It’s important to remember ATSB reports are written so’s not to apportion blame, and I think discussion on this and other forums should follow that lead. While it may be that the actions and/or omissions of those on board contributed to the crash, all of those people are tragically deceased. Their families and friends may well be among us, and we should be sensitive to those people.
That said, I feel the analysis of the crash itself is perfectly adequate and has probably identified all the major contributing factors. The ATSB couldn’t afford not to be thorough in this instance, given the Pelair investigation and the public profile of the Essendon crash, questions about building approvals, etc. I would’ve liked, though, a little more discussion about how a similar occurrence can realistically be avoided in future.
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