Thanks for the rferesher bubbers on the relay and CB'S.
Stated well, unanswered questions remain.
The Flight crew were the last defence in James Reasons Causal pathway, swiss cheese, yes its been discussed before,
Did the Spanish and European Air Transportation system fail the PIC and Flightcrew of JK 5022 ?
Is there going to be a commision of inquiry in the aviation system mandated by the Spanish ( EuropeanJAR ) judge in this ongoing case ?
No matter how professional flight crews can be and trained , can they be expected to outperform the system ?
One of the things that came out of the Dryden report is how profit and commercial pressures can take precedence over safety. Although companies state that it is primary.
What has changed and improved in the Aviation system since the accident in Dryden 1989 ? It appears that some lessons have not been learned
As per a report from the Rutgers Scholar perhaps the the Reason model can be improve upon,
" However, the Reason model does not fully account for the detailed role of the organizational system within which design and management decisions are taken and through which the consequences of such decisions are taken forward. That is, the Reason model, in its current form, fails to provide the detailed linkages from individual to task/environment to organization beyond a general framework of line management deficiencies and psychological precursors of unsafe acts. A review of the safety literature reveals that there is a gap between bottom-up approaches which start with the analysis of errors and safety events and top-down approaches that address the system from the level of the organization. Pidgeon and O’Leary (1994) note that if safety analysts do not understand the link between practical safety management initiatives and an organization’s safety culture it is impossible to begin to design initiatives to improve safety management practice except on a purely ad hoc and pragmatic basis. "
Below are the Organizational Factors in the Dryden Air Ontario Accident.
See any similarities ?
What about Deficient Inspection, Auditing and Control, Deficient checking, inadequate purchasing of Spares.?
Figure 2. "Organizational factors" in the Air Ontario 1363 accident. Disparate allocation of resources to safety and production activities (AO/AC) Deficient handling of information (AO) Inadequate management of change (AO) Deficient inspection and control (TC/AC) Deficiencies in operations and maintenance (AO) Inadequate purchasing of spares (AO) Deficient management of the F28 programme (AO) Low motivation (merger) (AO) Deficient lines of communication between management and pesonnel (AO) Inadequate policy-making (TC/AO) Deficient scheduling (overcommitment of the F28) (AO) Deficient planning in the introduction of the F28 (AO) Deficient monitoring and auditing (TC/AC) Goal-setting (failure to carry properly states' goals into deed) (AO) Deficient checking (TC