All the 'stuff' about design & systemic issues is valid, but shouldn't people be punished for not reporting or cooperating &/or lying ?
Within the context of a just culture we want people to put their hands up when they get it wrong.
Military reckless definition, a conscious & substantial & unjustifiable disregard for risk. Surely if, within the context of a just culture, people do not 'own up' or cooperate with an investigation they greatly increase the risk of recurrence?
This of course assumes you have a just culture and believe reporting is 'safe'!!