I couldn't agree more.. however, if the coroner is trying to find the cause of a death caused by an aeroplane accident, then surely finding the cause of the aeroplane accident is going to be a critical factor in finding the cause of death, is it not?
Could not agree more.. but there is one thing we all miss in this.. and that is human factors - something which wasn't taught even when I did my ATPL theory (well, nothing like it is today), which, admittedly, was a flippin long time ago.
As a young an inexperienced pilot, I could not understand why people flew into terrain, barring some inforeseen emergency or weather event. However, as an older and more experienced pilot, I did find myself afflicted by pressonitis - twice - you would have thought I learned the first time..
Both times were purely self-inflicted, but the second time, there was an external influence. The first time, which has been published in Aussie Flying and Pilot (UK), was where I ended up so frustrated, I pushed on regardless.. and the only thing that saved me from driving a burning hole in the ground was that I may not get the rental back in time for the next renter - not the fact that I would have left my partner and two primary school-aged children behind. Diving home from the airfield was when I realised that.. and writing about it now still sends shivers down my spine.
The second time, I took a look at the weather and even though it was well below my now VFR only minima, I thought it looks good enough.. and I pressed on. I won't go into the reason why, but it blinded rational thought.. and I knew it did, but still pressed on. The reality was, I didn't want to dissapoint some people who were very important to me - my family. Imagine how disappointed they would have been if I drilled a smoking hole in the luscious British countryside (as it was then.. looks a bit brown at the moment).
I am well trained, have had all manner of safety requirements drilled into me, and am normally of fairly strong will. Sometimes, the holes in the Swiss Cheese aliign well before the flight starts.
I have no idea how the airline the pilot flew for operates, nor what commercial pressure the pilot was under. But I do know that sometimes we put ourselves under pressure and mixing that with confirmation bias can lead to a deadly cocktail. The second time I found myself in a pickle over pressonitis, I ended up luckily sandwiched between two layers of strataform cloud, about 200' vertically separated. In the UK, you can normally rely on the military for vectors to a close by airfield, but the closest had been sold off, and was a housing estate.. the nearest was about 100nm away. I made a beeline out to a sparesly shipped part of the English channel, wedged between these two layers until I breached French airspace, were, amazingly, the clouds gave way to clear blue skies. I tracked the Freench side of EGLL (line between French and English airspace), until clouds thinned on the British side of the line. In the drama I forgot to ask ATC to relay to the destination airfield that I was turning back. Not only that, but do you think I had a lifejacket on and the life raft ready to be deployed? My partner waited at the destintion airfield until an hour after I was scheduled to arrive and without a word, raced to my son's departing to Europe on a school holdiay - the event I was prepared to die to miss, apparently. My partner was in tears, in the full knowledge I had perished.. But, if I had, no ATSB, AAIB, NTSB, Coronial Enquiry could have really established anything.. because they don't know what was going through my head at the time. And while you may judge, you don't know, either.
These are two occasions in flying that I do not deserve to have survivied. But, as aligned as the holes in the Swiss Cheese were, they weren't perfectly aligned.
Having trained in Australia, UK, US, Canada, and Germany, I can say Australia is as good, if not better than those. I am sure the pilot would normally implement her training - from the reports, there is no reason not to suggest otherwise. Also, there is no reason to suggest that had she made it to pick up her passengers, she would have conducted the flight in a way that would have resulted in their demise. We don't know what happened on that flight and we never will. That is the reality of most of pilot error accidents. I will not say it is pilot fault until I can read their minds.
May she rest in peach and all those affected receive my sincerest condolences.