Check out The Checklist Manifesto

by Jeff (BGS) , A starter home in suburban Tempe, Monday, April 18, 2011, 10:22 (5547 days ago) @ Jay

It doesn't specifically address single points of failure vs breakdowns in the system. But, it does address how well-written checklists can drastically reduce the frequency of these failures. Gawande uses the airline and construction industries as the best practitioners of checklists, and is pushing for their use in medicine.

I think the biggest problem with preventing as incident like this is that no one saw it as a hazardous situation until this tragedy occurred. By their nature, accidents are generally rare, and we are often lulled into a false sense of security when something things go well a hundred times in a row.