CGOV.13:4.3 - Require the account needed for the response
Ask the responsible participants to explain the discrepancy or exception: what occurred, what they knew at the relevant time, what they chose or controlled, what remains uncertain, and what they can now do.
Keep the findings distinct. A missed result can arise because necessary work was never assigned or was left undone, means were insufficient, execution was poor, an assumption was wrong, or an accepted uncertainty materialized. More than one can apply. An adverse outcome by itself does not establish misconduct, while a favourable outcome does not erase a violated condition.
Challenge an explanation where its unsupported premise matters. If the explanation points to another participant or a resource constraint, follow that relation far enough to establish a useful response. Do not infer individual fault from a measure that does not distinguish the relevant choices and circumstances.
Where legal liability, dismissal, a contested duty or a remedy is at issue, obtain the competent contribution for that question. Preserve any immediate protective or corrective action that is already warranted and authorized.