PJ2 (#2369 SMS aspects) I believe that we agree on the fundamentals of the problem, but for clarification I prefer to use ‘devolved regulation’ to describe the modern implementations of a State’s safety oversight responsibilities, instead of the generic SMS. There are many values in the concept and processes of SMS when used by an organization or individuals.
Where regulators forgo active checks of operations and enable operators to ‘self-monitor’, then there is reason for concern. Many other concerns have been outlined, but additionally the relative ‘remoteness’ of the regulator can reduce their knowledge-base and the opportunity to communicate knowledgably with other operators (and other countries). These are essential qualities in the process of continued airworthiness.
Whilst as yet, there is no evidence of weaknesses in regulatory oversight or operator SMS in this accident, there are signs of failure in continued airworthiness - a world wide process led by the prime certificating agency and the aircraft manufacturer.
There had been previous accidents and incidents involving configuration warnings and operational error. What were the recommendations from the investigations into these events? Were the recommendations implemented, and then reconsidered after further accidents/incidents – have all incidents been reported, have those reported been investigated?
Where additional system checks were required, was their effectiveness reviewed. Do all operators know of the checks and if so, are they implemented in the same way? If not how is this determined – who does the checking?
This takes us back to devolved regulation; all that the regulator might see is a statement from the operator that checks are done, without confirming that this is the case. Operators are supposedly to follow SMS principles and audit daily operations, but failure to action this is another opportunity to miss a deviation from the norm and thus open opportunity for additional error or malfunction to contribute to an accident.
More words, more questions. However, in a supposedly well regulated industry (possibly over regulated) who will seek answers relating to this accident. Hopefully the independent investigation team, providing that they are really intent on identifying a ‘root’ cause (as above) and providing the industry with something which will improve safety; something that I doubt that the lawyers will do.