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Old 8th Jan 2015, 04:24
  #2601 (permalink)  
Join Date: Jul 2008
Location: Australia
Posts: 2
Thanks Sidebar. Just reading the review however sort of backs up what is wrong with HF, its all good theory but doesn't really provide solutions.

His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization.
and then this from a reviewer at MIT:

The book is a model of organizational analysis and application of theory at multiple levels, including an ability to reveal the gaps in theory without undermining the theoretical analysis."
The ATSB HF experts are all very clever and can show you what led to the end result but it doesn't offer a practical solution. As an example QF1 went into all sort of details about flap25 and carbon brakes etc but overlooked the simple fact that if the go-around was conducted according to the manual (pressing the TOGA buttons) then it probably would not have happened.

Unfortunately accident investigation is being driven by organisational theory and bureaucrats with the end result being sub-standard reports like Pel-Air.
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