The present day Armed Forces are run on a day-to-day basis by two Bollywood terms. "Chalta Hai" and "Bhagwan Bharose". If the Board of Inquiry (BOI) were to carry out an impartial Root Cause Analysis, the blame would go to the very top. Yes, the very top. This is a systems failure.
Most of the Service Chiefs in recent times simply lack courage. Many veterans who have spent their best years in the Armed Forces are astonished at their pusillanimity.