I’m a proponent of the system level approach to addressing faults, errors and so forth ( Reason’s Swiss cheese model is a classic example of how they might occur). It takes a dedicated, step-wise review of all potential causal factors (root cause analysis -RCA) by a knowledgeable multidisciplinary team to come to a consensus conclusion on why an undesired outcome occurred and what, if anything, could be enacted to keep that outcome from happening again.
This isn’t to say an expert with all the details couldn’t make a very good guess. But that isn’t the way causal investigations work. More brains and less bias --the idea being a separate, equally qualified team, would draw the same conclusions when presented with the same evidence (sort of the opposite of the current media conjecture-thon).
Of course, there is the fact that we don’t know what happened yet.
