Anyone who relies 100% on the Mahon report and considers the crew to be 100% free of responsibility (I will not use the phrase 'blame') has their head in the sand as is anyone who believes the Company is without responsibility. My problem with the crew 'is blameless' angle is to accept this is to accept that the crew of an aircraft are merely passengers who have no input or influence on the outcome of a flight i.e. you believe that given the flight plan change and the whiteout conditions this crew were crashing on that day no matter what, it was destined to happen and every person on that aircraft was dead the moment it departed. The fact is that there were multiple opportunities to avoid this crash:
- if the crew had taken heed of the McMurdo controller who advised the conditions were not suitable, due to cloud and whiteout, for sightseeing in the area then the crash would have been avoided.
- if any of the crew had questioned the relative position of Bird Island then the position error could have been picked up.
- given the inability to see any of the expected landmarks in VMC if any of the crew (some of who were trained navigators) had plotted a position on the chart or atlas the crash would have been avoided.
- if the crew had decided that given their unfamiliarity with Antarctic operations they were just going to follow published procedures for let down below MSA instead of opting for a figure eight descending pattern in VMC when the CVR shows they weren't 100% certain of their position then the crash would have been avoided.
- if the crew had initiated a climb to above MSA at the first instance of doubt being expressed as to their situation the crash MAY have been avoided.
The Company had multiple systemic and organisational factors that contributed to the crash, the crew decisions and actions on the day contributed to the crash. The aftermath was appallingly handled by the Government, CAA, Airline and in my opinion Mahon, anyone who has been involved in safety investigation knows that we are not trying to allocate blame, we are trying to identify the causal factors that contribute to the incident and then see if procedures or knowledge can result from the investigation that may help prevent a similar incident in the future. The lack of a thorough and balanced report in this case goes against all best practice.