Double Back
Woow, this is like an airline investigation conclusion from 1950's, when nearly all was contributed to the infamous "pilot error". A bloody shameful conclusion, very hard to the relatives and friends, and the instructors of these poor guys.
The virtue of 'pilot error' (or 'crew error', as I prefer) as an explanation for accidents is that if it
isn't that, then you are just flying around waiting for the airplane to kill you. I will agree that organizational error can be a strong contributor to crew error, but the crew are the people at the sharp end.