Ops, you might wish to research more recent views on the limitations of safety investigations, particularly as industries become increasingly complex.
Investigators may be well qualified, but experience from previous investigations might not relate to new or novel situations.
With human interaction there may be several viewpoints; reports constrained by ‘factual’ reporting, opposed to speculative, probabilistic views of human performance which are required for learning.
The transformation of accident investigation. A lengthy view, the case studies can be skipped; if nothing else see the summary and conclusions, page 168.
http://www.functionalresonance.com/F..._accidents.pdf
Quality is not safety; safety is what you do, quality is only one possible outcome.