OK465, #32
, but don’t confuse benefit of the doubt with an understanding of various points of view.
Re First Air 737, I disagree, there could have been greater consideration, if only in supposition, and where many people ask why didn’t the FO intervene because it appeared that his awareness differed from the Capt's, perhaps this was not the required (correct) awareness / understanding; thus identifying weaknesses of in the expectation of cross monitoring.
In this accident, it appears that both crew had a similar understanding of the situation, but not necessarily the required one, which again questions the expectations of cross monitoring.
Offchocks “a Captain is ultimately responsible”. ‘Ultimate’ often infers overall responsibility – last in the defensive chain, first at the accident, etc, which is not 'responsibility'. This accident involved many powerful organisational issues; ‘responsibility’ in these areas should be considered.
“
Responsibility lies with those who could act but do not, it lies with those who could learn but do not and for those who evaluate it can add to their capacity to make interventions which might make all our lives the safer”. P. Capper, Cave Creek Commissions of Inquiry.
aa73, I dislike the ‘legal’ approach to decision making (#37); it implies searching for a way round the rules and regulations – “how can I do this” opposed to questioning “should I be doing this”, which might lead to a safer option.
This crew unintentionally violated rules; but as James Reason stated – “
it’s not the violation which gets you, it’s the errors when violating”, thus the focus should be on the origins of the errors.
Phantom Driver, you use automation (#41) – Rad Alt, Computed wind, but how accurate? Rad Alt is very accurate, less so the assessment along the runway / over the THR when you are ‘on top’; the majority of FMS generated winds lack accuracy, or have a time delay, this was covered in the report.