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Old 6th Jan 2010, 13:38
  #281 (permalink)  
PEI_3721
 
Join Date: Mar 2006
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Many posts are searching for ‘cause’, which unfortunately can lead quickly to blame.
The alternative is to consider the many possible contributing factors to this accident, irrespective of cause. Each contributor is a risk, similar to those encountered in daily operations; these risks have to be managed to assure safety.
Thus the lessons which might be learnt from this accident will probably come from the risk assessments associated with the decision to land and the handing of the flight thereafter. We should focus the discussion on the components of the risk assessments, the possible contributing factors, and how these are managed; the what if’s – constructive speculation without seeking blame.

Risk assessment has dependencies in situation awareness and guidance from SOPs and company safety assessments; the classic individual and systematic views of accidents.
If an operator has overlooked pertinent issues such as wet / tailwind / non grooved / rubber contaminated runway surface, there should still be a later line of defence via the crew – people can create safety.
What this accident might be telling us, like similar recent overruns, is that both the system (organisation) and individual risk management processes are weak; we, the industry and individuals, appear to be taking too many risks.
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