Thanks for all the comments.
These issues aren't just diving related, but applicable to so many walks of life. The healthcare area is a domain I am looking at too and have just finished two sessions with part of an ICU team looking to develop their teamwork and communications skills.
Fundamentally, without a Just Culture we will not learn. Sidney Dekker (and many others) make it quite clear: there are two reasons to undertake an investigation after an adverse event - you can either look to blame someone, or you can look to learn from the event. Unfortunately the two are mutually exclusive!!
If you want any more information, or have questions, just ask away! I love to help people!!
Regards
Gareth