Report?
Copy of a message I just posted in another forum:
1. Accidents are devastating to those directly involved and costly to many others.
2. Accidents should be prevented ahead of time by proper operations risk management (ORM).
3. Accident investigations should be performed professionally, and their reports written such that the knowhow obtained is useful and properly communicated to prevent them from recurring.
I am writing the following with a background including chairman of air accident investigation boards, authorized investigator of a certain state CAA, and have completed US postgraduate technical report writing studies.
4. Without prejudice, the report is written such that it deviates from what I view as acceptable standards in this important line of business. In doing so it is my impression that it fails to pass a clear message to decision makers. A proper format of accident report is for example used by the US Dept. of Transportation NTSB.
5. Excuse me for not reading throughall of it, a decision maker needs to read the main conclusions and recommendations in a one page introductory summary. I closed the report on page 7 and might have missed some info.
BUT- the inverstigation in my humble opinion failed to pinpoint the primary cause of the accident. The primary cause of the accident was the failure of the crew to make a safe approach to landing, while flying with a failed RA. A main secondary contributor to the accident is the RA system failure, but the RA or the AFCS isn't the captain, whose primary responsibility I mentioned.
6. This adds to a number of essay messages I wrote about cockpit automation problematics.