Jetopa - very well summed up.
Certainly not bashing non aoc ops, but without any real compliance monitoring of private ops like this one, the lines become fuzzy and it becomes very difficult to foresee any trends with crew performance / procedures / decision making etc...especially if the PIC is also the manager of the flight dept for the operation. An LPC once a year is not sufficient to establish all of these things.
It seems pretty clear that there were some seriously bad decisions made and that they were well outside of SOP's.
FNPL.