Originally Posted by 22/04
at least this one appears simple and not a system failure - an error.
I find it disappointing that we might draw this conclusion and believe that an investigation is complete. There may well be more behind the incident - asking 'how was this allowed to happen', or maybe 'how did the system allow this to happen', may elicit a variety of contributing factors which could be improved. For example, was there something in the phraseology used by ATC or the pilot which was ambiguous, is this an isolated incident or have there been similar occurrences in the past at this airport, were there any pressures on the crew of the HPJ which might have encouraged them into a 'go' mindset, have any HPJ flights generated any similar incidents in the (recent) past. Any of these - which are all elements of the 'system' - could be a latent weakness (hole in the Swiss cheese) which could be addressed.
Of course, it could just be an error - one of those unexplainable things or decisions that we all do from time to time - and completely out of character for the individuals involved. But without a proper investigation, no-one will ever know.