Paragraph377 (being called young is generous, thankyou! Although I WAS a kid when this happened). I've been involved in a few incidents over the years, there can be some very simplistic 'findings' when it comes to investigations. The involvement of management and ops in particular are of interest to me. I'm not looking to be able to blame anybody for this tragedy but I do want to understand the full picture. This is a classic example of the Swiss Cheese.