"What we have here is a failure to communicate."
Holy Moose Droppings, Batman! I suppose every whimpy report ever written goes down this road. Nobody gets blamed, and it's really easy to say "We fixed the problem by putting in a whole new bureaucracy dedicated to communication! Nobody can communicate except by going through these people."
I suppose no report will touch the real reasons, which we all know. Because that's un-fixable in the world of gov't politics.