Blame is the enemy of safety. Focus should be on understanding how the system behavior as a whole contributed to the loss and not on who or what to blame for it source: @worrydream tweet citing Engineering a Safe World: Systems thinking applied to safety
And a bit more
When trying to understand operator contributions to accidents, just as with overcoming hindsight bias, it is more helpful in learning how to prevent future accidents to focus --not-- on what the operators did "wrong" but on why it made sense for them to behave that way under those conditions
