We write up timelines. We reconstruct decisions. We explain dependencies. At the end of it, we hand over a document that contains the specific combination of events that led to the incident. Everyone nods their head, says "that makes sense", and we all move on with our day.

...huh? I've been in corporate America for 19 years now and I've never once had this happen. I've never seen anyone just look for the cause and not ask what can be done to prevent it in the future. Everyone KNOWS that question is coming next.