Comment by noitpmeder

I agree, but in this hypothetical situation the HR part needs to happen, despite the fact that most people don't want to be the squeaky wheel that explicitly starts pointing fingers..

It's way too easy to pretend the system is the problem while sticking your head in the sand because you don't want to solve the actual human problem.

Sure, use the post mortem to brainstorm how to prevent/detect/excise the systematic problem ("How do we make sure no one else can make the same mistake again"), but eventually you just need to deal with the repeat offender.