What is the underlying cause of the failed measures to prevent recurrence?
An incident is generally not just an incident and often only superficial causes are addressed. There is no better reason for improvement or change than a confrontation with an incident or damage. Because every employee in your company experiences the urgency!
Very human: after an incident, there is a tendency to blame those involved. Often, those directly involved also suffer from a sense of guilt.
Our working method offers security for these people because we assume that the same thing cannot happen again with other people in the leading role. If there is no reason to suspect intent, there is no reason to look for someone to blame for the incident.