The problem is a blame culture ensures the near-misses are never reported. Air safety discovered this many years back - a no-blame culture ensures anything safety-related can be reported without fear of repercussions. This allows you to discover near misses due to human error and ensure that the overall system gains resilience over time. If you blame people for mistakes, they cover the non-obvious ones up, and so you cannot protect against similar ones in future, so your reliability/safety ends up much lower in the long run. It's all about evolving a system that is resilient to human error - we will make mistakes, but the system overall should catch them before they become catastrophies. In air travel now, the remaining errors almost never have a single simple cause, except in airlines/countries that don't have an effective safety reporting culture.