Now the Irish Air Accident Investigation Unit has published its initial factual report on the fatal Manx2 commuter crash at Cork, the emerging details reinforce my argument that "virtual airlines" should be made illegal in the European Union.
The AAIU describes the organisation fronted by Manx2 like this: "The operation of the flight involved three separate undertakings; a Spanish holder of an Air Operators Certificate (AOC) that operated the flight, a Ticket Seller based in the Isle of Man, and a second Spanish company that supplied the aircraft and flight crew under an agreement with the Ticket Seller. The Ticket Seller held a Tour Operator's Licence issued by the Irish Commission for Aviation Regulation." Manx2 is the "ticket seller".
At times in this brief preliminary report, it sounds as if the investigators were shaking their heads in disbelief as they wrote their findings. For example: "The experience of both flightcrew members is being examined, as the commander was newly promoted and the first officer had recently joined the operation."
The captain was new to command, and the copilot was new to the airline, its SOPs, the type and the routes.
Scheduling two inexperienced pilots together is not against the law, but it is against responsible codes of practice - and has been criticised in countless accident investigations including the Air Inter A320 Mont St Odile crash in 1992.
This crew was flying without autopilot, autothrottle or flight director, because the aircraft was not fitted with them. All licensed pilots should be able to manage that, but not many are required to. That is an airline choice.
Because of the rather basic level of onboard equipage, the decision height for the aircraft on final approach on this foggy day was Category 1 (200ft), even though the ILS to runway 17 at Cork is Category II (100ft DH). But passing 200ft the captain told the co-pilot to continue. He waited until the aircraft was passing 100ft before calling for a go-around. By that time a warning horn had been sounding for 3sec. The AAIU believes it was the stall warning. The horn continued, as did the descent despite the fact that the pilot flying acknowledged the go-around call, but the aircraft behaviour by that time was indicating a loss of control.
The carelessness that led to this accident is more likely to thrive unnoticed in a "virtual airline" than in one with properly joined-up management. The AAIU must decide whether this type of structure was a contributory factor, or perhaps even causal, and make recommendations accordingly.
The recommendations may not be adopted because, legally, it is difficult to ban devolved organisations. But aviation is different. Like the nuclear power industry, the consequences of even small lapses can be dire.