because they had no NVG and the procedural let down was all they had. Could that have been executed better? Possibly
All they had to do was follow the route guide and they would have been home safe and sound, NVGs only become a feature of debate because they weren't following the route guide ie descended below the notated altitude of 310', Black Rock gets a mention under Hazards, being number one on the list. A pertinent approach brief using the route guide, rather than the one given, would have flagged what they were about to execute and the hazards thereto.
At 00.10 hrs, the Commander briefed the Co-pilot on the approach into Blacksod:
‘I think we just go straight over and when we're happy enough to step it down em down below two four we'll do the approach one all the way down, let it just fly the route, get the speed back until we’re comfortable and literally just let it fly all the way round em if we're happy with the visuals on the first run-in it'll be on my side so it’ll be my landing. We’ll go in, if not we'll just do a circuit all the way around and eh we'll make sure it’s on a two four zero heading’
The let-down procedure was briefed by the Commander, with all timings and acknowledgements by the Co-pilot presented in square brackets, as follows:
‘[Commander at 00.30:01 hrs] okay let-down procedure, can I wait until we're abeam this alpha position [an apparent reference to waypoint BKSDA] here [Co-pilot acknowledged at 00.30:05 hrs: okay] [Commander at 00.30:06 hrs] and then we're going to, I'm going to select alt pre down to two thousand and four hundred feet, [Co-pilot acknowledged at 00.30:09 hrs: roger] [Commander at 00.30:10 hrs] if you're happy we're clear of everything [Co-pilot acknowledged at 00.30:11 hrs: understood] [Commander at 00.30:12 hrs] I’m going to do an approach one all the way down to two hundred feet, eighty knots, [Co-pilot acknowledged at 00.30:15 hrs: yes] [Commander at 00.30:16 hrs] eh, it might be slightly past M O [an apparent reference to waypoint BLKMO] at that moment so we'll see what, how we are height wise at that moment, so I think we'll just eh take a heading, continue on past there go back around and the aim is just to follow the route all the way round em and eh [Co-pilot acknowledged at 00.30:27 hrs: roger understood] [Commander at 00.30:29 hrs] getting the speed back as much as we're comfortable, we're aware we're going to have a pretty high ground speed on the way in. [Co-pilot acknowledged at 00.30:34 hrs: Okay]’
Having just finished reading the report there is much to cogitate upon, what I've written above re brief is merely one element in the mix of organisational failures, still would have saved the day though, length of time they had been awake would explain why anyone would be off their game.