It reminds me of the NTSB's crash investigations. Instead of looking for a scapegoat or someone to blame, they look for the cause, and then look even deeper to find the root cause.

For example they discover a pilot made a mistake. But they don't end it there, they then look at the airline's training materials, see if other pilots would repeat the same mistakes, and so on until they reach a point where they have a "this won't happen again" resolution (rather than simply discovering what happened).

I feel like with Microsoft's breakdown they did the "this is what happened" post-mortem but then went to the next level and said "here's why this happened, and here is why it won't happen again."