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by avar 1047 days ago
The first line in the "causes" section of the official accident investigation blames ATC.

The murder of Nielsen is a tragedy, but that doesn't mean he wasn't responsible.

2 comments

The reduction from 3 to 2 operators, the acceptance of long breaks when there were two operators so there was only 1 in the room for a prolonged period of time, the pressure to cut costs, the lack of understanding of what systems were down during the upgrade, the surprising loss of hard lines without a tested alternative, the lack of a supervisor concentrating on the upgrades at the time, the lack of appropriate assessment of the risks.

Most of it seems to come down to trying to cut costs and reduce conflict with the staff (the acceptance of the “long breaks” overnight)

None of that lands on the overworked controller trying to do 3 jobs

Those are discussed in the "systemic causes" section, but as my sibling comment notes the controller has some responsibility for those factors too.

I'm not spouting my own opinion here, just noting that what the report says is at odds with claims in this thread.

ATC being the company, its procedures, operating with limited staff, etc. Not the controller.
You're simply misreading it, ATC refers to the specific person(s) responsible at the time.

Perhaps you're tripping over "responsible", it helps to read it as "if you, future person, are in this situation, consider how you could avoid a similar accident, given your position in the system".

It does not necessarily mean "this person is incompetent", or "this person is criminally liable". That's outside the scope of such reports.

If it didn't mean that, then someone in the ATC chair in the exact situation tomorrow would need to helplessly watch the same tragedy play out in front of their eyes, would they not? Even if they'd have the benefit of hindsight in having read this report.

After all they'd be a powerless puppet strung along by systemic causes.