, what did we learn?"

E de "Toyota’s Secret: The A3 Report":