I am not supposed to have an opinion - or to participate. However, on this occasion, having read this dreadful report I feel justified in making the following point - it is relevant.
I was told, many years ago when one of my aircraft (C404) crashed, the CAA were quick to tell me after the incident that this was yet another example of 'accidents never just happen, they are caused.'
I think this is probably a classic example and a very bad and sad one.
PPP