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> The way around blaming them is that it has a horrible systemic effect to do so.

That's why it's a good idea in complex systems to pre-assign to each requirement a responsible party. Otherwise, you could just use the "systemic effect" argument to either blame every party or no party in the system, neither of which is very useful.

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The fuel requirement was pre-assigned (for every other model of plane in the Air Canada fleet) to the flight engineer. Who that requirement was assigned to for this one model of plane wasn't really clear in the article.

It was never explicitly said. The plane used to have a 3-person crew and had moved to a 2-person crew (missing the flight engineer). This left the check unassigned. It is mentioned in the 2nd paragraph under the Investigation header.

You misunderstand my point, I think.

If you are running an organization that deals with a lot of complexity (airlines, web systems etc.), it's generally not a good idea to blame anyone but the system. If you look at everything systemically, then the organization continually learns. You have to trust the people in the system to be coming to work in good faith, if you can't do that you have other issues.

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