An alternative interpretation of the report is that the use of either process could result in a flawed outcome; same outcome, no difference, equally deficient.
The effectiveness of either process was only as good as the bounding system allowed, and apparently no one questioned the overall organisational system - FAA or Boeing.
Similarly the report could suffer flaws or influences of the larger system; who holds the responsibility for overseeing the totality of the regulatory system: - the highest levels of the governing administration, throughout and to each and every individual in that system.
The report was downwards focussed; whereas looking upwards might have provided a better balance in the findings.
“...no matter how hard they try, humans can never be expected to out perform the system which bounds and constrains them. Organisational flaws will, sooner or later, defeat individual human performance.”
Gary Parata of Air Nelson
“Responsibility lies with those who could act but do not, it lies with those who could learn but do not, and for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer.”
Phillip Capper – ‘Systems safety in the wake of the cave creek disaster.’
Last edited by alf5071h; 18th Jan 2020 at 08:56.