Thank you to all the Mr Hindsights who could have done better and can’t believe this happened; it did.
There’s an obsession with the outcome instead of dealing with the “Gorilla in the room”....Distraction and Tiredness (the word Fatigue is incorrectly used in the Report). These are the things we need to mitigate.
This is simply about Risk Management and Good Decision-Making; however, the system is, and never will be, perfect as long as we have humans involved in it.
A sad loss of life.