Culture
My condolences to the family's of the 2 that lost their lives.
There is a lot to be said and gained by have the right "culture" within a company.
A good Culture in a company starts from the top down, with the one's up the top embracing and establishing good systems and procedures. Open communication, proper SOPs, good feedback to staff and top management adding value to all this by beleiving that safety is the primary task. Not money!
The Power Distance (PD) relationships of some company's is very questionable. There have been operators in very recent times coming to greif with PD issues that more than likely helped the holes in the swiss cheese line-up.
Good CRM pays dividends for the company's that take it seriously. CRM is more than a "tick the box" exercise for CASA, however in Australia it seems to be the way company's generally perceive the exercise, and it "costs" money!
There is much more than can be written here.
It is a shame when accidents happen and lives are lost.
1. Safety
2. Passenger Comfort
3. Schedule
4. Profits
Many get the order of priority wrong when making decisions.