Step 1: Investigation: Gathering all of related data and information for further analyzing. Step 2: Analyze Take action to analyze when, where and how did the mistake happened or occur as well as what happened. And try to figure out what the root causes are. Step 3: Solution List all of root causes and figure out exact solution accordingly one by one. And it's better if potential risks could be retired with further or deliberated solutions provided. Step 4: Executive Take action to eliminate mistakes. Step 5: Lesson learn Gets lesson learn worked out. .....