@WillowRun, as you may be aware that the investigative process is overseen by ICAO; in this instance via the internationally agreed Annex 13 (not every State, and some have opt out clauses). There are also associated safety processes (forums) which include continued airworthiness (aircraft) and flight operations. Generally ICAO recommends, States implement, Authorities and Operators act.
In today’s complex operations the ICAO guidelines (even more so State / National interpretations) may hinder accident investigation, e.g. difficulties arising from the need to identify ‘probable cause’ and with the consideration of human factors.
Many, most accidents do not fit the old model of ‘cause and effect’; they are better represented with a systems view where outcomes emerge from ‘
the seemingly random conjunction of many factors, each necessary, but in isolation not sufficient’ (James Reason, et al).
Therefore to improve safety it is necessary to encourage a systematic view, which currently is not at the forefront of safety activity, and international changes are slow. Fortunately several national investigators do venture into supposition and conjecture to provide more relevant understandings of the accident, but according to international agreements insufficient to recommend change.
An investigator can make recommendations to another State for action by a National Authority (more often operational issues); also recommend changes via the State of aircraft certification to a Manufacturer (technical issues). (ICAO Annex 13. 6.8 - 6.10)
Fortunately many National Authorities, Manufactures, and Operators will consider safety enhancements based on the subjective discussion, but this requires a ‘good’ report. IMHO this report is ‘fair to good’ given the circumstances.
Thus because more ‘worldly’ safety activity still requires factual arguments (evidence), the complexity and incredibility of modern accidents leads to frustration in judging how to manage the different points of view of safety actions, particularly where influenced by inherent human bias.
Even your examples reflect bias, suggesting that these points are known ‘causes’ (fact), whereas from a systems view they may only be contributions in a process applicable to a particular situation (probably never to be encountered again).
From the theories of high reliability organisations (the current level of safety qualifies aviation as such); it is difficult if not impossible to identify the mechanism of the next accident. It’s equally difficult to make effective recommendations from past accidents unless there is a change in safety views and processes.
Such changes take time, willingness, and understanding.
A lesson from quantum mechanics, first accept that nothing is certain.
We live and operate in an uncertain world, thus our safety activity must involve managing uncertainty, particularly where changes could be applied to aspects which were previously assumed to be satisfactory.
What was uncertain in this accident?
From a systems view, the industry’s problem is that we may not know what the problem is.
In ‘problem situations’ the human can be an asset in resolving the issue, but with ‘messy situations’ the problem is often the human.
How complex systems fail.
Systems Thinking.