Swiss Cheese model, to prevents bad things from happening we need to focus on preventing situations where those bad things could even arise.

Britain's Maritime Accident Investigation Branch (EU rules required members to have such agencies, although I think the UK had several of them before that anyway) published a memorable report where, despite this usual practice they offer zero recommendations.

The accident was basically some guys took a fishing boat out, did a lot of heroin, got into trouble and all died. And there were no recommendations because heroin is already illegal, operating a fishing boat while on heroin is also illegal, so, yeah, we already told you this was a terrible idea, there's nothing to recommend.