What jumped out of the report for me was,
GFS had a quality system for the internal monitoring of standards within flight operations. (be there in 20 mins) There was no documented system for the proactive identification of hazards and systematic management of risk.
and
The pilot returned to work with a GFS colleague. In conversation during the journey the pilot expressed his growing concern in relation to the targets that had been set by the GFS.
Having made those feelings felt only shortly before the accident you can understand why he may have done what he did in terms of route selection, particularly if some comment had been made about his turn around previously. Also the report does not make clear that the crew KNEW it was a non emergency case.
I'm reminded of a crew where I worked being criticised by the head C & T'er when doing a annual SAR check for "wasting time" by doing a brief prior to stepping. Trip was also being used as a trainer for a back seater on his first trip. Cant please everybody it seems.
The report seems to want to hang it all on the pilot. (he screwed up despite all the training we gave him - CRM etc. Once again, as with the first quote, my humble opinion is that its time management started to attend CRM to understand the impact and effect their decisions can have.)
To quote Stanley Roscoe
The tenacious retention of ‘pilot error’ as an accident ‘cause factor’ by governmental agencies, equipment manufacturers and airline management, and even by pilot unions indirectly, is a subtle manifestation of the apparently natural human inclination to narrow the responsibility for tragic events that receive wide public attention. If the responsibility can be isolated to the momentary defection of a single individual, the captain in command, then other members of the aviation community remain untarnished. The unions briefly acknowledge the inescapable conclusion that pilots can make errors and thereby gain a few bargaining points with management for the future.
Everyone else, including other crew members, remains clean. The airline accepts the inevitable financial liability for losses but escapes blame for inadequate training programmes or procedural
indoctrination. Equipment manufacturers avoid product liability for faulty design,. Regulatory agencies are not criticised for approving an unsafe operation, failing to invoke obviously needed precautionary restrictions, or, worse yet, contributing directly by injudicious control or unsafe clearance authorisations. Only the pilot who made the ‘error’ and his family suffer, and their suffering may be assuaged by a liberal pension in exchange for his quiet early retirement – in the event that he was fortunate enough to survive the accident
There is a lot of truth in as well,
Career flying is an uptight, stressful occupation. Laymen have little conception of the pressures under which a professional works. His work is regulated to the point of absurdity by non flying management and federal officials who pretend to understand flying better than he does. He carries a thick book of rules so confusing even its authors can’t explain them. In effect, a committee of deskbound experts ride with him on every trip, instructing, admonishing, warning, watching – until there’s a problem. Then all fingers are pointed at him.
May God rest their souls.