Concours, re 4 similar accidents. #1334,
Recalling that we might always ‘find what we look for’, an alternative POV.
Start with the technical malfunctions and associated weak or complex alerting indications. AF447, 737 Schiphol RA, CRJ Sweden Att, Lion, …
Pilots don’t ‘loose’ SA; this view requires understanding (definition) of what ‘this SA’ consists of, and what aspects the crew had before they lost ‘it’, and why they lost it.
In order to improve our hindsight biased understanding, the better view is that the crews’ SA was insufficient to manage the situation, but without knowing their actual perceptions and understanding at that time, or their mental resource to update these, we cannot conclude anything about the crews performance except that it may have been the best for the situation as they ‘saw’ it. The situation overwhelmed the human, so fix the situation not the human.
If those situations were at or beyond human capability, it is unlikely that any further understanding (training) will improve this, particularly without knowledge of ‘lost SA’. Instead we should look at the overall system in which we ask humans to operate in, and the manner in which we ‘outsiders’ look in - generally backward.
The better approach is to start with the machine and operating environment and consider what might be changed. AF447; the pitot change was in progress, but in other accidents the technical malfunctions are as yet not even in work; perhaps delayed or unrecognised by the blindness of the ease of blaming humans.
An intriguing association in many of these accidents is ‘grandfather rights’, situations ‘not identified in certification’, and the covert belief that ‘the pilots will always manage’.
From this we might conclude that the people in the design and certification processes also encountered situations which were beyond their human capabilities, understanding, or forethought. If so then we might be reaching the limits of safety.