A good example of how the category “human error” can cover up a deeper problem.
Related paper here : http://www.visualexpert.com/Resources/trainaccidents.html
This guy is a gem : http://www.visualexpert.com/why.html
Lot of good articles at that link, many people drive cars so the examples are useful.
This one had a lot of good info: Understanding Human “Error”: Fault Tolerance, Practical Drift And Traps
From that article
The Dull End Of The System Creates The Fault Tolerance But Avoids Blame
In the scientific study of error, it is common to distinguish between the “sharp” and the “dull” ends of the system (Reason, 1990). The “sharp” end is the human who ultimately interacts with the hazard. Since his action immediately precedes the negative outcome, he is most often blamed. Our innate sense of causality biases us to fix blame based on temporal sequence (Michotte, 1946/1963): if A immediately precedes B, then A caused B. The people in the “dull” end, the authorities, designers and managers, are more remote in space and time to the negative outcome and seem less directly connected. Their role as causal agents is not as intuitive. They are often shadowy figures who are not sitting in the courtroom and whose identities may not even be known. They readily escape blame despite having had much more control over the outcome. Unlike the driver who may have a few seconds to make a life and death decision, for example, designers and authorities have much more time and knowledge to develop and test possible solutions.