It is interesting to note the various causal factors, direct or indirect, that were available to the BoI and Reviewing officers. These include;
- Human Factors (Non-Aircrew) (Negligence) – The breach of Duty to take due and reasonable care in carrying out their task.
- Unsatisfactory Equipment - Equipment not satisfying the needs of the User
- Organisational Fault - Failure to provide adequate training, instructions, materiel or manpower
As the good book (AP 3207) offered these options, it follows the BoI was obliged to consider them and , if evidence existed, state why it had been accepted or rejected.
Try as I may, I cannot find any evidence that these causal factors were properly investigated; and the RO’s most certainly didn’t want to go there as they, along with CAS’s staffs, were party to the failures in the first place.
Very clearly, evidence supporting all three existed, for example, the negligence in releasing the aircraft to service against a fabricated CA Release and Release to Service. Also, the related failure to demonstrate in the Master Airworthiness Reference that installed equipment performance had been properly assessed and established (pre-requisite to determining Limitations) and, of course, the failure to provide proper FRCs (Instructions) and training. There is more, but all trails lead back to the Release process being hasty, ill-considered and premature.