BluSdUp et al
Dmitri Victorovitch Zotov is the NZ based air accident investigator who created the eponymous 'Zotov Error Map', (ZEM).
This fascinating technique creates multiple timelines that track back from the moment an accident occurs. Each timeline represents the contribution made to the history of the accident and includes the crew, operator, manufacturer, national aviation authority, repair station, equipment suppliers, training organisations ... everyone who made the smallest contribution even if this was many years before the accident.
I learned about the ZEM thanks to working with an expert in SMS, Dr Steve Walters. I hope this technique is used by the accident investigators looking into this case because clearly there are issues about decisions taken by those other than the crew that appear to have had a material effect on the way this flight was conducted.
David Beaty's book 'The Naked Pilot' should be compulsory reading for all those assigned to the task of Pilot in Command. It will alert them to the tendency to find a convenient scapegoat in the pilot, especially if he or she is no longer around to defend their actions. Zotov helped the accident investigators by allowing everyone involved to be included in the analysis.
G.