Lonewolf 50
Suggest you add a caveat to clearly identify what is speculation, since some of your steps are based on inference / deduction from the sparse facts available. At least the parts I marked in red, perhaps more.
Agree with your sentiment.
I don't see the value in guessing at possible links in a causal chain unless one is prepared to suggest a viable action to prevent future accidents. In the proposed chain by A0283 there is nothing offered to be actioned against and we are still awaiting such facts.