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Old 26th Sep 2012, 07:12
  #386 (permalink)  
Lookleft
 
Join Date: Jul 2008
Location: Australia
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James Reason never intended to have his model used as a template for accident investigations but it was a theory for why accidents occurred. In this accident the Reason model is a valid explanation for the poor support given to the crew to commence the flight. It is also is useful as a way of explaining how two pilots with not much experience were on the flight deck. It can also be used to explain why the rules governing the flight were not as tight as they could have been (i.e. charter instead of aerial work).

It cannot be used to absolve the PIC from his responsibilties once he realised that the weather was not as forecast and that he did not have the fuel to divert. CRM and TEM are supposed to be the defenses available to crew to prevent that last hole lining up but where were they? I notice that a lot of the PIC's advocates are silent on the decisions (and the lack of decisions when it came to notifying the Unicom of where they were ditching) that were made from ToD, other than the ridiculous assertion that a 146 that made a successful landing when faced with a similar situation proved that the PIC was not responsible for the outcome(and I'm the one claimed to be the idiot!)
This is where Reason exits the stage and CRM is supposed to enter but it didn't happen. The fact that it didn't happen is the crew and utimately the PIC responsibility. If anyone can explain the organisational issues involved in the period from ToD to ditching that were beyond the crew's control I would be interested to read it.
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