If you e.g. push your employees over the limits and tell them to ignore all kinds of reasonable safeguards and regulations. And then, one day, after a ton of near misses Joe slips and falls into the meatgrinder, it would be very easy to blame Joe for skipping the safeguards.
But the true reason for the accident was the environment and culture Joe had to work in and it might have also hit a random different person.
The most evil variation of this is "we'd rather have the increased productivity than spend the resources to actually avoid X so our guidelines say they're to avoid X but really they're to blame a line worker when X happens so we can keep saying we don't want X". See the rash of train derailments and toxic spills we're lately now that railroads have imposed "precision railroading/precision crew scheduling".
Also: A organization can have foggier responsibility structures than "the boss says $X which is why $X is done".
E.g. you could have a boss who says safety is truly important and even does a ton to help with that, while lower management is so obsessed with other metrics that they sabotage that on a conscious or subconscious level while emulating compliance to their higher ups.
This is very common.
The "evil boss"-scenario is the simple one where it should be very clear that Joe is not to blame. This is precisely why it is important to also look at less clear ones where it would be easy to blame the accident on individual human error — instead of finding the actual root causes.