When something goes wrong, the most visible actor often gets the blame.

That can be right. It can also be lazy diagnosis.

Find the transition

I prefer to work backwards through the process and look at the transitions:

  1. What was meant to happen?
  2. What actually happened?
  3. What did the person at this step know?
  4. What options were available to them?
  5. What did the environment reward?
  6. Where did the intended path become harder than the workaround?

The point is not to excuse poor behaviour. It is to avoid fixing the wrong thing.

Observation is not conclusion

Seeing the same outcome repeatedly is useful evidence of a pattern. It is not automatically proof of the cause.

A useful diagnosis separates what was documented, what was observed, what is inferred and what is still unknown.

That distinction matters because a persuasive explanation can still be wrong.