A book I like on this general topic is The Field Guide to Understanding Human Error by Sidney Dekker. He's writing from the perspective of investigations after

A book I like on this general topic is The Field Guide to Understanding Human Error by Sidney Dekker. He's writing from the perspective of investigations after airliner crashes. His core point is that you shouldn't be looking for who to blame in a punitive sense (assuming nothing malicious has happened), but rather how policies and procedures allowed the error to happen. The human is just the last domino in the chain. Accountability ultimately lives with management that establishes policies and procedures. But management often does't like that idea, because yelling loudly and sacking someone feels like you're being proactive, even though in the net it makes another error more likely.