The Reason model of causality probably fits to some extent to this event, however, the event also may serve to indicate that the behavior of aviation safety systems are in fact dynamically non linear and also have unbounded chaotic behavior, which results in stochastic or non deterministic system behavior.
Gosh! someone has invented a way of expressing Murphy's Law in a pseudo-scientific way. I think I prefer the original: "If it can go wrong it will go wrong."
Sod's corollary to Murphy's Law (with acknowledgments to Perry): "When it goes wrong it will be at the worst possible moment."