All very depressing, but it would seem to be an integral part of human nature when it comes to the blame game. By the same token, we should recognise that there does not always need to be someone to blame when something bad happens.Unforeseen and unimagined things do happen. People do not always observe and adhere to rules and procedures, Errors of judgement can be made innocently and in good faith,
As the name suggests, Duty holders have a duty , which includes, inter alia, the duty to act diligently and professionally, to exercise their professional judgement to the best of their ability, and to pay due care and attention to the matters in their charge. You can pick different words if you wish, but there is no getting away from the fact that they cannot be expected to be perfect in every respect at every moment. It should also be recognised that decisions are rarely taken against the standard of achieving zero risk. ALARP is much bandied about, but stop and think what it means ; As Low As Reasonably Practicable.Clearly there is a degree of subjectivity involved, and reasonable people could easily differ as to what is reasonably practicable without acting unprofessionally or dishonestly.
Taking as an example the decision to require Hawk Pilots to perform PEFATO training on a regular basis. How might a reasonable duty holder have gone about reaching this decision? Obviously, as a single engined aircraft, loss of engine power at takeoff is a serious problem, and whilst with modern equipment far from an everyday occurrence, still a measurable risk of it happening. What are the consequences when the risk occurs? Best case, pilot manages to land safely, next best crew eject safely aircraft crashes into an empty field, worst case, aircraft crashes into a built up area with crew aboard. Clearly the last of these is catastrophic, whilst the first is but a minor drama, and an outcome whose probability can be dramatically increased by pilot training. The Duty holder diligently and properly arrives at the conclusion that pilot training is warranted, and next sets out to determine the form this might take.
Simulator training is attractive, as it can be undertaken without exposing the pilot or the aircraft to the real risks associated with reducing power in an airborne aircraft for a PEFATO drill, so simulator training is mandated.
The duty holder is however concerned that this is not enough, and agonises over whether "real" PEFATO drills should be mandated. Deeply mindful of the Meteor asymetric landing fiasco, they are faced with trying to evaluate whether the risks from the training are greater than the risks they are trying to mitigate. Any attempt at such an evaluation requires the duty holder to make an estimate of the likely number of engine failures at take off and compare it with the likely number of casualties from PEFATO training. Given the size of the Hawk fleet, its length of service, the frequency with which PEFATO drills would be flown, and the number of things which could go wrong, it is inconceivable that the duty holder could have concluded that there would be no casualties from the introduction of mandatory PEFATO training.
The fact that we are now dealing with just such a casualty does not automatically mean that there is a duty holder to blame. Rather, we may be looking at an accident which was anticipated when the decision was made to implement PEFATO training, and however tragic, it does not negate the validity of the original calculation.
As it happens, there is much about this particular incident which in my view calls the duty holders into question, but I did want to offset some of what I felt was a drift in this thread towards the position that there was always and automatically a duty holder to blame.