Understanding how bureaucracy develops

When you treat every negative outcome as a system failure, the answer is more systems. This is the cost of a blameless culture. There are places where that’s the right answer, especially where a skilled operator is required to operate in an environment beyond their control and deal with emergent problems in short order. Aviation, surgery. Different situations where the cost of failure is lower can afford to operate without the cost of bureaucratic compliance, but often they don’t even nudge the slider towards personal responsibility and it stays at “fully blameless.”

A negative outcome is a system failure, even if it is a personal failure that drove the outcome, because that is a failure of the system to prevent personal failures from causing negative outcomes.

You can't stop personal failures from happening because people are people. You can design processes to minimize or eliminate those personal failures from yielding negative outcomes.