For policy setting that's the wrong question. The real ones are: how likely is it to happen, how much would training/comms change that, and how acceptable is that risk. Their answers seem to have been: very, not enough, it's not.
Where the problem is and how to change it is an interesting topic, but likely irrelevant for the decision.
Where the problem is and how to change it is an interesting topic, but likely irrelevant for the decision.