Alf,
This is a very well-crafted report which covers a range of issues from
different angles; it should be safety reading for everyone, for individuals,
operators and regulators to heed and learn from – to do something. It
illustrates how there can be many relatively minor or insignificant aspects
within normal operation or founded by training and procedure, which together
with some ‘latent’ traps, come together when we (everyone) might least expect
it.
The report does not conclude root cause or seek blame, but it does
provide strong and timely pointers to safety actions, some which have been
identified previously. Lack of activity in these areas suggest that the industry
has been riding it’s luck, and to some extent did so again here – there could
have been many fatalities with any one of several minor differences in
circumstance.
The industry is facing a major problem with determining actual
runway conditions and thus a safe landing distance; there are problems of
measurement, reporting, communicating and understanding – airport, ATC,
dispatch, training, and crew.
Human activity in these areas is always a
problem, so perhaps this is a reminder not to rely on them too much and ensure
that the defences against ill-chosen courses of action have greater depth.
..
Precisely.
(post hilighted again because, sadly in this forum, the more important details get lost amongst all the chaff
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