Track this one down from Transport Canada...
The F28 accident at Dryden, Ontario, in March 1989 is a good example of this model. Taken at face value, this was a clear cut case of pilot error. The immediate cause of the crash was the failure of the flight crew to obtain adequate protection against wing icing prior to departure. The inquiry yielded a 6 volume report; probably the most exhaustive air accident report ever. The conclusion:
"The accident was not the result of one cause but of a combination of several related factors. Had the system operated effectively, each of the factors might have been identified and corrected before it took on significance. This accident was the result of a failure in the air transportation system as a whole."