But if you can focus in on a single technical decision that had such a large impact, you can at least focus attention on how that particular technical decision got made. Yes, many humans will have been involved even in that single technical decision; but it's still a lot more manageable to look into how it got made than to look at how the entire plant got designed.
We could do something silly to consolidate the guilt
I'm not talking about guilt; I said I wasn't advocating ritual suicide. I'm talking about how to prevent it from happening again. To do that, you need to be able to focus on something that can actually be changed. Take your bus driver example:
Do we punish the driver for his negligence, or his shift supervisor for threatening him into taking an extra-long shift, or someone even further up who knowingly encouraged a culture of overwork?
Depends on the facts. Was the driver negligent? Could he have reasonably predicted that he would fall asleep at the wheel? How could he have acted on such a prediction?
Did the supervisor actually threaten him into taking an extra-long shift? If so, how did he get away with it? Aren't there rules about preventing driver fatigue? (Certainly commercial airline crews have strict rules about how long they can fly before they have to rest.) If not, why not?
Is there a systemic culture of overwork, encouraged from higher up? Do bus drivers in this company routinely drive longer hours than the industry average? Than the average in other similar occupations?
The point is that if you can focus in on specific causal chains, you can direct efforts at changing them. In the case of Fukushima, if you can focus in on how the technical decision to site the backup generators that way got made, you can direct efforts at improving that process. Did the engineers just not realize that siting the backup generators that way was a bad idea? Was the question never even asked? Or did the engineers realize it, but management overruled them? Or did the original design have them sited differently, but time pressure during construction persuaded someone (not the engineers or managers who did the original design) to change the location in order to meet some deadline?
All this, btw, reinforces your point that ritual suicide doesn't help anything.
Such things sometimes can't be predicted. If you fall asleep because of exhaustion, you don't necessarily see it coming (it happened to me several years back, one minute I was fine and the next I blacked out). You cannot criminally persecute a person for falling asleep. Only if he did something against the law, like also being under the influence of alcohol.
> Did the supervisor actually threaten him into taking an extra-long shift?
You know very well that supervisors rarely have to threaten their subordinates in low-end jobs. I have a personal acquaintance who's a truck driver. And he was explaining to me how when the new management came in, they first did some lay-offs based on silly reasons and after that nobody dared arguing.
Also do some reading on Japanese culture. Subordinates rarely question their bosses (or change jobs for that matter). It happens in many cultures. If you're from the US, then what's natural to you may not apply in other countries or cultures.
I'm not saying that blame cannot be assigned (it can clearly be, especially in the case of broken engineering designs), but seeing people here suggesting "ritual suicide"? OMG.
Sure, but who's responsible for that? I don't mean to say that there must be many technical causes of incidents, but rather that it is almost impossible to find a situation where there is a singular human cause.
The multitude of engineers that saw the plans before they went final? The managers who pushed for the generators to be placed there in the first place? The contractors who built it knowing full well that the design was garbage? How high up does it go, and how many degrees removed from the situation do we require before you're absolved of guilt?
We could do something silly to consolidate the guilt, like, "the last person to stamp the designs gets the blame", but that seems like it would encourage a culture of hot-potatoing instead, especially if the stakes are your own life ;)
To put a more extreme example of it: a bus driver falls asleep at the wheel, jumps a curb, and kills a person. Do we punish the driver for his negligence, or his shift supervisor for threatening him into taking an extra-long shift, or someone even further up who knowingly encouraged a culture of overwork?