Comment by lamontcg

You can't say that without knowing the details.

I've definitely seen issues where the engineers at the keyboards that day weren't at all at fault, and were just doing exactly what was asked of them, but systemic issues caused something like this. You can blame poor tech hygiene by the whole team, and lack of foresight by the manager, but most of that would be 20/20 hindsight.

This is why blameless postmortems are a good thing, because humans are simply awful with hindsight bias.

Best thing to do is just figure out how not to do it in the future.