Tuc, Chug, Others,
Not wanting to disagree, but just hoping to clarify.
Having ploughed through the SI report again, I am struck by the uneven quality of the document and the layout. I fully understand why people reading it are confused and unclear over how its findings relate to what appears to have happened.
The report sets out on Page 1 of Part 1.4 how it is going to group its 'accident factors': cause, contributory, aggravating, other, and finally observations. I can see their logic that separates a 'contributory' from an 'aggravating' factor. I don't think it's especially helpful, and in this case makes it harder to grasp the accident 'chain'.
Here's my take, for what it's worth.
The 'accident' was the death of the pilot. It was caused by an inadvertent ejection, followed by malfunction of the drogue and scissor shackle assembly. Years ago, these two factors might have been called 'primary' and 'secondary' causes.
Like any accident, they lie within a longer and often complex chain of events. A good report sets out how that chain came into existence, and what triggered the sequence. I honestly don't think that this report does that especially well. I can see why the SI sets its findings out differently, but my opinion (and that's all it is) is that they have followed process at the expense of clarity.
Anyway, that's my take.
I agree that the SI does not do enough to follow up why information got lost, and what happened to the normal airworthiness management functions. The lack of documentation of the relevant 22 Gp/PT meetings, lack of hazard reporting, and general lack of grip of the process is just astonishing, and I would put it as much, much higher up the chain that an 'other' factor. (I agree with Tuc that it is highly probable that MB told the MoD about the shackle issues at some stage, and that the information dropped down the MoD's organisational cracks). The lack of a seat Safety Case has to be a huge worry for DE&S - why didn't the DE&S assurance processes pick that up? What's happened to internal QA? What happened to the PT's ISA?
Then we get to the next level up: Where was the MAA's 'Oversight' Division? What about MAA 'Surveillance'? When was the last MAA audit of the PTs?
I suppose this is where I meet Tuc's main concerns - how does the system ensure that those questions get properly asked? I think it's clear that you can have the biggest and shiniest set of regulations (and regulators), but they mean nothing if they aren't actually being implemented.
Hope this helps, best regards as ever to those picking up the pieces
Engines