Yeah, unfortunately true. One red flag for the CRM breakdown on leadership IMHO was the transfer of controls from the flying pilot to the non flying pilot so he could get "credit" for the sortie during the return. In the emergency return brief, I doubt they briefed who would fly the airplane/run the radios and who would run the checklist, based on a pay issue - I doubt it even more that anyone would do that in a checkride, or be able to defend the position with a straight face. Now I wasn't there obviously - but these sorts of things typically reflect a crew that's going along for the ride rather than excecuting a well rehearsed game plan.

A more serious issue at large was the fact that these guys were in leadership positions - instructors, check airman, etc. It's impossible to say "pilot error" and walk away from this and still have any sort of credability at the higher up levels of leadership. The pilot error "might have been" the result of a culture that allowed certain norms to exist that may not have been all that normal.

Like the feds say, "Safety Is No Accident, It Must Be Planned"

I still stand by the fact that we are all fallable though. Things like this happen, very suprisingly, quite often - without the results of an accident. It's typically the leadership of one or more crew members that wake up and say, "hey, why don't we back off and make sure we aren't screwing something up here..." and the accident chain get's broken. That takes a lot of leadership in the heat of the battle, training in the right sort of human factors skills and lots of cultural support for CRM like John said to prevent something like this from reaching the bad outcomes.

David G., you have a very solid point on the human factors front. As a tax payer, I won't feel like I'm getting my money's worth unless the accident investigation also includes a really good look at the external factors that affected the decisions that were made. This accident seems really cut and dried on what happened, but we still might be able to prevent another one if we know why and make cultural changes.

Look at me, I'm getting on the dog pile like I said I wouldn't. Let me get back off and go get a coffee. Everything makes sense when we are under no stress and leisurely sitting in front of a computer monitor, I guess that's why monday morning QB pay sucks (unless you are in the media).