From the House of Lords report, Quote:
"56. Important parts of the hydraulic flight control systems were housed in a small closet, colloquially known as the "broom cupboard", at the rear of the cockpit. There were two control pallets containing respectively 23 and 26 threaded inserts for component attachment. On 10 May 1994 the thrust balance spring attachment bracket on the aircraft's thrust/yaw control pallet had detached; this was due to the somewhat inadequate method of attaching the inserts to the pallet. This detachment had resulted in an undemanded flight control movement (UFCM) in the collective system.[23] An engineering report of the following day relating to this incident stated among other things,
"Detachment of the bracket within the flying control closet during flight could present a serious flight safety hazard, with the danger of a detached bracket fouling adjacent flying controls".[24]
57. After the accident the investigators found that both inserts for the thrust balance spring attachment bracket had detached as well as most of the other inserts to both pallets. The AAIB stated, "as an insert could apparently pull out of the pallet without appreciable distress to the components necessarily resulting, the possibility that insert(s) had detached prior to the accident could not be dismissed" (para 7.4.2). In the Flight Control Summary the AAIB reiterated that "the possibility of control system jam could not be positively dismissed" and further stated that "little evidence was available to eliminate the possibility of pre-impact detachment of any of the pallet components" (para 7.4.9).
Unquote.
So. A failure of the flying controls HAD previously occurred and was put down to a design fault in the flying control system. EVIDENCE in the wreckage suggested that this could have occurred again on the flight resulting in the accident.
Surely not an insignificant point?
Here was an aircraft type, without the normally required Release to Service and certainly without an icing clearance, that had previously suffered both undemanded engine runaways and flight control failures. Neither fault had been resolved by a modification or design change. The aircraft was put into service on this fateful day, in marginal weather conditions, where the crew had no option to climb to Safety Altitude, due to icing conditions, to carry a particularly valuable group of passengers.
The negligence is undoubtedly there, but where SHOULD it have been placed? Management chain? Severe likelihood of obvious serious legal repercussions! Aircrew? Whitewash? Scapegoat?