Most of the problems are systemic. Most people are probably not "clearly inept". You probably make dozens of mistakes in a week but, just by the nature of your job, nobody dies. Procedures, policies, and even technology should exist to prevent and mitigate mistakes because humans are deeply flawed.
Unfortunately the fact that the situation is life-and-death with huge liabilities that there really isn't significant effort to improve things. It's legally safer to continue practices that mostly work but are already standard than try something new.
Unfortunately the fact that the situation is life-and-death with huge liabilities that there really isn't significant effort to improve things. It's legally safer to continue practices that mostly work but are already standard than try something new.