Isla-Nublar Post-Mortem Document (1993)

A fun and informative take on how a postmortem would look if we were to examine the incident at Jurassic Park in the original 1993 film! The takeaway should be that you walk away knowing the steps involves in a postmortem and the reasons for taking them.

Transcript

1. PRE-HISTORIC POST-MORTEM Title The Incident Incident Description On June, 2 1993 a major incident on the island of Isla Nublar caused the deaths of 5 people, 8 dinosaurs, a cow and a goat. We need to investigate what happened and note what can be done differently in the future. How was the incident detected? At about 00:56:08, all of the locking mechanisms in the park shut off. We are not entirely sure how this happened. How was the incident stabilized? The power in the park needed to be manually cycled (rebooted) in order for the locking systems to be fully operational again. This happened at about 01:43.28. How were customers affected? We’re lucky in that the park had not yet been opened to the public. There were 0 customers affected! How were employees affected? 5 dead … damn. Timeline [Everything should be in the same time zone.] Pre-incident • 00:02:57 – Person opening the gate for velociraptor fell • 00:03:30 – “Shoot ha! … Shoooooooot haaa!” • 00:32:58 – Cow Dies – Fed to Raptors • 00:41:45 – Tour vehicles enter JP gates • 00:49:00 – Tour manually exits vehicle (Triceratops Paddock) • 00:53:34 – Dennis goes to vending machine Incident • 00:56:08 – Locking systems shut off • 00:58:15 – Tour stops outside T-Rex paddock : Fences disabled • 01:00:21 – 3 failed login attempts by [ray arnold] • 01:03:12 – Goat dies – Fed to T-Rex • 01:03:36 – Vehicle1 doors open – we assume 1 passenger exits • 01:03:59 – T-Rex fence breaks • 01:05:08 – Vehicle1 door finally closes • 01:05:52 – Vehicle1 disturbance detected (seems to be wobbly)
2. PRE-HISTORIC POST-MORTEM • 01:06:06 – Vehicle1 roof breaks (children touching equipment?) • 01:06:30 – Vehicle1 completely off track (too heavy for children) • 01:07:05 – Vehicle2 door opens • 01:07:41 – Major damage to men’s room detected (death confirmed) • 01:33:01 – Complete system shutdown / done manually • 01:37:51 – Raptor fence broken, confirmed escaped • 01:43:28 – All power restored / power disruption on 1 fence Post-incident • 01:53:58 – Security Systems Reactivated • 01:58:37 – All remaining people leave safely What went well ¯\_(ツ)_/¯ Contributing causes & Corrective actions 1. Children were messing around with the valuable equipment … and trashed the kitchen a. Cancel the “Bring you kid to work” program 2. Dinosaurs were able to open doors a. Make a Home Depot run for door knobs 3. Employees / Contractors were not washing their hands after dung inspection a. Hand sanitizers everywhere 4. Scientists are stealing other people’s ideas and then just taking the next step a. Continue 5. Our best hunter didn’t understand standard raptor attack formation a. Remove [Muldoon, Robert] from payroll 6. Female paleontologist is plotting an all-female world a. Smear her good name in court 7. We lost our best, and only, engineer a. Search for a programmer who can network 8 connection machines and debug 2 million lines of code … on the cheap. Metrics When did the incident begin? • 00:53:34 – Dennis goes to vending machine When did the incident end? • 01:53:58 – Security Systems Reactivated When did we detect the incident? • 00:58:15 – Tour stops outside T-Rex paddock : Fences disabled
3. PRE-HISTORIC POST-MORTEM Time to Detect 02m07s Time to Resolve 57m50s