accidents happen regardless blame
My husband wrote a report for a trial in court about safety. He spent all free time this summer and his research hours to write it. I'm not getting into details, because it's not public. But what I can say in general is the point that for safety it's important to move away from the question of guilt and shift attention to mistakes in the process of action. When we want safety, we should focuss less on blame and focuss more on what happens. Look more at decisions that lead to error, factors that lead to error, situations that lead to error.
Unfortunately, when we look for a person to be the reason of an accident, there is a real chance that another accident will happen.
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