Could the Clutha families ever have been satisfied with FAI outcome?

The first phase of Sir Martin Moore-Bick’s inquiry into the Grenfell Tower disaster described how the blaze began as an electrical fire at the back of a resident's fridge freezer. Behailu Kebede, in flat 16, was found to be entirely blameless, having done all the right things on being woken by his smoke alarm and spotting the fire.

READ MORE: Clutha crash caused by pilot's failure to check fuel pumps, inquiry finds 

He called for help, closed the kitchen door, alerted neighbours and waited for the fire brigade. Hours later 72 people would be dead.

What becomes more complex - and what is under dispute - is who was, then, to blame for the events of June 14, 2017. There has been outrage at the suggestion the London Fire Brigade is responsible and pleas that fire fighters should not be made scapegoats for the fatal incident.

At the same time there have been calls for the service's chief, Dany Cotton, to resign after failures from the service to alter its "stay put" advice to residents inside the burning building. Sir Martin's report makes clear that more could have been saved had the building being evacuated sooner.

The inquiry's second phase, expected to be finished in 2022, five years after the fire, will be a deeper investigation into how the fire could have happened in the first place.

Footage being shared earlier this week showed Boris Johnson in 2017, responding to concerns raised about cuts he made to the fire service while Mayor of London, with the words "get stuffed". The video of the meeting, held not long before the Grenfell disaster, shows a colleague of Mr Johnson raising the issue of a lack of fire safety in housing as a result of the cuts. Get stuffed.

It seems far too simplistic to blame the fire crews when, at the top, there was such utter disdain for the service and the resources needed for fire safety.

READ MORE: Inside Clutha pub after helicopter crash revealed as FAI rules pilot error 

At the Clutha Fatal Accident Inquiry it was clear from the start that families of the victims who died when the Police Scotland helicopter crashed through the roof of the Glasgow pub did not want the pilot to face sole blame.

Instead, they wanted to know whether there had been systemic failings at the top - was there a problem with the helicopter? Had there been problems with training or management or maintenance?

It was a far cry from the last major Fatal Accident Inquiry in the city when automatic sympathy for the driver of a bin lorry that ran out of control on Queen Street and killed six people quickly turned to disgust as it became apparent he, Harry Clarke, had lied about previous health problems.

Yet in the one case where blame did appear to sit with the man at the bottom, rather than come from the top down, Mr Clarke faced no criminal charges.

While suspicion of pilot error had been an immediate suggestion and then constant explanation almost since the day of the crash, the Clutha families, and bar owner Alan Crossan, were clear that they did not simply want Captain David Traill to take the blame for the deaths of their loved ones.

Captain Traill's fiancée Lucy Thomas was represented at the inquiry, which ran from April to August this year, and her QC, Shelagh McColl, asked that Captain Traill - an "extremely accomplished and experienced pilot" - not be blamed for the crash.

Sheriff Principal Craig Turnbull could not give her what she asked for. His findings stated that the crash could have been avoided had Captain Traill followed procedure set down in the Pilot's Checklist, realised that two fuel transfer pump switches were "off" and so not sending fuel to the supply tanks, and switched these on.

Had the switches been turned on, there was enough fuel on board to feed the twin engines and the helicopter would have made it back to Glasgow Heliport.

This is baldly put and stood out as unfair to the families who had heard evidence lead which gave reasons why Captain Traill might not have checked the switches and why he might not have responded as per the Pilot's Checklist in response to low fuel warnings.

Captain Traill was wrong to ignore the five low fuel warnings that sounded during the final flight but the court heard clear reasons - relating to issues with fuel sensors in the EC135 helicopter - why he might logically have ignored them.

A less highlighted fact, and one important to mention, is that Sheriff Turnbull also found that had Airbus included an aural attention-getter that sounded when both fuel transfer pumps were switched off, the crash might have been avoided.

So, disappointment for the families with regards to blaming Captain Traill and not anyone further up the chain.

Disappointment too at feeling removed from the process of the inquiry which they waited six years to attend.

On behalf of Mary Kavanagh, the partner of victim Robert Jenkins, QC Donald Findlay said that those who died and their families had "merited scarcely a mention". It was a sentiment repeated by those loved ones who turned up day after day to the inquiry and sat, dignified, through what must have been evidence traumatic for them to hear.

Some wanted questions put to the emergency services who had attended the victims. "No evidence has been led to show what more, if anything, could have been done to save them," Mr Findlay again. "It is submitted that this is what people would wish to know and are entitled to know."

Of course families wanted clear answers to their questions but, without a black box recorder in the helicopter, any answers were only ever going to be hypotheses. The sheriff, too, cannot be solely motivated by pleasing the victims and relatives when conducting a fatal accident inquiry. That is not his role.

For those intimately involved it is impossible to separate emotions from proceedings and emotions do not always guide us well.

However, it has been acknowledged by James Wolffe, the Lord Advocate, that the FAI system must better involve the bereaved and survivors with improved information sharing. He had pledged additional funding to achieve this, and to speed up a system whereby lengthy delays can further traumatise victims.

Sheriff Turnbull, in his Clutha conclusions, also highlight the issue of the impact delays have on those involved.

The families of those who died in the Clutha accident are not satisfied with the outcome of this inquiry but they will perhaps be satisfied with these acknowledgements.

One certainty, at the end of six years, is that the families involved deserve praise for the dignity with which they conducted themselves throughout. Those at the top must match them in a resolve to speed up and improve the system.