My best example of what Mars and others rightly suggest is the Air Methods Bell 412 crash at Bluefield, WV several years ago.
The flight was a Two Crew, fully IFR equipped Bell 412, operated on an IFR EMS Operation based at a Hospital. A different Vendor, operating a VFR Single Pilot BK-117 experienced a Fatal Crash several years earlier while operating from that Hospital. The first Crash happened when the aircraft impacted a mountain side near Fancy Gap, VA. That crash prompted the Hospital to upgrade their operation to the Two Pilot IFR Program.
If one does a front-line only review of the accident....it would show the crew never found the Glide Slope on the ILS, reverted to a Localizer Approach, completely missed the Airport and flew into a Mountain several miles beyond the airport.
There would be some question as to how they could have managed that as it would take some really gross incompetence to do that.
Then if you were to take a larger look....as was done....one then sees there was a structural problem.....there was only an Outer Marker Beacin.....not a Locator Outer Marker Beacon.
Then you see, despite the Crew asking to be vectored well outside the Marker, ATC (Radar) turning them inside the Marker.
If you stopped looking at that point....you would then miss the rest of the story.
The aircraft the crew was flying was a "Spare" aircraft flown in that day by the Corporate Check Pilot who was there to do IF Base Checks. The "Spare" aircraft had different Avionics, particularly Area Nav, than did the Base Aircraft.
The Bluefield Flight had been turned down due to weather and the Crew had decided to fly to another location that had suitable weather and do a Public Relations Appearance.
The Captain, was the Base Manager, Safety Officer, and Base Training Pilot.
As the Operator bragged about its IFR capability in its sales and
PR....the Crew felt compelled to do the Bluefield Flight after the Corporate Check Pilot had flown in with the Spare Aircraft and the Med Crew had swapped over the Medical Kit.
If you lay out the Accident Chain on this fatal crash that killed four people....the second fatal crash at that one EMS Operation.....it shows a much different situation than if you limited it to what happened from Takeoff to Crash.
I used the crash data to create a Simulator Training Scenario....without telling the Trainee's anything about the flight. I set up the Scenario by suggesting we go someplace none of us had ever gone before....and made a show of flipping through the Approach Plate Booklet and happening upon......Bluefield, WV.
Then I acted as ATC and provided the vectors to place the Trainees in exactly the same location the AM Crew found themselves that day.
Out of a dozen or so such flights in the Sim.....not one crew crashed or came close to hitting anything.
I firmly believe a thorough wide ranging investigation to effectively describe all of the factors that play a role in these tragedies. That is why I suggested a "Shields Down" investigation of this latest crash and the industry itself in light of the past several ditchings and crashes.