Dervish
I think you captured the essence very well. The only thing I’d say is that when using the term “chain” it is correct on the context of chain of events or airworthiness audit, but when considering the whole it is better to use the Reason (Swiss Cheese) Model as explained often by flipseal because that better demonstrates your point that a single event does not usually cause accidents. But I know exactly what you meant. Excellent.
To illustrate just one example of what Dervish talks about, the BoI gave Flt Lt Tapper a roasting over his “failure” to report (properly) the serial failures of SuperTANS.
Fine, I’ve no problem with that because if you don’t report, you can’t complain if it isn’t investigated. However, he had reported before with no progress.
BUT, and this is the whole point of what is being discussed at the moment, one does not stop there. One asks as WHY such an experienced, diligent and competent officer would do such a thing. At the time, any engineer involved in maintaining airworthiness (and I’m not talking about line techies but Engineering Authorities and MoD Technical Agencies - the named individual responsible for a given equipment) would immediately tell you that AMSO (RAF) had chopped all funding for Fault Investigations (never mind defect investigations, a quite different thing). That is, the world and his dog knew that in one sense it was wasted effort filling out a MF760/A because the RAF themselves had stopped further action.
That single issue would have revealed the systemic failings to the BoI. The BoI is full of such examples. As Dervish asks, why did they not go there? perhaps one should ask if the person who oversaw this policy change was a recipient of the CHART report mentioned by the BBC. (And you just know I know the answer, don't you?). So, does he rescind his policy and look stupid (and finger himself for previous accidents) or does he bury CHART?