I’ve done this work in manufacturing, in BPO, in academe and in international development programmes, and the pattern never changes. Systems rarely get designed. They grow. A workaround here, a checklist there, a spreadsheet only one person understands, until the workaround is the process.
So when something breaks, the room asks “Who made the mistake?” The better question is “What in the process allowed it?” One question looks for someone to blame. The other looks for something to fix.
Most problems come from systems nobody ever designed on purpose, not from a lack of effort or intelligence.