Living dangerously here, but when I see people die as the result of an "incident/accident", my blood pressure rises.
My worry us that the standard response to a problem these days seems to be to surround it in paperwork, rubber stamps and signatures in triplicate.
That way, the problem becomes so mired in audit trails, and all the other buzz words that are so beloved of bean counters and backside protectors, its unlikely that anyone other than a masochist will ever get to the bottom of what the original problem is, as it is now surrounded by so much irrelevant bureaucracy that making sense of the issue becomes many times more complicated than it ever used to be.
I've read a number of threads in different areas here today, and the underlying and scarily common theme seems to be the dilution of real skills and replacement of those skills by SOP's, or CAM's or just plain straightforward mountains of paper than obfuscate the problem so that it loses it's significance and urgency, until of course a significant number of people die. Then, all manner of mountains of paper are dragged out and examined to try and determine which aspect of the supervisory system failed and allowed the problem to continue.
Far better to fix the problem in the first place. A friend recently commented that the aircraft wasn't fit to fly if the weight of the paperwork was not greater than the weight of the airframe. Having seen some of the mountain that is now needed to do something like a lease return, I can believe it.
Does it make the industry safer? Does it save lives? Do we really learn from having 20 rubber stamp impressions on a piece of paper rather than one stamp at the end? Too much of what is being justified as supervision is now regrettably only backside protection to make sure that someone else can be blamed or worse when the unthinkable happens. That's not a safety culture, that's a defence against ambulance chasing legal eagles that would be better employed doing something productive.
Not a good scenario, not al all. I just hope that this the ultimate cause of this tragic event wasn't a known issue that was mired in obscurity in order to allow "the system" to carry on operating.