Hear we go again; not necessarily so.
Consider the mindset, the thinking, which should precede activity.
The thinking required in evaluation, design, testing, production, and the assumptions made about human performance.
The responsibilities which the higher levels of management should have held which were systematically past down through the organisation, apparently without considering the local capabilities and effects; effects which would rebound back up to the highest level of management.
Instead of looking at outcome, consider the process of safety management and the responsibilities which should be inherent.