When mistakes occur, blame the process, not people.
Root Cause Analysis is the means to fix the cause, rather than treat the symptom.
- What allowed the mistake to happen?
- What will prevent mistakes from occurring in the future?
- Assume people continue to make mistakes, so build fault‒tolerance into your improvements.
https://herdingcats.typepad.com/my_weblog/2019/06/a-compendium-of-root-cause-analysis-resources.html