Buzz B - A good point well made.
SMS is the responsibility of the Safety Manager. Ensuring that the company has a safety culture and awareness. It is also the responsibility of every member of staff, especially management to ensure those safety practices are adhered to and that line managers understand risk and safety. There were several layers of risk lined up before this accident that should have been spotted across several departments. If it was SDS in the captain, then that's just lady luck playing a bad hand, but there is enough evidence here to suggest it could have been a combination of factors that led to the accident that certainly aren't bad luck. What ever the actual cause, which will never be known for sure, it has exposed a culture across the industry, certainly not limited to LEA, that risk is certainly not being managed. We have a 'risk based oversight' system now, with 'self regulation' of that risk. That in itself is a huge risk. What's the point of regulation if the regulator turns a blind eye and fails to enforce the regulations?
In the report it refers to a risk assessment done by LEA themselves saying that it is a risk to operate the KA single crew, yet this flight, and indeed every flight they do on the King air is single crew. So not actually following there own risk assessment. And the regulator clearly thought this was OK. They also thought it was OK for a passenger to operate as second pilot, with no type rating, formal training on type, or SOP's in place for a proper 2 crew operation. This practice, is in fact illegal, but the CAA failed to either spot it, or act on it. The fact that this was actually written into the LEA risk register, and the CAA failed to spot it and act on it surely puts some of the blame at their doorstep.
An accident in a KA flying with a 'PA' from a marginal airfield was inevitable. I actually hope it was SDS, as at least the poor chap didn't know anything about it. Can't say the same for the PA though who was never really given a chance to recover the situation given his lack of training, knowledge or rating on the type.