A military report into the crash that killed a Red Arrows pilot said more could have been done to identify the risks to the safety of the elite unit.
Flight Lieutenant Jon Egging, 33, from Morcott in Rutland, was killed when his jet crashed following a display in Bournemouth, in August last year.
At an inquest last week, a coroner ruled the likely cause of the crash was that Flt Lt Egging was suffering "ALOC" – almost loss of consciousness – due to being impaired by a maximum G-force of 6.3.
A report into the incident by the Military Aviation Authority (MAA) found supervision of the famous aerobatics team was lacking.
The military panel said the issue of the oversight of the unit was made more significant because supervisory failings had been highlighted in a report on a mid-air collision involving the Red Arrows in Crete, 18 months earlier.
The report by the MAA said: "The loss of Flt Lt Egging in the circumstances of this accident was both unexpected and, moreover, tragic.
"However, with the benefit of hindsight, the potential for such an accident could have been identified more clearly in advance and more effective mitigations put in place."
It stressed elite units such as the Red Arrows "require a healthy degree of external oversight and assurance to mitigate the chronic risk that over time 'we're different and we do it this way'".
The panel said there were potential risks "across a number of areas".
It found: "There is evidence the questions asked over time by the supervisory chain were inadequate in breadth and depth.
"Taken together, they raise questions about the quality of supervision of RAFAT (Royal Air Force Aerobatic Team) at a number of levels in place at the time of this accident."
The service inquiry following the Crete crash had highlighted shortcomings in supervision, standards and risk management.
It said the chain of command accepted the recommendations and indicated a clear intent to implement them.
But the panel said: "It is apparent from the findings of this inquiry that they were not acted on as comprehensively as they might have been." It said much was done after the Crete accident to manage risk within the display.
But this did not include a sufficiently robust examination of some relevant categories of risk such as G-force-induced loss of consciousness. However, the panel said: "Since the Bournemouth accident, considerable work has been undertaken by the current chain of command to rectify the shortcomings identified.
"It has resulted in 'sharper focus on risk management and a renewed emphasis on standardising operating procedures'.
"Continued investment in these areas can only serve to underpin RAFAT's culture and hard-won reputation."
