Well there are some lessons to be learned here, yet again.
The good news is that we don't have to blame anybody to learn them. All we have to do is read and decide that we don't have to go there.
Predictably some will fine tooth this claiming the lesson was unclear and that it was really the fault of this and that.
Most will remain neutral and vow that they will ensure that it won't happen to them.
Chief pilots please take note, the lesson is for you.