Human beings make mistakes. What happened, why did it happen, what can we do to prevent it happening again. Open honest reporting to break that chain.
If the human beings have been told of the likely outcome of their policies, the deaths have come to pass and they continue with their policies, are those individuals or the system they have created and perpetuated, fit for purpose?
I wholeheartedly agree with your comments as applied to the vast majority, but there is a malign controlling influence at the heart of all these accidents, and they are continually allowed to judge their own case.
We should never lose sight of the fact MoD will always try to compartmentalise and localise the issue. The simple fact is, we've been here before and, yet again, the systemic failures have their roots in the same policies.
Neither should we lose sight of the fact the SI looks at the cause of the incident (the inadvertent firing); the subsequent death is an unfortunate outcome. The Coroner, on the other hand, looks at the cause of death - which focuses on chute failure. MoD's focus, the firing, conveniently directs attention away from the long term systemic failings and the DIRECT links to previous accidents. The SI does a good job, and points to this, but is not allowed to dwell or even offer an explanation for these failings. There are many recommendations, but no explanation as to why they are necessary. Much to MoD's relief, I imagine.
I'd also like to say that, while I'm critical of the MAA hierarchy, who today are part of this "controlling influence", these failures are so long term (1980s) and deeply embedded in MoD policy and practice, that it would be nigh on impossible to eradicate them in the 4 years the MAA has existed. In that four years, we have seen the instigators of the policies even write to the press defending themselves, and their exact words repeated in the House by the Secretary of State. Being MAA DG under that weight is a crap job. But at no point did either MAA DG write to the SofS and say "You're being lied to". Which is why it would be better off outwith MoD. As you say,
Open honest reporting to break that chain
is required.