Originally Posted by
DaveReidUK
I disagree. An open verdict would have been entirely inappropriate.
The Coroner's responsibility is basically to establish how the deceased came by their death(s). In this case 15 people died as a result of an aircraft impacting the ground. That fact remains undisputed whether or not the scope of the inquest is widened to consider the chain of events and causal factors that led to the event - Coroners are not expected and do not need to be accident investigators,
Dave
I respect your opinion.
The Coroner's responsibility also includes making recommendations to prevent recurrence. They are not expected to re-investigate unless, for example, there was an obvious deficiency in the original investigation. This is the argument that persists in so many military accidents/Inquests, as military investigations are nothing of the kind. This was reiterated a year ago in the Coroner's decision in the Jon Bayliss case, where she ruled the MAA was not independent and had omitted much from the official report. It is why all Coroners have investigators, who are very often retired senior police detectives. They came to the fore in the Bayliss case by tracking down evidence MoD denied the existence of.
Many of the same issues arose here, with those who investigated allowed to judge their own case. Especially, the serious certification failures noted but not explained by the AAIB (itself a deficiency) were put to the CAA, who were allowed to judge their own case. But the Coroner was not allowed to 'go there', it taking a High Court ruling to stop her. So, the question remains. Given, as you say, the aircraft crashing caused the deaths, why was it flying when the AAIB report set out why it should not?