It has always fascinated me how time produces different versions of what a coroner or court established and concluded about events. It happens all the time here when people try to rewrite the factual findings and substitute their own version of events. Generally, it is the version of facts that the court did not find but that the poster wishes they had.
Courts and tribunals are lauded when some posters agree with them and the same courts and tribunals are lamb blasted when they do not agree with some posters opinions.
I have been reading some of the major accident investigations in Australia. Particularly those that occurred when I was not in the country.
I am up to 'Transair' and I have read the voluminous PPRUNE postings on that event.
With all due respect and sympathy for all those touched by this event, the Coroner, Mr Michael Barnes, said on 17th October 2007 in Brisbane:
'I have highlighted what I consider to be a number of deficiencies in CASA's surveillance and audit of Transair and its departure from its own procedures. I have made recommendations about how some of those issues could be addressed, as has the ATSB.
That does not mean that CASA is to blame for the crash. There is no compelling evidence that if it had scrupulously followed all of its procedures and processes, the deficiencies that led to the crash would have been obviated, although it is impossible to avoid the conclusion that the risk may have been reduced.
The families of the victims, understandably, want someone to blame for their loss. The passengers were entirely blameless and their deaths have caused extensive and on-going suffering. The pilots are dead; the company is in liquidation and its chief pilot has left the country. It is tempting for those bereaved by the deaths to identify numerous deficiencies or departures from proper standards that Transair had been guilty of in the various operations it was conducting around the country and internationally for five or six years leading up to the crash, aggregate those issues into a cumulative list of failings and say that CASA should have detected them and acted to prevent Transair from operating.
With all due respect to those families, the making of scape goats in that manner is not part of my function.
I find that CASA could have done more to insist that Transair improve certain aspects of its operations but I do not believe that the evidence supports a finding that they could reasonably have stopped it from operating or prevented the crash. (My bold).
All I am saying is that bashing and blaming the regulator, in any country not just Australia, is fine when all the parties, including the operators, are squeaky clean.
Sorry about the length of the post.