Sorry, no intention to criticise your post which was well thought out and expressed. I was trying to use part of it to illustrate what I call the 'who' level at which these things tend to stop. 'The pilot failed to lower the wheels' level.
it's not what they did, it's why they did it that is the most important point to understand.
We agree totally.
Also, go back to my definition. The word 'system' is important.
On a broader note, you could find root cause in the NTSB's lack of ability to be able to enforce its recommendations on the FAA. Not surprising, as I understand it, the NTSB does not have these powers. Dig deeper and you may have an interdepartmental government failure!
And for goodness sake please don't start me with the military court martial, board of inquiry system. Both guaranteed to get to the root cause.
