4468 wrote:
This incident will have been a case of all the holes in the Swiss cheese lining up. Or put another way, many of the contributing factors will be present on many days, but only rarely will they ALL be. I believe it has also been termed the 'accident chain'? No big single event caused this incident, but that is overwhelmingly the case in most. Any errors are relatively small, and all well understood, which is why we attempt to 'trap' them by having procedures to combat those pesky fallible humans that we ALL ARE!!!!
All very correct except: thankfully the very last hole in the Swiss Cheese didn't quite line up this time. I can think of two ways it could easily have happened and brought the aircraft down.
1) When the cowls were ripped off the l/h engine no fuel and oil pipes were ruptured (unlike the r/h engine), so there was no fire and (presumably) the engine continued working well, giving high levels of thrust.
2) Had any of the departing cowls damaged the tailplane, possibly disabling the control surfaces.
I believe this was a very close call......