A look at how expert investigators, managers, and the public respond to accidents lends support to [the] argument that there remains a strong tendency to focus on human failure, human fallibility, and person-centered, internal causes of accidents. Evidence of psychological phenomena such as the fundamental attribution error suggests that this sort of tendency is much broader, possibly affecting society or humanity as a whole.
… The problem is that even a knowledgeable and well meaning professional may succumb to some of the biases of human nature described above. Biases may have at least three specific effects.
First, the bias to view accidents as products of a linear chain of causation may lead investigators to identify human action as the sole proximal cause, then to investigate the causes of human action. This is acceptable, except when the accident did not have a single proximal cause but rather resulted from a combination of co-occurring chance and non-chance events. …
Second, the salience of human action, especially in retrospect, may obscure distal contributors to safety problems which may not appear to be as obvious. If so, limited resources will not be spent on investigating deeper and distal systemic causes remain undiscovered. …
Third, even when some erroneous or risky human action has prominently contributed to an accident, it is a challenge to overcome the tendency to attribute that accident to some characteristic of the worker. …
Other behavior-based approaches to safety management, however, recognize that human behavior has multiple causes and that changing behavior requires changing the whole system not just the person in it ….
[my bolding]