you have to look deeper at the underlying culture if you want to reduce the likelihood of the next "accident from a hitherto unthought-of cause".
I will bet there are lots of "thought of causes" that are not spoken of by anyone except perhaps over that Pint or two in quiet smoky Pubs someplace.
If you step back and think about in as an objective manner as you can.....there are so many vested interests at play in the mix that only a completely independent investigator could begin to poke Lances into all the Sacred Cows that exist.
If One points out a shortcoming....immediately there shall be a defensive response from the folks holding jurisdiction over it. Some will yell about costs, technical problems, jurisdiction, research results, manning, training, and dozens of other excuses.
Just work your way through the 225 situation beginning clear back to when the Design Engineer first put pencil to paper.....and work your way forward till today. Connect all the Dots and mark all the links that lead to issues that affected how we got to where we are today.
This is just one example of how complex and convoluted the path can be and remains yet.
I am not singling out the 225.....just using a recent topic as an example.
What we don't want to get into is a Finger Pointing exercise where it looks like a circular firing squad. What we want is every player to be frank and honest about how to improve what they do and improve the way they interact with all the other players.
The CAA and
other Authorities darn sure need to improve things at their end....as we have seen some glaring examples of Design Testing and Certification failures. Manufacturers also need to improve the way they do business.
Operators need to look at their Training and Operations policies, procedures, and techniques.
The Oil Companies need to improve the amount of money they are willing to spend to improve infrastructure and safety.
Above all....each Individual needs to do some Soul searching and find the courage to start speaking up when something needs to be improved.
The CAA and other authorities shall not clean their own houses....just as the Manufacturers will not...or will the Operators or Oil Companies until they are convinced of the absolute need to do so....be it by popular acclamation or pure embarrassment after being called out in public by the independent investigation.