False Engineer
Grouter, I am not associated with QF nor have I ever been, but I have been reading all the threads on this subject with some interest and you appear to be one of the few who have read it right. We should agree then that there is a systemic failure in the QF L.A.M.E./Company Approval Tracking System (assuming they have one, it is mandatory). Lets hope they are addressing the problem through their Safety Management Sytems because there could be not just one missing slice of the cheese but also a very large hole in the remainder.
I happen to know that the regulator asertion "it is a one off" is not strictly true, it is out there in all professions, sometime a little more subtle and therefore very hard to pin down by a professional investigator let alone busy company managers. Fortunately many are picked by peers when a lack of competance is noted but in this case that person may well have been quite competent and continued unnoticed for years.
cheers
Flyker