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You're simply misreading it, ATC refers to the specific person(s) responsible at the time.

Perhaps you're tripping over "responsible", it helps to read it as "if you, future person, are in this situation, consider how you could avoid a similar accident, given your position in the system".

It does not necessarily mean "this person is incompetent", or "this person is criminally liable". That's outside the scope of such reports.

If it didn't mean that, then someone in the ATC chair in the exact situation tomorrow would need to helplessly watch the same tragedy play out in front of their eyes, would they not? Even if they'd have the benefit of hindsight in having read this report.

After all they'd be a powerless puppet strung along by systemic causes.



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