The Terms of Reference for this Service Inquiry are pretty much verbatim as they have been for many others:
The purpose of this SI is to investigate the circumstances surrounding the incident and to make recommendations in order to prevent recurrence.
It's the "
...in order to prevent a recurrence..." bit that drives the board down every rabbit hole that presents itself, with nary a thought for the context or prevalence of the factor being presented. This confused smorgasbord of factors, facts, policies and regulations almost deliberately avoids stating the obvious. On the day, circumstances conspired to put an experienced aviator into a deadly trap as old as flying itself, and him being part of the RAFAT didn't make a blind bit of difference to the tragic outcome. Of course all the other organizational issues amplified the consequences, specifically carrying out the manoeuvre with a passenger (he clearly was NOT supernumerary crew, despite some convenient and disingenuous institutionalized attempts to redefine that role) but there was no mystery as to the root cause. There may be a huge corporate reluctance to admit it, but it is a salutary lesson indeed to demonstrate that even with the level of experience and and skill available in the cockpit, he was not immune from the terrible consequences of getting it wrong on the day. You're only ever as good as your last flight.