I think there is another thing to take away from some of the case studies - if you design and implement operating procedures and alarms, do so in a way that is simple, effective, and does not draw an undue amount of time and attention to itself. I have dealt with too many systems that sound the "everything's OK alarm" constantly and procedures that have good intentions but no effort to streamline the gratuitous amount of time and effort needed to be followed.
It is not constructive to blame employees for failure to heed poor alerts and protocols.
It is not constructive to blame employees for failure to heed poor alerts and protocols.