Another SI riddled with instances of non compliance with the services own regulations and procedures, some relevant to the incident, some not, but indicative of institutionalised lack of operational discipline.
The section regarding electronic authoriSations ( rather than the American authoriZations as used throughout the document) is frankly comical, with individuals able to use electronic copies of others' signatures to approve critical documentation. This, as does much in the report, illustrates a fundamental inability to understand what controls are for. The comments regarding the difficulties and delays in obtaining documentation from other parts of the RAF are more than a little concerning too.
The report goes to great pains to explain how the onset of the stall could well have been barely perceptible to the pilot without exploring what looks like being the unfortunate reality that he could not have escaped from the position he was in even if he hadn't stalled. The manoeuvre was botched from an early stage and should have been aborted long before it was. The background to why the pilot felt the need to press on as far as he did would be relevant, and I cant help thinking there might be some clues in the redacted comments. There seems to be something inferred regarding his sense of how he was perceived within The Arrows.
The Human Factors comments about fatigue from being overworked from, inter alia, collecting the packed lunches, tidying the kitchen, and making sure the IT works do not inspire confidence, or build credibility in a supposedly elite echelon of a 21st century air force.