The people responsible have quietly left and taken posts elsewhere or played the too stressed to help answer questions to the reports' authors. Let us remember that the fatalities were the equivalent of 3 jumbo jets crashing and killing everyone on board. Yet there seems to be little desire to find out what went wrong and whos decissions let to that state.
We have far too many layers of management in all levels of our society, yet absolutely no one taking resonsibility. It is the same in Hospitals, banking, parliament, the BBC.
They always say lessons have been learnt but they have haven't.