Originally Posted by Big Pistons
I respectfully disagree. The accident chain started with the deliberate decision to continue the approach below minimums. By removing all of the altitude margin they made a crash inevitable when the engine asymmetry caused the fatal roll.
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You are correct in the fact that there are many lessons to be learned from this terrible tragedy but for professional pilots the primary take away should IMO be Do not descend below minimums EVER.
I haven't had time to read all of the report nor many of the recent posts on this thread yet but it seems to me that suggesting that the accident chain started on the aircraft is a huge misunderstanding of the events. The chain started way, way before.
There is no question that the crew made errors on the day of the accident. The report offers proposals to explain some of their actions. They were at the sharp end and sadly, along with some of the pax, paid for these errors with their lives. But the most important question is why/how they were put in a position for which they were so poorly equipped and supported. In the report there is a catalogue of weaknesses in the systems that put the crew where they were and which should have ensured that the Operator/Owner supported better the people at the front end. These weaknesses were there either because of incompetence or deliberate by unscrupulous people running the various organisations.
Yes, you may well be right that if the crew had not busted minimums, the accident may have been prevented. But if the chain of events had been broken at any opportunity - and there were many - the accident may not have happened.
Let's go right back to the start, or at least one starting point - Manx2, the virtual airline. You cannot blame anyone, let alone someone who thinks they are a businessman, for exploiting loopholes or grey areas in a legal system.
The report illustrates that there were many clear and, in some cases, blatant breaches of law and regulations but the existence of a 'virtual airline' wasn't one of them. As I read it, Manx 2 set themselves up as the ticket-seller and sold tickets; something that appears to be entirely legal. At the root of it all is the European Commission's desire to have a common and mutually recognised set of aviation regulations but in making it all legal the failed woefully to establish an oversight framework that was fit to deal with cross-border activities. Instead, we now see most opportunities for effective oversight missed by national agencies saying 'I thought it was their job' and pointing to any one of the others in the frame.
If you've got this far, please bear with me while I continue my rant by pointing out that the European Commission was actively aided by EASA which drafted the legislation. This is an agency that is happy to develop reams of sometimes barely comprehensible regulations for all parts of the aviation system.....and also happy to pass the buck to national oversight agencies when weaknesses in the regulatory system contribute to an accident like this.
Much of the reason we have safety regulation is to stop events of this sort. So that the fare-paying passenger, who knows very little about the business of aviation, doesn't need to be afraid of getting on an aircraft because there are experts overseeing what is happening on their behalf. But in this instance, almost all of the multitude of opportunities for the regulatory agencies to challenge the way in which the aircraft were operated were wasted. So yes, the crew made mistakes, and if they had the chance to relive the day with the benefit of hindsight, I have no doubt they would act differently. But though they may have held licenses and been 'legal' up to a point they could easily control, the licences prepare people to work in an environment where the rest of the rules are applied properly - and this, most certainly, wasn't the case in this organisation(s). This crew were working at the entry level to the business, and although fewer lives may be at risk, crews at this point in their careers may well be faced with many more difficult (given their level of experience) decisions and choices to make, and very different pressures, every day than a crew in an organisation where the proper support is provided. This shouldn't be a surprise for any professional working in aviation - and the same issues exist in other sectors of the industry - and it should mean that the regulators are more rigorous (and I don't mean inspect the small operators to death) and ensure that what the crew on the day have a right to expect from the organisation they work for is actually in place.
I could quite accept an argument that the accident chain started the day that Manx2 started up. And the report identifies plenty of holes in the cheese in just the latter parts of the chain.