[midasuni]

The reduction from 3 to 2 operators, the acceptance of long breaks when there were two operators so there was only 1 in the room for a prolonged period of time, the pressure to cut costs, the lack of understanding of what systems were down during the upgrade, the surprising loss of hard lines without a tested alternative, the lack of a supervisor concentrating on the upgrades at the time, the lack of appropriate assessment of the risks.

Most of it seems to come down to trying to cut costs and reduce conflict with the staff (the acceptance of the “long breaks” overnight)

None of that lands on the overworked controller trying to do 3 jobs

[avar]

Those are discussed in the "systemic causes" section, but as my sibling comment notes the controller has some responsibility for those factors too.

I'm not spouting my own opinion here, just noting that what the report says is at odds with claims in this thread.