The first question I ask when something goes wrong is who did it. It is a fast question and it feels like accountability. It has almost never given me anything useful.
There is a verse in the eighteenth chapter of the Gita that embarrasses me a little every time I read it. Krishna takes an action apart to show what it is actually made of, and he counts six things.
ज्ञानं ज्ञेयं परिज्ञाता त्रिविधा कर्मचोदना । करणं कर्म कर्तेति त्रिविधः कर्मसंग्रहः ॥
jnanam jneyam parijnata trividha karma chodana karanam karma karteti trividhah karma sangrahah
Knowledge, the thing to be known, and the knower are the three impulses behind any action. The instrument, the act itself, and the doer are the three parts the action is made of.
That is six components, and the person is one of them. I go straight to that one every single time and leave five perfectly good explanations sitting there untouched. So I have started running all six, in order, before I settle anywhere.
Knowledge, which is whether anyone in the chain actually knew how the thing was supposed to be done, or whether we all assumed it was obvious.
The thing to be known, which is whether the work was ever defined with enough precision that someone could get it right on purpose.
The knower, which is whether the person who understood it was anywhere near the work on the day it happened.
The instrument, which is the machine, the file, the format, the checklist. Tools carry far more of the outcome than we give them credit for.
The act, which is the process as it is written, and in most places that is a process nobody has opened since the year it was created.
The doer, which is the person, arriving sixth on this list and getting asked first almost everywhere.
By the time I reach the sixth one honestly, the answer is usually already waiting for me in the third or the fourth. And on the days it does come down to a person, that person is very often me.
The next time something breaks in your organisation, start at knowledge and work your way down. Give the person the courtesy of being last.