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Will the judge look any further or is this going to be another case of finding the obvious without asking why?”
A necessary and very sensible question.
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Now we can let it RIP.” #2521
So now knowing
what happened, do we leave industry/public to allocate blame by default without considering
why. No, not good enough!
We are members of a professional, well respected industry, which has an exceptional safety record. In part, this success is due to asking ‘why’ in previous accidents.
One aspect in this accident appears to be that lessons from similar accidents were not learnt – actions not implemented. Failure to ask why or implement the answers yet again might contribute to further events.
Even if the legal responsibilities are met by establishing what happened or by allocation of blame, it is not, nor can it be the way in which our industry is to progress.
In the absence of a formal report as to ‘why’, then everyone in the industry should consider what this accident might mean to them.
There is plenty of evidence in this thread and in
ASW Dec 08 that the form of human error in this accident has and will continue to occur. Also, there is evidence that a TOCWS will detect error and benefit safety.
Thus for me a lesson learnt is to ensure that the TOCWS is serviceable for every takeoff; either by checking or by use of a robust monitoring / warning system.
We may not be able to eliminate human error, but every effort must be taken to reduce the occurrence of these errors.
The industry should look closely at the surrounding factors which contribute to rush, distraction, complacency, or violation of procedures. Perhaps it is time to re-evaluate the befit and risk of initiatives such as slot times, or the ever increasing commercial pressures on the ‘sharp end’.
We are told that error is more likely in times of change, but in the aftermath of this accident, unless we change, error will prevail.