It is not enough to blame failures on the human error of low level employees. Deep systematic flaws such as latent human error are considered in accountability measures. In this context, a process such as 5-whys is helpful. For example:
Accepting and reviewing complaints from anyone i.e. members of the public
Audit trails – digital records that capture everything that happens on systems
Authorization and authentication – limited number of people who can access systems and resources
Clear roles and responsibilities
Clearly defined decision authority that always falls to a named person
Code of conduct
Internal controls e.g. approval processes
Managing low performance
Performance management process
Red flag system
Responsibility documentation e.g. RACI matrix
Risk management processes
Separation of duties
The principle that accountability can’t be delegated
A train crashed.
The locomotive engineer was going too fast.
The locomotive engineer was under pressure to meet a schedule.
The operations team is often missing deadlines and is under pressure to improve.
Executive management has been underinvesting in systems and infrastructure for more than a decade such that the firm has serious capacity and reliability issues.