This is common practice in post mortem analysis to try to determine the root cause in a blameless manner. On the next iteration of this issue the eventual culp

This is common practice in post mortem analysis to try to determine the root cause in a blameless manner. On the next iteration of this issue the eventual culprits of the first probably won't be there to remember what went wrong. What might survive until then though is the set of procedures and guidelines put in place following the investigation recommendations. So it's more effective to determine what process were insufficient than which person had the capacity to avoid something.