Missing bolts
The door plug that blew out of a Boeing 737 Max 9 airplane was missing
four bolts meant to hold it in place. They were missing because Boeing
maintenance removed them and did not put them back in again.
Some workers actually made the mistake, but they were working as part
of a work system that Boeing management was responsible for setting up
and running. That's where the real fault is.
I suggest passing a law to require aircraft manufacturing and repair
companies to have a certain fraction of licensed commercial pilots on
their boards. Perhaps 66%.