Bari1
I like the "holes in the Swiss cheese" analogy. If any one of the contributing factors were absent, these folks would still be alive.
I'm not sure I can agree with this. But just in case I'm missing something could you put forth a list of contributing factors that you believe are in a direct line, rather than trunk lines?
The failure to retard was in my mind an egregious factor which may have overridden some other suspected contributing factors bandied about in the overall discussion.. But I will await seeing your list.