We should not judge less we be judged.
Reading the translated extract @ #151 without considering wider aspects, we might mistakenly conclude human error, which moves to blame and train, dismissal, …
Not wise.
parkfell, there is no evidence to support rash conclusions about 'mentality' or management, nor without explanation how we might learn from 'CRM'.
A philosophical view of 'cause' argues that because of inherent human variability and our inability to avoid hindsight bias, it is impossible to understand the actual human reasoning in past situations; humans cannot be a 'cause', only a contribution; both good and not so.
We learn from trying to understand that contribution, differences from the norm, both our and others expectations; there is little to be learnt from absolute conclusions - extreme positions without reviewing the supporting evidence. Hopefully the report will be translated in full.
In particular we need an understand why the decision making process was faulty; - because the academic view and HF teaching considers that both good and poor decisions stem from the same process.
Similarly for faulty implementation; a choice of action but how was this justified - a balance of probabilities assessed at the time in that situation, with recalled knowledge and influence of teaching, training, and experience.
Which specific principles of CRM were not applied, what are they, and how might they have been applied in a situation which we only see with hindsight.
A glib comparison with other accidents could conclude that CRM as a concept is flawed, because of the association of many accident outcomes with the often reported 'failed' CRM; but associations are not causation.
Opposed to seeking true cause (our view of it) there will be greater safety value by starting from a position that we don't know, and then consider influencing factors by which we can learn from this incident.