Exactly, it's not about the "blame" is some abstract sense, it's about the process that has to be permanent in order to keep the risk low. Different people alre

Exactly, it's not about the "blame" is some abstract sense, it's about the process that has to be permanent in order to keep the risk low. Different people already mentioned here a work of MIT Prof. Nancy Leveson http://sunnyday.mit.edu/ http://sunnyday.mit.edu/ An important quote from her book "Engineering a Safer World" section "Questioning the Foundations of Traditional Safety Engineering": "Old Assumption - Major accidents occur from the chance simultaneous occurrence of random events. New Assumption - Systems will tend to migrate toward states of higher risk. Such migration is predictable and can be prevented by appropriate system design or detected during operations using leading indicators of increasing risk." So it's: either the organizations are themselves able to keep the risk from increasing (as quoted, that is even "predictable" and of course it "can be prevented") or there have to be the external influences in that direction. In this case, the organizations themselves failed.