I view lead analysts as a form of an 'organizational therapist'. We both seek to understand the basis of human reasoning, which is why good people often make bad decisions. Unfortunately, most people judge others by the outcomes of their decisions, not their intent. Holistic RCA is all about understanding the intent of the decision. Contrary to popular belief, in most cases it’s not the decision-maker who caused the bad outcome, it’s the organizational systems that failed them that are the culprits. These are our policies, procedures, training systems, technology systems and more importantly, the effectiveness of our support, oversight and enforcement systems. If we provide our workforce the right information to make the best decision, they will!