For one, there's no single executive who pushes a red button marked "Deploy The Skull-Splitter". Rather the opposite in fact, especially in eg german industry where people very much care and demand proper adherence to safety.

Assuming good faith; sometimes, the holes in the swiss cheese line up [1]

Advanced safety and reliability cultures don't look for people to blame [2] [3] . Your first goal is to look for the causes and you solve them. Very sometimes, someone does deserve blame (due to eg malice or gross negligence), in which case then you get to blame them.

[1] https://en.wikipedia.org/wiki/Swiss_cheese_model

[2] https://en.wikipedia.org/wiki/Just_culture https://www.faa.gov/about/initiatives/cp (FAA Just Culture)

[3] https://www.atlassian.com/incident-management/postmortem/bla... https://sre.google/sre-book/postmortem-culture/ Atlassian, Google SRE