In virtually every aircraft accident report I've read, there have been a chain of actions taken by different people that led to the eventual tragedy. This one is much the same.
Why should one link in that chain carry the entire burden of blame?
In my experience, there is rarely one very clear, absolutely definitive, cause for an accident.
I faced a BoI many years ago, after having missed something through lack of foresight that nearly caused the loss of a Canberra. The words of the BoI chairman still ring in my ears "You are only getting away with a formal reprimand because you were foolhardy enough to fly in the aircraft after signing that the TI was safe". The chain of events leading to this incident was so far-fetched as to still cause disbelief amongst those who hadn't witnessed it.
Needless to say, this has caused me to exercise a great deal more care from that day on, but I regret to say that I have still missed the odd potentially dangerous item from time to time. We should, perhaps, accept that human fallibility is a generic attribute that we have to accept to a limited degree.
VP