I agree that the report is very well written and covers the physiological processes that can result in loss of SA. However I believe that is the result of a chain of events, let me give you an example.
A regional turboprop crash in the states, an inexperienced crew crashes an aircraft on a Dark and Snowy Night at a small regional airport. The accident report can explain in great detail the handling error made by the crew that resulted in the crash, they can identify which crew member manipulated which control which resulted in the crash, however this is only the first layer of investigation.
The more detailed modern view is to assess the chain of events that resulted in the crash.
In this case the Airline management spent as little money as possible on crew or crew training.
They paid very low salaries so only very inexperienced pilots were hired, they spent as little money as possible on training, so pilots received inadequate training and commanders were upgraded with minimal training and experience.
They would not invest in flight ops management so there was no oversight of crews and limited support to crews operating the flights.
And finally they based the inexperienced lowly paid pilots at far flung bases where they had to commute for duty on there own time, and then made them work long and difficult days in the poor weather of the northern US which led to chronic fatigue
The result was the pilots made an error which RESULTED in the crash, the fault lay with the Bean counters.
Of course the Bean Counters believe that Flight Safety is a given and would invest no money in that.
There is another accident closer to home that is scarily similar to the above.
I believe the same detailed examination should be applied to any Aviation accident and incident, I see that someone has detailed the AC accidents from the last 15-20 years, it fills me with no pride to see that listed nor do I feel any pride in the fact of knowing that it is the tip of the Iceberg. The near miss with the AW-139 within days of the PC-9 crash points to the AC’s stubborn self belief and naivety.
Flight Safety is not an Accident, I saw that on a poster many years ago, I think given my years of flying I finally understand the meaning of that poster