[walterkrankheit]

All good points, although "rather than just punishing, he spent 8 hours discussing with his team"...? There needs to be less punishment as methodology out there, but an eight-hour discussion IS a form of punishment in my book. And for everyone else, too.

[zwischenzug]

They discussed for 8 hours because they had to figure out how to avoid a repeat in a practical way. The discussion was not with the offender, but among the leadership team.

[mcguire]

At NASA, this is called a "Root Cause Analysis" or RCA. A multi-hour meeting all about punishing the guilty via embarrassment or at least making sure you can shed the guilt.

On the other hand, "announce what you are about to do" is likely the best way to solve the problem.