As a retired ATCO, I recognise elements of those awful sequence of events, fortunately without the fatal consequences. The holes in the swiss cheese lining up. You take away just one item and the incident/accident does not happen. You just have to hope that while you may be very good at what you do 99.99 % of the time the moment you do have a lapse, and you cant go through a long aviation carreer without having one, the other links in the chain are working as they should.
Obviously, you cannot plan for every eventuality, but procedures and management must be robust enough to provide an adequate safety net and regulatury authurities should be prepared to bare their teeth where they consider all is not what it should be. Sorry if this may sound a bit emotive but "been there, almost done that"
My thoughts are with all concerned, especially those who lost their lives and the bereaved.