When there is a failure, the most common reaction is to look for someone to blame. That isn’t an effective strategy for managing an organization. Most of the time, the failure is a failure of the management system. Figuring out what weakness in the management system allowed the failure so that the management system can be improved to make that failure less likely in the future is an effective strategy.
Even in those cases where a person did mess up, why did the system allow that? Did the system put that person in a situation where they were not prepared or qualified? Did the system have adequate mistake-proofing safety measures in place? Was the person asked to do too much (were they stressed or exhausted due to the management system and therefore failed to do what they normally would have known they should do).
Was the data on the system adequate so that it notified of the risk of failure? If not, why not? Was such a warning ignored (if so, why)? Sometimes there isn’t a reasonable measure that would have provided a warning, but think about it and see if there is a way to use internal process measures to warn when there is increased risk. Was the person responsible fearful about asking for help (due to the management system)?
Should the process involved have a checklist to improve the long-term reliability of the process? Did it have a checklist that wasn’t followed? If so why wasn’t it followed? Should the checklist be modified to make a repeat of the current failure less likely?
Thinking about such questions and figuring out how to improve the system can improve the results going forward.
Yes, occasionally, the answer might be that the employee was hired sensibly, managed, and coached sensibly, but they just won’t do what they know they should do and won’t respond to coaching. But normally, that won’t be the case, even when the person seems nearly totally to blame (and that isn’t even a very common situation). Normally there are obvious weaknesses in the system that put them in a position where failure was more likely than it should have been and will likely put others in that position at risk in the future.