What came across at the Inquest was that nobody took responsibility for fitness for purpose. Obviously there was an awful lot of back sliding going on and failure to recall, but having personally sat through days and days of evidence I came away thinking the RAF and MoD didn't understand what they were trying to achieve or how they were supposed to achieve it. But 2 Gp seemed to get the lions blame for failing to make the request for foam to DEC/IPTL. I certainly believe some of the individuals involved were basically not qualified/competent to make the decisions they were making.
WRT transcript/notes, not my property I will ask if I am allowed to reproduce in full..