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Old 7th Oct 2007, 13:17
  #2727 (permalink)  
lomapaseo
 
Join Date: Mar 2002
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Barit1

I don't have an exact list for this accident, nor (I suspect) does anyone else other than the parties to the official investigation.

And (as I used to tell my students) you cannot PROVE your case by analogy, but you can certainly use it as a powerful teaching tool.

The point to be made is that it's unlikely a single causative factor is the culprit.
Well of course I do agree with your statement above.

Some of the layers of swiss cheese are simply environmental issues that are not normally controled, although assumed as normal operating conditions In this case, weather, runway length, pilot fatigue, etc. These types of layers may possibly be controled as potential solutions to prevent future accidents simply by assuming that wrong throttle may occur yet again and that by placing restrictions in the operating enevelop of the plane an accident can be prevented in the future (not terribly practical from a commercial standpoint).

On the other hand there may be some effective layers of swiss cheese preceding the wrong throttle command that if corrected may have prevented this accident, training and prior knowledge of manufacturer's recommendations comes to mind.

So in summary, it's not removing any layer of swiss cheese, but rather selecting the effective layers to remove that prevents the next accident
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