At what point in the process is the Authority (FAA), the Manufactuer, the Operator, and the Pilot expected to anticipate such an event and take preventative action?
We have to consider the legal concept of “the burden of knowledge” in looking at this tragedy.
Another way is to define the failures to act that allowed these five people to be in such a situation.
At times like this I wish I had gone to law school after my military service as I would be making a wad of money out of this!