Too much focus is put on retroactively heaping blame on involved persons whenever things go wrong, but that is a really bad approach in my view; enforcement/punishment for things like this should be as light (and consistent) as possible.
But instead we get insane inconsistency (depending on exact outcome) thanks to media amplification and selective outrage.
All that achieves in the end is that people become better at shirking responsibility and playing the blame game, and it hinders not only investigations of past incidents but even increases future risk by incentivizing everyone to cover their ass first and actually fix things second.