"One man cannot possibly hope to make sense out of all the bits of information weeks, months and years before 2nd September without specialist knowledge and assistance. That is the job of the board".
If BOIs looked back BEFORE accidents in any detail, and made judgments or recommendations on what did or didn't happen, then;
a. There would be fewer accidents, and,
b. The reports covering, for example, the loss of a Tornado and two Sea Kings on successive days in March 2003 would be vastly different. (And so too would the Coroner's verdict).
That they don't do this is precisely why we have to go round this tragic buoy time and again. The mistakes are seldom corrected. Lessons are not learned. To do so would cost money and force MoD to admit liability.
Parliament made a momentous decision by repealing Sect 10 of the Crown Proceedings Act of 1947. That is, those responsible for, inter alia, airworthiness lost the protection afforded by Crown Immunity. It forever changed the way the MoD had to conduct their business, particularly in the aircraft world. The first step was DCI GEN 89 in March 1993, followed by the up-issue or creation of various JPSs and Def Stans. (A process which, by the way, is still not yet complete).
Critically, however, the powers that be either didn't appreciate the financial implications and the need for complementary funding to bolster the underlying processes, that themselves had to change almost overnight; or they knew but ignored it. Given the cuts in funding at this time, the most savage aimed fairly and squarely at the process of maintaining the build standard (which includes airworthiness and safety), I go for the latter.
While this probably affected very few of you directly (i.e. you did not have airworthiness delegation), we can all now see the outcome - which was predicted in very precise detail by those charged with managing the process under this new legislation.
Again, I don't think the Services are to blame here (except perhaps the people who, for example, sat passively on the Defence Airworthiness Group dictating processes but saying nothing when funding was denied). There are common factors here with other accidents which, because the remit of the BOI is so narrow, will never be exposed or overcome.