it would seem neither were being done.
Indeed, but
why? And what system or methodology or rule would help save others from being drawn into the same position. I know we think it can't happen to us, but it
has happened.
We need to know
why there was no monitoring, so we or others do not fall into the same trap. We all know we can't do it, but I want to know the crew flying my family won't suffer the same mistakes.