I work in the nuclear industry, where most places are pretty good about maintaining a "blame-free" culture. You focus on what processes and procedures failed, what controls were missing, etc., that allowed somebody to make a mistake. As this attitude was adopted, things shifted too far (at least in the opinion of industry groups, and my observation) to the point where people underperforming to the point of negligence…
Well (to play devil's advocate just a bit) - isn't the ultimate end-goal of an end-state robust process one in which people can not just underperform, but be replaced completely?