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Old 4th June 2009 | 08:04
  #835 (permalink)  
GMDS
 
Joined: Feb 2007
Posts: 320
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From: i don't know
There is too much fixation on what exactly must have happened in this accident. Experience shows that it takes up to 5 contributing factors to end up in a fatal accident. One might be governing, but the others, if sequential or additional, contribute the rest to make it unsurvivable. Accidents like this one, with so little hard evidence up to now, and most probably for a very long time, are extremely hard to analyze in this respect.
Another thing we see is the debating of one single factor on a general, sometimes theoretical level. Sure enough every pro has his view of the things, but even he is basically a Monday morning quarterback, as the decision during the game is required on the spot, without handy close-up replay function. Any action or decision might be the third best option theoretically, but could be the best, worst or only one in real time.
The Swiss cheese model tells us that the holes might become lined up and that we must constantly try to mitigate this. The holes might look random from all our different angles, but they might have just aligned for the poor crew in question. Their angle of the circumstances is very difficult to duplicate.
Such factors/ holes would typically be: Crew training, crew experience, crew composition, sops, aircraft design. Subsequently flight planning, severe weather, fuel/load decisions, company pressure, fatigue and on top of that your bad day and simply bad luck.
There is the tendency to try to blame one or maybe two factors, but to actively forget the others.
It is a matter of perspective and interest. Keep that in mind.
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