IMHO, framing some of the crew’s actions as “pilot error” is not particularly helpful. “Error” implies that the pilots’s actions were inconsistent with the training culture and operational expectations to which they were exposed. We have a sense for what Boeing expected the pilots to do in this situation, but there was obviously a gap between their assumptions and reality. Before we get anywhere near suggesting pilot error, I think the following questions should be asked and answered:
- How often and when was the last time these pilots practiced a Runaway Stabilizer event in the sim? Was this accomplished at low altitude? How much exposure did they have using the manual trim wheel?
- How often and when was the last time these pilots practiced an Airspeed Unreliable event in the sim? Was this done during the takeoff phase and did it include an erroneous stick shaker?
- Were the pilots ever taught to associate a bad AOA input with unreliable airspeed and altitude?
- Did any of the pilots’ training involve multiple malfunctions, startle, or distraction?
- What was the automation policy at the pilots’ airline, and did their training and operational culture encourage or discourage hand-flying?
- Did any of their training or experience prepare them for situations in which there was no obvious written procedure available?
To the degree that the pilots reacted in a manner consistent with how they were trained, I think it is inaccurate to file those actions under the label “pilot error.”