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Old 1st February 2010 | 02:02
  #2576 (permalink)  
safetypee
 
Joined: Dec 2002
Posts: 2,765
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From: UK
so what was the reason for the crash?
“Accidents arise from the unforeseen and often unforeseeable concatenation (linking) of diverse events, each one necessary, but singularly insufficient”. - James Reason

Look for the contributions which are part of everyday operations – those we take for granted, but might not fully appreciate the risks; e.g. ATM patterns, training crewing, use of automation, instrument scan, systems knowledge, etc, etc.
Then consider the unique event(s) which enabled these weaknesses to combine; and the ‘unsafe act’ (or inaction) which triggered the route to the accident – issues of human performance, didn’t see ‘it’, didn’t think of 'it' at the time, etc, and the likely reasons for these.

There’s no ‘cause’, only contributions; perhaps a significant one is the industry’s complacency in accepting operations which are too close to the edge of safety – they have become the norm, whereas each requires continuous risk assessment for the expected task and situation.
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