In QF1's case, if there had been fatalities, the sod in seat 0A would have been legally required to carry the can, CAR 224 notwithstanding.
It does make you wonder where the guy in 0A does sit, given the comments from the report. Bolding mine.
Significant latent failures
Significant latent failures associated with Qantas Flight Operations Branch activities were:
• Company-published information, procedures, and flight crew training for landing on water-affected runways were deficient.
• Flight crew training in evaluating the procedural and configuration options for approach and landing was deficient.
• Procedures and training for flight crew in evaluating whether or not to conduct an emergency evacuation were deficient.
• Procedures and training for cabin crew in identifying and communicating relevant information during an emergency were deficient.
• The processes for identifying hazards were primarily reactive and informal, rather than proactive and systematic.
• The processes to assess the risks associated with identified hazards were deficient.
• The processes to manage the development, introduction and evaluation of changes to operations were deficient.
• The design of operational procedures and training were over-reliant on the decision-making ability of company flight crew and cabin crew and did not place adequate emphasis on structured processes.
• Management culture was over-reliant on personal experience and did not place adequate emphasis on structured processes, available expertise, management training, and research and development when making strategic decisions.
Responses to the pilot survey, along with information obtained during interviews, indicated that the Qantas One flight crew were not atypical of most other company B747-400 pilots. There was, therefore, an unquestionable link between the performance of the crew and the company flight operations system in which they trained and operated
The flight crew did not use an adequate risk management strategy for the approach and landing. Given the minimal level of procedures and training provided to the crew regarding landing on water-affected runways, they were not equipped to appropriately handle the situation they faced. It is, therefore, unreasonable to expect the crew to have developed an adequate risk management strategy for the approach and landingBoeing's opinion was not sort until after the event.
Again from the report
Boeing - we do not advocate intentionally increasing brake temperatures as a means to increase carbon brake life. We have concerns that such techniques could result in increased occurrences of fuse plug melting and dispatch delays for brake cooling. Additionally, some of the techniques we have heard discussed, such as reduced landing flap settings and the use of idle reverse thrust, have a negative impact on airplane stopping performance. Therefore, these techniques are not recommended as standard practice…
Boeing did not support the use of idle reverse thrust as a standard practice for normal landings or for increasing brake temperatures of carbon brakes. Further, they were concerned with the human factors implications of having idle reverse thrust as the standard practice
There is no evidence that Qantas had sought Boeing’s opinion regarding the safety impact of the new procedures and their potential effect on carbon brake wear. Management personnel agreed that Boeing’s opinion on such issues would be useful, and that they would normally consider the manufacturer’s opinion before changing procedures. Boeing has since stated that it does not support the use of idle reverse thrust as a normal procedure as it increases landing distance. It has also stated that modified braking techniques alone would produce almost as much reduction in brake wear as the combined effect of the flaps 25/idle reverse procedures.
• The performance differences between idle and full reverse thrust, and between flaps 25 and flaps 30, were not fully examined. Such an examination would probably have highlighted the significant differences in landing distance on wet or contaminated runways using these various configurations.
• There is no evidence that a systematic attempt was made to identify all the situations for which flaps 30 and/or full reverse thrust would be more appropriate.
• The term ‘contaminated’ was used in the flaps 25 procedure but was not defined.
• There appears to have been no review of the human factors implications of the new procedures. For example, there appears to have been no consideration of the extent to which the use of flaps 25/idle reverse could become a skill-based habit (i.e. ‘ the norm’), and therefore might be used by crews when a more conservative configuration was required.
The post-implementation review of the effects of the changes was shallow, informal, and undocumented. Flight crew were asked in newsletters to provide feedback. Fleet management received limited written and verbal feedback. Although mainly critical in nature, this feedback appeared to be disregarded as the number of sources was relatively small, and many of the sources were perceived to be resistant to change. There was no method of actively obtaining information from flight crew or check-and-training personnel. It is reasonable to conclude that a more detailed and positive feedback program would have identified the strong views of many line pilots about the operational benefits of flaps 30 over flaps 25 (see section 1.7). Such a process should also have identified the lack of flight crew understanding of aspects of the procedures, such as the meaning of the term ‘contaminated runway’.
As much as some people hate the Reason model, when holes line up is it reasonable to place the entire blame (hate the word) on 0A.
The comment that it may become the "norm" seems prescient in hindsight.