All Problems are Systemic
Understand your system.
There are no isolated incidents or one-off’s. If a problem pops up once, it will pop up again because system in which it occurred is imperfect.
Well, it was only one team member who made a mistake, we’ll just re-train them. Well, that one team member is a part of a process, part of a team and part of an organization.
Do you truly think that the problem won’t arise again if you don’t address elements of the greater system?
The problem for systems is that they are imperfect and prone to problems.
The problem with problems is that they can never be fully eliminated.
The best you can hope for is to reduce the magnitude and occurrence of problems by optimizing the system.
You can’t address the problems if you don’t understand your system.
If you don’t understand your system, you have a big problem.