donotdespisethesnake
We are not in the business of apportioning blames and in this particular case nobody did a "mistake". A slip of the tongue ( lapsus) is per definition inconscient , You mean to say something but your brains says another and you do not realize it . It happens during periods of high mental workload, and happens quite often in our professions , although most of the times without consequences as it is corrected by the person seating besides you , the PF if you are flying your coordinator/ assistant if you are a controller. The first " hole" in this incident is that she was alone to take up Gary Brown remark about Reason's model. .
The UAL crew did not do any "mistake" either they performed what was asked as it is common to do so in the USA and they used the FAA phraseology they are most used to.. the other hole here.
Another hole was that the sophisticated automated conflict detection tool in the TWR supposed to detect such things did not activate ( reasons explained in the BEA report)
However 3 holes were closed and that is why it was only an incident :
The EZY crew by looking out if approach was free while lining up closed a hole, it was good airmanship.
The UAL crew spotted the attempted line up and performed a go around even before it was mentioned on the R.T another hole closed
The visibility allowed visual detection of the conflict.
Gary Brown :
She added that she was preoccupied by the anticipation of changing positions" at time of the incident.
Indeed, most probably one of the reason that caused her lapsus.