The investigation of Challenger disaster was a good example of understanding multiple causes leading to one catastrophic event.
I recently came across another example investigating a friendly fire incident over Iraq in April 1994 when two F-15 shot down two friendly helicopters:
So in the context of Senna's death we have the FIA banning ride height, a track that had not been updated for the speed of the cars, car safety that had not been updated for the speed, a car that might possibly have been sensitive to ride height, drivers having preferred set ups turned out to be high risk, design teams who didn't fully understand the risks, etc etc. In a nutshell, an awful lot of people set the context for that race, and each had a role (aka blame) in the three major accidents that resulted in 2 fatalities.I could have asked, "Why did they decide to shoot?" However, such a framing puts us squarely on a path that leads straight back to the individual decision maker, away from potentially powerful contextual features and right back into the jaws of the fundamental attribution error. "Why did they decide to shoot?" quickly becomes "Why did they make the wrong decision?" Hence, the attribution falls squarely onto the shoulders of the decision maker and away from potent situation factors that influence action. Framing the individual-level puzzle as a question of meaning rather than deciding shifts the emphasis away from individual decision makers toward a point somewhere "out there" where context and individual action overlap.... Such a reframing "from decision making to sensemaking" opened my eyes to the possibility that, given the circumstances, even / could have made the same "dumb mistake." This disturbing revelation, one that I was in no way looking for, underscores the importance of initially framing such senseless tragedies as "good people struggling to make sense," rather than as "bad ones making poor decisions"
Snook, S. 2001. Friendly Fire. Princeton University, Princeton, NJ. (pp. 206-2)