Engines, your post makes sense and you are obviously better placed to provide expert comment. For sure, rebuilding experience levels is a must but this will take a generation to achieve. I find myself asking why did the hierarchy choose to circumvent process? Were there operational/budgetary imperatives? Were the VSOs naive/ignorant? Had the rot already set in? This clearly takes us back to Haddon Cave who threw the pebble (or should I say hand grenade?) in the pond. Do we just ensure a return to compliance with the process(es) or also take the opportunity to ensure that the regulations are wholly fit for purpose?
Chug, we crossed posts. Take my favourite example of a Red Cross on a helicopter. By definition, that aircraft was unairworthy - we had implemented a modification without proper approval. Did that particular unairworthiness 'greatly increase' the chances of the aircraft killing me and some others?