Turn something that went wrong into a checklist that stops it recurring

Something went wrong. I want a checklist out of it, not a feeling about it.

What happened: [THE FACTS, IN ORDER, WITHOUT DEFENDING ANYONE]
What it cost: [TIME, MONEY, TRUST, A CLIENT — be specific]
When we first could have caught it: [YOUR BEST GUESS]

Work through this:

1. THE TIMELINE. Reconstruct it as a sequence of decision points, not a story. At each point, note what was known at the time — not what we know now. Hindsight contaminates every post-mortem and I want it kept out of this one.

2. THE EARLIEST CHEAP CATCH. Find the first moment where a five-minute check would have surfaced the problem. Not the first moment something was wrong — the first moment it was findable at low cost.

3. WHY THE CHECK WASN'T THERE. Pick one: nobody thought of it, someone thought of it and it was skipped for speed, it existed but was ignored, or it existed and passed anyway. These have completely different fixes and people conflate them constantly.

4. THE CHECKLIST. Now write it. Every item must be:
   - Phrased as a yes/no question with an unambiguous answer
   - Answerable in under two minutes
   - Impossible to answer "yes" to by habit without actually looking

   Cut anything that fails those three tests. A ten-item checklist nobody completes is worse than three items they do.

5. WHERE IT LIVES AND WHO RUNS IT. A checklist without an owner and a trigger is a document. Name both.

6. WHAT THIS WON'T CATCH. Be explicit. A checklist creates a feeling of coverage, and the gap between what it actually covers and what people assume it covers is where the next incident comes from.