Having followed this thread from the outset, and made a few contributions along the way, it does strike me that we are now reaching a point where there is significant degree of consensus around the key points:
- The regulators failed dramatically. This aircraft should not have been flying, this pilot should not have been flying it, and they should not have been attempting to fly this display. Prioritise these any way you like, but had the existing regulations been effectively applied to any one of them, we would not have had this incident.
- The investigation has not provided a convincing or ( in my view at least) credible outcome. For example, The apparent power deficit during the fateful climb and the evidence regarding the fuel pump diaphragm were staring them in the face, yet they chose to ascribe a conclusion to Rolls Royces analysis which Rolls Royce themselves had avoided.
Also, how come the traffic lights weren’t set to Green as had been mandated? If the traffic hadn’t been queuing, it seems highly likely that fewer lives would have been lost. Why is this not properly developed as a theme?
- The Coroners conclusion regarding the victims being “unlawfully killed” verges on the Kafka-esque. A moments consideration of the facts by primary school pupils would lead to that conclusion. Leaving aside there isn’t a verdict of being “lawfully killed” , the tragic victims obviously did nothing to warrant what transpired. Ignoring some of the directly pertinent evidence to arrive at such an arcane verdict does little to enhance the credibility of the process, and I fear will provide little enduring comfort for the relatives of the deceased.
The existing system could and should have prevented this incident, and made its consequences less severe. None of those who presided over or were directly responsible for the failure to implement it have been held to account. I’m sure the various changes which have been introduced can make things safer still, but ONLY IF THEY ARE ACTUALLY APPLIED. Where does the confidence that they will be come from?