In reading the report it is quite clear that the underlying failure was once again that of management.
I recall reading another report recently where management at an Italian airport were ultimately to blame for an accident.
Wouldn't it be nice if (for once?) senior management was made to take responsibility for their failures. Maybe one or two long prison sentences might just concentrate the mind of these people.
I speak as a senior manager within the transport industry (not aviation) where my actions are subject to very close scrutiny with very serious legal implications when I get it wrong. I am also a regular air passenger.
This does not appear to happen in the air transport industry, or am I wrong in this assumption?