Originally Posted by
Europa01
Here's a polite challenge. Given your previously expressed views on what you consider to have been the inadequacy of this crew, are you sure you aren't levering your preconceptions into the TEMS model rather than applying it from first principles?
An astute observation. I am not conducting a first-order analysis for a very specific reason. A first-order analysis would step through the initial threats, the barriers, and the errors (trapped and untrapped) and the outcome of each untrapped error. I think that has already been done in spades, though not necessarily through the lens of TEM. We know there were errors, and we know many of those errors went untrapped despite the theoretical presence of numerous barriers. I am doing something more of a second-order (and in some cases third-order) analysis that suggests that the "barriers" did not function as expected because they actually contained unrecognized
threats. Those threats, being unrecognized, had no mitigation strategy or barrier to contain them and thus led to a series of actions resulting in the loss of this aircraft.
As far as the "inadequacy" of the crew, I think the picture I've been painting here is the inadequacy of the system that put them in that cockpit. These pilots were a product of their training, experience, and environment. In theory, that system gave them the tools (i.e. the barriers) that would have made this accident avoidable. Rather, my conjecture is that instead of creating resilient barriers, their training and operating protocols were actually producing unperceived, and hence unmitigated, threats.