Humans make mistakes, processes or the lack thereof allow them to happen. When mistakes of a certain threshold happen, the organization should have a post-mort

Humans make mistakes, processes or the lack thereof allow them to happen. When mistakes of a certain threshold happen, the organization should have a post-mortem to ensure such a scenario does not recur. In addition, the person who failed should hold their own post-mortem in private, with the possible addition of a supervisor to determine how they failed, if at all, and how they can use the incident as a learning experience. "Blame process, not people" is great in that it encourages folks not to pillory someone for a mistake that they themselves could have possibly made, but it is not a "Get out of jail free" card.