[satellite2]

This is common practice in post mortem analysis to try to determine the root cause in a blameless manner.

On the next iteration of this issue the eventual culprits of the first probably won't be there to remember what went wrong.

What might survive until then though is the set of procedures and guidelines put in place following the investigation recommendations.

So it's more effective to determine what process were insufficient than which person had the capacity to avoid something.

[mannykannot]

In cases like this, I doubt you can determine which process were insufficient without noticing which people had the capacity to avoid the problem, yet did not exercise it.

[satellite2]

That's correct, but unless the investigation determined they acted with malice, they should not be explicitly mentioned.

[mannykannot]

Good point.