FE Hoppy:
You have perhaps described WHAT may have happened.
Can we reasonably presume that all the individuals concerned would have started that day with the intention of doing the best job they could? The most professional they could be. Exactly the same as many of us?
The generally accepted point of investigation is to attempt to explain WHY things happen to (or are omitted by) reasonably conscienscous people, so that we can prevent similar things happening again.
At least this way we don't ALL have to make EVERY mistake, in order to increase our experience. We can learn from others who are probably very, very similar to ourselves!
(To be fair this type of incident HAS happened numerous times before, so it seems, so far, we haven't learned enough !!
- Maybe this time eh?)
Nobody here has the foggiest AUTHORATITVE idea WHY this incident occurred, nor WILL any of us until the full story is known.
Is there anything else to say until the report is published?