If you've been investigating workplace events for any length of time, you've seen it happen. Someone makes an error. A deviation occurs. The investigation team digs in, asks why it happened, and eventually lands on a conclusion that sounds something like this: "The operator failed to follow the procedure." Or: "Human error during the filling process." The CAPA gets written. Retraining gets assigned. The deviation record closes on time. And six months later, a nearly identical