A Sukhoi superjet 100 is missing

[grizzled]

PEI 3721

Sometimes it's just not worth the effort...

If fullforward truly believes that this accident was caused solely by the Captain's actions – and his "psychiatric factors";
and if BOAC truly believes that the lesson here “is simple and clear - know where you are, and if you are not sure, get the **** out of there”
then it’s likely nothing you or I or anyone else writes will change their minds.

The notion of accident prevention through lessons to be learned and the resulting widespread advancements in the real benefits of proactively examining contributing factors (such as culture and human factors) seems to have left a few people behind. Accident investigators, safety professionals, and most professional pilots the world over have come a long way in the years since fullforward and BOAC’s view of things was the norm.

A few simple “Whys” exposes the inadequacy of the simplistic and problematic “pilot error” view:
Why did the aircraft end up in that specific (and inappropriate) place?
Why were none of the flight crew situationally aware? (Or, if aware, not vocal or assertive?)
If the TAWS was ignored (or disabled), why?
If the vis was so reduced as to affect the ability to remain VFR (or VMC) why did the crew continue flight in an unfamiliar area at that altitude?
If the aircraft deviated from its flight plan, or its intended and briefed activity, why?
There are many other “whys” in this (and every) case. (Including, for instance, several related to ATC).

The answers to such questions will expose factors that need to be addressed to prevent a recurrence of a similar accident. One major reason aviation is as safe as it is, is as a direct result of such processes in the review of incidents and accidents. (That fact applies equally to the medical (surgical) profession and other safety critical endeavours.)

One cannot expect to reduce incidents and accidents if one does not examine each of the factors or actions that, if removed or amended, would have prevented the accident.

veteres canes somnum