Like you said (and illustrated well in the book) it's never just 1 thing, these incidents happen when multiple systems interact and often reflect a the disinvestment in comprehensive safety schemes.
I was sure you were going to link to Clarke and Dawe, The Front Fell off.
https://m.youtube.com/watch?v=3m5qxZm_JqM
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Like you said (and illustrated well in the book) it's never just 1 thing, these incidents happen when multiple systems interact and often reflect a the disinvestment in comprehensive safety schemes.