Dani,
I may be missing your point, but I am having a problem seeing anything constructive behind your interventions. You have fingered the cause of the accident, and apparently would prefer others not to discuss it further (your comments about closing the thread).
Supposing we appointed you to be the investigating committee, all by yourself. So you can write what your best judgement tells you. What safety recommendations would you come up with "for the purpose of accident prevention and any resultant corrective action"? And how could you persuade us they would work to aid safety?
PBL