Originally Posted by
safetypee
An extensive report; comprehensive and thorough to the point
The report states that the PF had been working 12 hour days for the three weeks before the accident, flew out to the operating location, had three days of acclimatisation in theater and was then sent off for the accident flight, the first of the crews rotation.
In the three day acclimatisation period they completed a handover, theatre read-in and mission planning.
The PF was unable to remember any details of the handover brief, nor did the PF or PNF manage to commit either the aircraft parking location or take off time to memory.
The use of the term "consistently fast" on the approach, which the PNF called out twice, is quaint. Maybe "approach speed was never stabilised"? That's also a good indicator of something...
"The panel concluded that fatigue was not a factor"
It appears that the definition of fatigue used now extends to 'they had a good sleep the night before' in a single section which considers fatigue through the narrowest of windows. To my reading, the rest of the report is littered with indications of significant fatigue factors.
The report is also spectacularly verbose, I opine.