Literally breathtaking. If you step back far enough, you begin to see a very worrying picture of Airworthiness post-Haddon Cave. This report contains pages and pages of descriptions about risks, ALARP, insurances, Government Contracting and Sub-Contracting arrangements, operational pressures, AWC Audits and a whole host of "protections". But despite all that guff, a service pilot got airborne in an aircraft that had fundamental serviceability issues with a non-service pilot whose qualifications were never fully established by the Board. When the aircraft developed problems maintaining power, the most basic of airmanship principles appear not to have been applied in recovering to a forced landing, resulting in the tragic loss of life.
My point is quite simple, have we become lost in our own Byzantine safety culture to the detriment of applying the most basic supervision and airmanship principles?