Nick has a point and I usually am the first to complain about accident reports that cannot explain the cause of a crash that kills the pilots and then goes on to "blame" the pilots.
This is just another of those occasions I fear. It is evident the pilots played a role in the final outcome...the aircraft flew into the water. There was no distress call, report of a malfunction, and the circumstantial evidence fails to point to anything other than CFIT.
I look at this tragedy as I do most...what can we learn from it...and how do we prevent another one from occurring (if at all possible).
One does not have to go very far to wonder how long the CVR had been installed incorrectly and seemingly inoperative since that point in time. If it had been tested and been working correctly, the investigators would have had a much better chance to track the crew's actions for the half hour prior to the accident and maybe know what configuration the autopilot and RadAlts were in and what the pilots were doing...or not doing as the case might be.
What could the pilots have done that would have set them up for this to happen? Did the investigators interview other crewmembers and determine how the PIC/SIC normally operated the aircraft....autopilot configuration, RadAlt setting procedures...altitude callouts and such. Was there a discussion of the approved procedures that would surface a potential problem in the cockpit procedures used by the company?
The company in question is in the process of merging two company operations into one.....did that play a role in this accident? Did the NTSB review training procedures and crewing decisions to see if there are any systemic problems in that regard? With recent shuffling and reassignment of personnel in the Chief Pilot, Training Department, and Base Management...did effective training take place or did something happen in all that turmoil?
What was the maintenance history of the aircraft? Any autopilot problems in the past? RadAlt problems? What was the deferred defects for the aircraft?
For Nick's sake, even if we accept it was Pilot Error.....the question has to be....what was it....and how did it happen to a very qualified and experienced crew?
For the dead pilots sake, did the NTSB, FAA, and other investigators merely pick over the carcass of the helicopter and only the information directly linked to the event or did they look at it with a view to determine the total situation that applied to the environment that the flight took place in, and consider ALL of the possible factors?
What does AVAD cost for a S-76? That alone could have prevented this one in all liklihood. That one last backup system that makes up for a human mistake sure seems cheap insurance after the fact.