[tialaramex]

Well first of all blaming people is the wrong thing for an accident investigation to be doing anyway.

The purpose of accident investigation is not to fuel Americans' apparently insatiable appetite for revenge, you already have plenty of means for that, the purpose is the Prevention of Future Harm. Why Future Harm? Because we don't have time travel.

You clearly won't prevent any future harm by blaming anybody, whether alive or dead. To prevent future harm you will need to change what is done or how.

Almost invariably‡ the Right Thing™ will be some mix of procedural changes and engineering changes. For example ensuring that the right staff are empowered to stop something that's a bad idea being done even if senior management are short-sighted enough to demand it.

So the result is never "Bob is to blame because Bob did X" but rather e.g. "Bob did X. The Foozle should be modified to prevent doing X" or "Bob did X. Company policy did not say that doing X was forbidden. Change policy to forbid X".

‡ I've written about this before on HN. The one investigation report I've seen that did _not_ have any actionable recommendations was into an accident where two people died when their fishing boat sank. The cause? They'd taken so much heroin they couldn't operate the boat safely. Why no recommendation? Using heroin is already illegal. Using any intoxicating substance while in charge of a boat is already illegal. This was already obviously a terrible idea.