JTO
I was hoping someone would say the Panel and MilAAIB identified the serial violations, but they were withheld from the final report. Is that what you're saying? Parts of the report are indeed thorough and excellent, but my first year apprentice would have pointed out what's missing, which is always the bit to look for. Repair/maintenance/servicing is not complete until verified. The death of Sean Cunningham in one line, taught in your first week. The remainder of the report should have developed that, exposing the root causes.
It did not mention that the MAA was seriously conflicted, as it was directly involved in this root cause. The regulation requiring the Panel to go straight to PUS was not followed. It is unclear if the Panel recognised the violation, in which case it wouldn't have understood the implications and conflict. But, as I said, they didn't ask. And nothing in their individual background or training would prepare them for it. (Not a criticism, just a simple fact). They did criticise aspects of the violation (development of the RTI) but missed both that it was prohibited and the work it required bypassed the laid down servicing instructions, rendering the seat unsafe and unserviceable. They also missed the rather important fact that the information Martin-Baker were later accused of not providing had been provided, but an instruction issued to groundcrew not to use it. Reiterated two years after the accident. Given this conflict, was it proper for the MAA to provide the prosecution's 'star witness'? (HSE's words, to the BBC).
I agree there were failings in DE&S. Particularly, not having a valid Safety Case, and no Safety Case Report, for the seat and major components of it. (Not just the Hawk variant - Tornado also). But if I were DE&S, I'd point to the greater offence of being instructed in the past not to bother with them, and funding and manpower being pulled to make sure. And false declarations being made by the Air Staff they did exist. (Again, untrained, and poorly advised). The Service Inquiry just stopped at there being no Safety Case Report. Good spot, but how did the projects teams pass MAA audit? Another conflict. Also, the aforesaid star witness declared lack of Safety Cases was irrelevant to airworthiness. DE&S staff must be thoroughly confused, as were the courts.
Which of course doesn't get away from the fact M-B pleaded guilty to not providing information; information which the Judge quoted in her remarks, even naming the MoD official who signed the report. (Did the SI try to track him down? They didn't speak to other witnesses. Or Google and download the information it said couldn't be found).
These issues, and that described by Distant Voice, may seem separate cases. In fact, they share the same root causes and are recurring. One need only read the Nimrod and MoK Reviews.