A recent Australian "Flight Safety" magazine review of the accident.
http://www.casa.gov.au/fsa/2004/dec/25-31.pdf
I repeat a section of the article because it focuses on the systems failures which are a feature of the modern day "Why the !@##$ did that happen" investigation process. Its does not always hang on the front seaters who pull the trigger. Its others who quite often have loaded the gun.
A systems story
In his conduct of the inquiry, the Royal Commissioner showed considerable foresight in taking into account the system failures that allowed the accident to develop, rather than simply concentrating on the immediate operational factors that triggered the disaster.
Mr Justice Mahon in fact foreshadowed by 10 years, the reasoning in a Commission of Inquiry, appointed by the Canadian Privy Council, on a fatal Air Canada F-28 take-off accident in freezing conditions at Dryden, Ontario, in March 1989.
That Commission found that although the captain bore responsibility for the decision to takeoff, the “system” had failed him, placing him in a situation where he did not have the resources to make a proper decision.
The “system” also failed the crew in the case of the Mt Erebus accident. Although the judicial processes of its Royal Commission overrode technical issues that are traditionally the prerogative of the pilot-in-command, it introduced the concept of “system safety”, putting air transport managers on notice that they too have a responsibility for the safety of their flights.
In today’s highly technical, complex and computer-controlled airline operations, it is clearly not reasonable for pilots-in-command to bear all the responsibility for the safety of their aircraft – the traditional concept of command inherited from countless generations of seafaring experience.
Modern air transport by contrast, with its various administrative, technical and operational functions, is a complex socio-technical system requiring constant vigilance by all the parties concerned.
Throughout the western world today, the concept of enquiring into this “total system” has become the standard in aircraft accident investigation. The Canadian Commission of Inquiry in 1989 is generally regarded as the turning point for this style of investigation.
Although later court decisions questioned the way the 1979 Mt Erebus Royal Commission was conducted, perhaps Mr Justice Mahon was simply ahead of his time.