In the aerospace community when a catastrophic failure occurs we look for "links in the error chain".
Basically for any catastrophic failure multiple errors have to occur before the failure occurs. Generally these are failures in:
- Personnel - Engineer screwed up sick, impaired, distracted, etc
- Training - Training was incomplete or incorrect for situation
- Procedures - Errors in procedures or instructions
- Hardware - Missing speed control hardware. Other hardware failures
- Software - Software failed to warn engineer of excessive speed
- Risk Management -Management accepted single hazard control, Engineer no backup
(The above examples are just hypotheticals for this situation. Nothing is confirmed yet)
Having been involved in few of these efforts I can tell you that even if the engineer is found primarily responsible for the crash he will not be wholly responsible. At the bare minimum we know the automatic speed control hardware is required but wasn't installed yet. There should also be systems and procedures in place to support the engineer.