"The accident was the culmination of airline culture, lack of training, lack of observance of SOP's by all crews, unclear briefings (the reason for lack of SOP observance, hell, the airline even used the lack of SOP observance as publicity). Captain Collins and crew unfortunately pulled the trigger of a gun manufactured and loaded by many others. A seminal accident for the James Reason Swiss Cheese model. RIP all."
That would be the most accurate precise account of this tragedy that I have seen . It does not agree with Mahon's findings, which is why this question has been raised so many times.