(haven't yet read the full report) If NTSB in non-aviation areas works the same way as in aviation areas, that's definitely covered by the investigation. That'

(haven't yet read the full report) If NTSB in non-aviation areas works the same way as in aviation areas, that's definitely covered by the investigation. That's why ridiculously common case summarized as "pilot error" usually involves several components including organization, training, etc. EDIT (After reading the report): And indeed, "what we found" section and "what we recommend" is all about how PennDOT and related orgs operate.