Very unfortunate… we see a lot of accident investigations like this. Regardless of what you may see/read on LinkedIn, root cause analysis tools are a MUST have in any SMS, as well as having TRAINED/COMPETENT personnel using those tools. In my 30+ years, I have come to learn that the RCCA element of an SMS is one of the top 5 elements of a successful SMS. Without it, we can kiss a “learning culture” goodbye.It ain’t the tool fool; it’s the fool with the tool!!
Me, Circa 1994 

