Does your root cause analysis stop at human error?
It's easy to blame someone in the team. It limits the need for self awareness and helps us avoid looking hard at the things that are difficult to change.
The type of deep exploration that encourages us to admits we got it wrong. We are called to be a little vulnerable.
Why did the human error? Wrong hire? Bad process? Inferior technology? Incorrect strategy? Lack of resources? Corner cutting culture?
When things go wrong - ask 5 whys.
Why did that person make a mistake or error? Why were they able to? What encouraged them? What wasn't in place that could have been? What is there that need not?