Opportunities to help prevent a mid-air crash between two jets which killed three RAF servicemen were missed, an official report has said.
An investigation into the tragedy found a catalogue of errors, including the failure to fit a collision warning system (CWS) onto the airmen's Tornado planes.
Flight Lieutenant Hywel Poole, 28, Flt Lt Adam Sanders, 27, and Squadron Leader Samuel Bailey, 36, died in the collision over the Moray Firth in July 2012. Another crew member ejected and survived but was severely injured.
The men were all based at RAF Lossiemouth in Moray.
The findings are the result of an 18-month long investigation by the Military Aviation Authority (MAA), which the Ministry of Defence (MoD) has been facing calls to publish for months.
The report found that one of the deceased crewmen had a fear of flying at high levels. Despite being diagnosed with a "phobic anxiety disorder", investigators found that there had not been an effective care plan for him.
However, MAA director general Air Marshal Richard Garwood said on the balance of probabilities "I do not believe his medical condition had any material bearing on the outcome of this accident".
Instead, the MAA said that the cause of the accident was a "lack of recognition" of converging flight paths. This led both aircraft to be in the same airspace at the same time.
The MAA found that the MoD had repeatedly delayed placing the collision warning system on the planes, in part because of cost, and at one point the programme was cancelled altogether.
"CWS should have been fitted at the time of this Tornado accident," the report concluded. It also listed among its 50 recommendations a call for CWS to be installed as a matter of urgency.
The warning system is not due to be fully functional until the end of the year, despite being approved shortly after the 2012 accident.
The MAA also found that as late as 2013, crews were forced to fax each other hand-drawn routes of flight plans in a bid to prevent mid-air collisions.
The investigation also said that bad weather played a part in the tragedy. Its findings have now led to calls for a fatal accident inquiry.
SNP defence spokesman Angus Robertson, whose constituency covers the air base, said the report was "extremely distressing for the families involved and damning for the MoD". He added: "[The report] catalogues unacceptable delays, poor decision-making and communication. There is now an overwhelming public interest case for a fatal accident inquiry.
"It is scandalous the MoD committed to a Tornado collision warning system in 1998, bizarrely cancelled it 12 years later, then changed its mind; but it was all far too late to potentially avert the fatal crash in 2012.
"This makes the tragic event of July 2012 even more distressing. The report highlights the delays of installing the system were financially driven. This is utterly unacceptable and a breach of the duty of care we rightly expect the MoD to provide and our service personnel to have."
Mr Robertson said it was imperative that all lessons were learnt from the fatal Tornado collision and its subsequent investigation.
He added: "The recommendation to install a system now is obviously welcome, but far, far too late and the recommendation for the Secretary of State [Philip Hammond] to hold a review into the procurement is not enough."
The MAA said: "As with many accidents, bad luck has to be part of the explanation, particularly in the closing stages when they were belly up to each other; a few feet difference in altitude of one of the aircraft would have created a near miss rather than this tragic accident.
"Unfortunately, the final safety barrier which would have generated awareness of their close proximity did not exist as the Tornado GR4 is not fitted with a CWS."
An MoD spokesman said the investigation had found that the lack of a CWS did not cause the accident, but was one of a number of factors which made it "more likely to happen".
He added: "The MoD is committed to reducing the risk of mid-air collisions and has developed a collision warning system for Tornado which is currently being trialled, and is expected to be introduced from the end of 2014."