Perhaps I should clarify that these are drawn from the causal factors in the incident. That is their remit. What they cannot do is question the underlying methods of working, determine railway policy or, as you suggested earlier, recommend a return of guards onto DOO services. They generally highlight where existing procedures and practices have slipped and highlight these for the relevant bodies to address.
However, they have identified aspects of DOO operation, such as despatch using DOO monitors, as being causal factors in incidents. For example, the consequences of the incorrect positioning of the train relative to the monitors at Huntingdon and the imperfect view that they accorded to the driver were identified as causal in the incident where a passenger was dragged under a train after their coat was caught in the train doors.
O L Leigh