The NTSB states the obvious (#566), but remains biased towards a pattern of ‘blame and train’.
Blame the Feds, the Operator, the senior management, the crew. Yes all held extensive accountability, but much more might be learnt by trying to explain and understand the reasons why the people and organisations behaved as they did; why was their understanding apparently so poor, why were procedures written as they were, why weren’t they followed, why did the crew choose this particular alternative and continue with it; why didn’t the crew Go Around.
Why didn’t anyone, – why doesn’t anyone know?
The style of the NTSB report promotes a ‘legalistic’ approach to safety (not litigious), whereby operators / managers / pilots seek ways of continuing the operation – ‘how can we do this’, the ‘how to’ or ‘can do’ attitude.
The industry’s safety interests require “should we be doing this”, the ‘why’ attitude; evidence, reasons.
The NTSB apparently does little to help with these safety questions.