69: No offense, but I can not agree with your last post. All correctly analysed and probably what happened, but throwing percentage numbers onto the crew I found somewhat disturbing. Why 60 % and not 69 % or 49 % or 33.3 %. You give yourself a disclaimer at the end, basically saying that you dont mind the opinion others since its just your personel opinion. But accusing the crew to have 90 % (why not 88.7%?) responsiblility shows a lack of fligth safety related knowledge. Lets just quote James Reason, classification of errors:
• Intentional Noncompliance
• Procedural
• Communication
• Proficiency
• Operational Decision
One of which led to the catastrophic outcome of the accident. But what about the firewalls which are in place to avoid those errors.
The holes in the defences arise for two reasons: Active failures and latent conditions. Nearly all adverse events involve a combination of these two sets of factors. So latent conditions being a part of the error chain or rather the error prevention and recognition program. We find tons of latent conditions and neither one prevented things from happening in Madrid. CRM, SOP, Maintenance, Opertional supervision, Training and so on. It correct, at the end it was the SIC who made the mistake. You might as well blame his hand who didnt move the lever.
The US NAvy developed a system called HFACS (Human Factors Analysis and Classification System) a tool developed to investigate conditions which are leading to errors based on the Swiss Cheese model.
You might know all this, but allow me to jeapordise your blame post.