Kill the messenger

In october 2009, the Ketelbridge suddenly opened, without any visual warning or fallback system closing down the automated barrier bars. A multiple car crash with four people injured was the outcome. Or was it?
The bridge is located on a relatively busy motorway, running from the north to the south and used by commuters every day. The incident is covered by the media to date and led to public debate as well as an official investigation by the Dutch Safety Board comittee. They officially concluded a "problem" was the cause for the "uncontrolled" opening of the bridge.
As it happens, the case was brought to court. In and of itself one gets to wonder if someone could be held responsible for such a tragedy. Because to err is human. There are some huge failures that are still unfolding here as we speak...
 
Fail 1: Interface design flaw
Bridges used to have these towerhouses next to them, manned by one or several people operating the bridge. Nowadays, many bridges are operated automatically and monitored remotely. Safety measures and protocols apply in case remote controlling the bridge for some reason fails and a representative is sent down from somewhere to check out the situation or take over control. It would seem obvious that someone who isn't used to operating a bridge manually (perhaps hasn't even done this in his entire life) would need at least a good manual, a clear mind or an intuitive control panel. In this time and age it should be nowhere near possible to manually open a bridge in a freeway (or anywhere for that matter) on peak hours without the system either blocking this action or closing down the barriers and turning on the warning lights. For some reason this is exactly what happened.
 
Fail 2: Bring to trial
Of couse we don't get to hear the whole story, unless you were part of it or are otherwise involved in some governmental role in the aftermath. But what good does a trial do AGAINST THE OPERATOR no less? What has this man done wrong? Unless he intended to open up the bridge beyond reasonable doubt or was found drunk when he did it, I would not have it in my right mind to think of this person to pay for his 'crimes'. It seems like a waste of money and effort that could have been spent on improving safety measures.
 
Fail 3: Kill the messenger
Then the Dutch court has the ordasity to actually condone the trial and CONVICT THE OPERATOR! Even while experts have stated under oath there was a 'technical malfunction' of the system (albeit usability wise or otherwise), we crusify the righteous and let the murderer go. And to make this insult complete, it was stated the Ministery of Infrastructure cannot be brought on trial because it is an institute! ...Early on 2011 the bridge malfunctioned again, disabling it to go open.
 
This anecdote reminded me of Donald Norman (User advocate in human centered design) where he wrote in his book The Design of Everyday Things how he got involved by the governement during the investigation of an accident inside a US nuclear power plant.
It seems like we would never learn from our mistakes and are doomed to muddle through, even though we use controls that may make a difference between life and death. One bright sparkle of hope is the announcement the system is being reviewed and altered soon but this is one shameful example of Dutch design (and law) for sure.