I have taken a keen interest in watching the enquiry quite often.
What came across was incompetence, disregard, arrogance, inability to remember, lack of awareness of their own responsibility, callous disregard for thinking of anyone but themselves, self-protection, lack of insight or even care as to how their actions may be perceived, off loading of responsibilty, denial of any consequences for doing their job badly, being wildely overpaid beyond their competence, complacency, mediocrity and a complete and total lack of imagination, creativity or moral obligation.
And in all this lives were lost, families ruined, careers ended, relationships collapsed, and trust in the system completely destroyed.
I really do hope the investigation gathers pace and justice is served, otherwise it will be more of the same forever... what a depressing thought.