Post-incident reviews that miss the point
This is not incompetence. It is the system behaving exactly as it did before, including in the room where the review takes place. Describing the incident instead of explaining it Most incident post-mortems or retrospectives reconstruct the sequence of events. What happened, in what order, and what could have been done differently. Useful, but shallow. The more important question is usually skipped: what had to be true about the organisation for this to happen at all? ...