Key Safety Issue(s)

The hierarchal "chain of command" system in place at the time of the accident did not always provide for effective flight crew resource management. Additional training was identified as being needed to ensure the flight crews recognized the value and merits of flight crews breaking down the more formal hierarchal structure. This approach leads to a more participative and collaborative process to ensure that all members of the flight crew feel free to speak up and provide the captain with all relevant information relating to the safety of the aircraft.

Back to top