Investigate the accident yourself from the available NTSB information.

What is the job of the NTSB in an accident investigation?
Were investigators effective?
Did the NTSB overlook or disregard a factor?
Why, and why this is important?
First, describe the accident in your words, not quotes.

Second, analyze the findings yourself

Analyze, do not take the easy route and just paraphrase back the the NTSB.
Was the investigation thorough; why, why not?
Do you agree with each of the following, why, why not?
primary cause
secondary/contributing causes
What factors are involved and how is each involved or important?
– medical
– other
Where do you see the SMS in the accident?
what principles are evident?
What principles are missing that could have prevented the accident, and HOW?

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