I presume the taps weren't opened unless the crew thought they were on the CL.
The "procedure" for lining up had been followed, but the crew member made an error, probably a perceptual error.
WHY did the crew member make that error? THAT is the question.
The ATSB acknowledges some criticism that their investigation model focusses on "organisational" factors, to the detriment of the acts and omissions of the individual. If the addition of another f
ing procedure is the best recommendation/observation that comes out of this report then I suggest the criticism is valid.
