By the time something surfaces as a visible issue, the conditions that produced it have already been in place for a while. Work has already moved through several stages. Decisions have already been made. Tradeoffs have already been accepted, often without anyone realizing they were making them. The system has already narrowed things down to a small set of possible outcomes, and one of them just showed up as the problem. And now, the org is reacting to something it has no hope

When the same type of result keeps showing up, the system isn't failing intermittently. It's behaving consistently. The outcome looks like a problem, but from the system's perspective, it's just what happens given how the work is set up, how it moves, and how decisions get made under pressure. Not random. Predictable.