it is almost impossible to find a situation where there is a singular human cause.
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.
> Could he have reasonably predicted that he would fall asleep at the wheel?
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.
As I said, I'm not talking about guilt, or blame (and I'm certainly not advocating for ritual suicide); I'm talking about what could be done to change the causal factors that lead to harmful events. All of your comments are basically pointing out particular facts that are relevant to assessing those causal factors.
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.