Justice asks what happened; wisdom also asks what prevents it happening again.

Assigning responsibility for what already happened is only half the work. It settles the account and leaves the conditions intact, so the same thing recurs with different names attached. Asking what made it possible is less satisfying, because it produces no one to blame, and it is the only part that changes the future.

After something goes wrong, run both questions deliberately. Who was responsible, and what would have to change for this to be much harder to repeat. Do the second one in writing and give it an owner, or it will evaporate once the immediate anger has passed.