CONF iture, you make a strong case for the sorry state of safety in our industry, but perhaps a bit one sided.
An accident investigation authority can make recommendations to a manufacturer for system change; these may or may not be accepted.
Changes can be proposed and mandated by the certification authority, although this action is unlikely without consultation with the manufacturer and more usually with other certification agencies.
The manufacturer did advise operators of the accident and the most probable cause; previously modifications had been proposed but not universally installed.
The industry and each operator have responsibility for maintaining safety, and thus with knowledge of previous problems, modification or procedural action could/should have been taken.
How was Congonhas different; for the reported conditions a normal operation may have had marginal landing distance safety factors. If the runway was flooded, then with CS25 rules, reverse could be claimed, but if not available then the landing should not be attempted.
We do not know what the crew knew or decided before landing, but on scant evidence there appears to be erroneous contributions from both the human (crew) and the wider organisational system.
We should not focus on a single entity for blame – fundamental attribution error. Nor be influenced by hindsight bias; a more open view might be that the industry still has much to learn from accident investigation and who and how remedial activities are implemented.
“You can take a horse to water, but it may not drink.”
Why System Safety Professionals Should Read Accident Reports.
What Can You Learn from Accident Reports?