OK, this is a lot to digest, but the biggest failing seems to have been in identification of the suspect and communication of that identification. At no time did the surveillance team have a positive ID on de Menezes as being Hussain Osman, and the only basis for his even being surveilled (over and above others who left the block of flats that morning) was his darker-than-northern-european skin tone and subequently a report that he "looked nervous".
I find that absolutely stunning.
Because only the more positive-sounding ID reports were reported, and wishful thinking and a desperate desire not to let any potential terrorists cause another 7/7, the tentative IDs were considered as positives, and the more uncertain ones weren't actually reported to the commander (which contributed to her own subsequent failures). There seems to have been a mutual reinforcement going on, followed by outright communications failure where radios didn't work underground, and the commander was under the impression that the officers were going to detain, rather than shoot, de Menezes.
At no time was the "KRATOS" policy of lethal force (headshots) actually enacted, with the result that the firearms officers acted on their own initiative based upon over-hyped and inaccurate intelligence and their own fear of what would happen if the guy really was a bomber.
There are other failures and examples of (in hindsight at least) bad practice, but I'll end up typing out the whole report if I go too mad on those.
IMO all de Menezes did to contribute to his death was to walk toward the police and not raise his hands. It seems that the officers may not have opened fire if he had been seen to comply with the shouts of armed police that were allegedly made, in other words if he'd gone to his knees, hands in the air, he might have survived. As it was, moving forward, keeping his hands near his waist area, plus the confirmation bias of the hyped-up officers, led to his death. In defence of the officers (reluctantly), some at least do seem to have been wearing body armour and "Police" baseball caps. But should we really expect an innocent man to be able to work out exactly what to do when aggressively confronted by armed police? He didn't raise a weapon, didn't go for a bomb trigger. This "should I shouldn't I" problem is somewhat unique to suicide bombers and not something UK police have experience of, of course.
I was under the impression until now that the trigger-pullers had clear intelligence that de Menezes was their man, and that a lethal-force response was enacted. Neither seems to have been the case, and by my reading of this document, the shooters are at least as culpable as the surveillance team and the operation commander. HOWEVER, it's worth pointing out the failure of Cressida Dick as Gold Commander, to clarify the RoEs in light of the failure to identify (or otherwise if she believed a positive ID had been obtained);
In the context of what had occurred it is clear that this was more than a normal police stop order and that in those circumstances she should have said that KRATOS had not been engaged and that CO19 should not shoot unless there was an absolute justification.
There remains the inquest, and potential further prosecution of four remaining officers according to some news sites. I'm not clear on who these might be having read the report itself. I have quite a headache after wading through those 170 pages.
