TC, the video footage is quite self-explanatory as to where responsibility lies and where the various holes all started lining up.
Everyone is fallible and have made, do make mistakes. Many are fortunate enough to prevent the final holes lining up, however every year people make errors and often pay with their lives and 16 hours or 16000 doesn't change the trend, though obviously some here find the idea of an experienced person making a rookie mistake quite unforgiveable.
Human error is inherent in everyone.
Perhaps one day we can all be fortunate enough to be error free in which case Human performance can be dropped from the curriculum in favour of a more meaningful life skill, such as knitting.