The last few posts are not exactly coherent when you read, even fast read, the full report.
As ever, there were a number of (human) factors acting towards a poor outcome. Traditional "break the chain" was required, but the pressures prevented it.
Unless there are blatant factual untruths in there, I cannot see the Poles have much to complain about.
If you want to get into the "blame game", then more than 1 individual bears responsibility. However, if you wanted an overall/principal cause, I would go for "Organisational Failure(s)" - that set the scene for the subsequent indiviudal errors.
NoD