"A linear chain of events assumes a simplicity which is not present in the complex technological systems we build today."
http://sunnyday.mit.edu/papers/nelson-thesis.pdf

Everybody want to hold one person or one event responsible for an accident. "If you'd done XXXX differently, YYYY would not have happened.

Maybe it's not that simple. Maybe there is more to be learned from accident reporting than pointing one finger.

Prof. Nancy Leveson of MIT has been working on this issue for decades. Needless to say, NTSB is not interested in a holistic approach to accident investigation.
http://sunnyday.mit.edu/

This is a much needed approach to accident investigation, especially considering the increased complexity and computerization.

Another good read concerning accident investigations is "Why Planes Crash" by David Soucie. He was the one who figured out that time life by hours didn't prevent the 20 minute average cycle problem that blew the roof off a 737 in Hawaii. He also left the FAA after seventeen years. He explained that they, accident investigators, we ordered to first make the FAA look good, second find fault with operator, pilot, or mechanic, and lastly make recommendations to prevent future accidents.

As your STAMP lady says, this kind of finger pointing is not very helpful.