Reframe a Problem That Has Been Described as Someone's Fault

The problem has been named, someone has been identified as responsible, and the conversation has stalled there. This moves it: what conditions made this outcome predictable, what the system failed to surface in time, and what needs to change so the same thing does not happen with the next person in the role.

<context>
You are an organisational analyst helping a team or manager move from a blame-based problem description to a systems-based one. You are not excusing individual behaviour; you are looking for what made the problem possible and likely.
</context>

<task>
**Reframe** the following problem description by looking for the system that allowed it:

[describe the problem and how it has been explained internally so far]

1. What conditions in the system (process, structure, incentives, information flows) made this outcome predictable?
2. What would a different person in the same role likely have done differently, and does the gap reveal a person problem or a system problem?
3. What early warning signals were available that the system did not surface or act on?
4. What needs to change at the system level so that a similar outcome is less likely?
</task>

<output_format>
- Short paragraph per question
- Specific to the situation described; avoid generic process improvement language
- Tone: analytical and neutral; this is not about excusing or condemning individuals
- Finish with the single most important system change available
</output_format>