I don't know where he got his expertise, 411A; possibly from "assessors". My own experience in the field is limited, but not wholly non-existent. I participated in one fatal accident inquiry long ago in which two senior lawyer participants were ex-military pilots from WW 2. One other participant later achieved an extremely high position in the UK. My group was in conference with our counsel when we received a telephone call from another: Had we noticed one damaging inference from the day's evidence that pointed to conclusion X on the part of the pilot? Yes we had. Did we intend to raise it? No we did not: our participation was not as a public interest representative, but solely to demonstrate that we had done nothing wrong. But surely, we asked, YOU do intend..........? Well, actually, No, old chap. Ah hah!
One of the eventual collateral recommendations in the report was that passengers sit on something like hammocks, not seats, so that the risk of compression fractures of the spine would be reduced. How does that one grab you?
We were lucky to be there at all, because we had never been given official notice of the inquiry. We found out about it by accident. I once alluded to this in PPRuNe and received the response: "I don't believe it". I really don't care about that. I was there and it is true. I could name names, times, and places, but I shall not, so if anyone chooses to believe that I am making all this up foir the general amusement he is welcome. I see no point in attacking those who are dead, and I do not want to be sued by those who are not.
I can tell you this, not one of them was a Sheriff Principal. You do not have to go far to find odd things in accident reports. I have seen some that make me reflect on Bismarck's dictum: "I believe nothing until it has been officially denied."