Conpetent Personnel and Procedures
There is no doubt that everybody involved in the incident was properly qualified and certified. However, even people judged competent by having the proper qualifications and certificates need to constantly exercise their skills to remain fully competent. Where a person is removed from their area of competence for other duties, they need to undertake a through reorientation to return to ir irrespective of the limits of certification. In the case of combination of lack of familiarity, awareness, stress and perhaps tiredness appears to have made a major contribution to this accident.
There would appear to be a significant number of near misses that occured before this accident. It is important that all near miss report are scrutinised and appropriate action taken promptly to avoid the top event from happening.
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