What happened here was that, although all the necessary actions had been identified, they were not all put into place. The worst bit for me is that someone, somewhere HAD recognised the possibility of an indident there, and then the map was "lost", and the signs appear never to have been put up.
Had they been the incident would have ended with the unfortunate death of the rider.
If everyone does what they have been told needs to be done, then the TT should run smoothly. Sometimes we all cut corners, thinking it's only a little thing, it doesn't matter, but the consequences can be hugely out of proportion to the oversight. The devil is always in the detail.
Haven't we all lamented the loss of viewpoints (I've sat there for 20 years and nothing has ever happened) well, this is a warning to us all. Maybe the missing word is YET.
As most of the things which came out at the inquest had already been identified by the organising committee, I am sure they have devised ways of making sure everyone is vigilant and conscientious now.
Our role is to obey the signs, and if we see something that gives us concern us, bring it to the attention of a marshal or an official. We ALL need to be aware of safety, if the TT we love is to go on.