Originally Posted by
alf5071h
The report is an exceptional example of a thorough investigation and well considered analysis of an accident involving human factors. This should be referenced for all investigators as how it is possible to identify significant contributions to adverse (but as might be expected) human performance, yet not conclude by blaming the human - as we might do.
Although the conclusions focus on the human aspects, which in many circumstances could be labelled ‘error’ and blame, this is skilfully avoided with balanced discussion of many diverse potential contributing factors.
The safety recommendations identify many significant issues, contributing factors, which deserve consideration by all operators and regulators. Particular issues relating experience of other aircraft types and differences in trim systems, depth of training vs information available in manufacturers manuals, both aircraft and HUD, assumption re PM being able to identify rare situations requiring intervention - incapacitation, and the limits and limiting influence of SOPs in rare situations. The HUD observations should concern everyone who uses them, questioning what is taught, display formats over the range operational situations.
Yet again issues of thrust-trim coupling during GA are identified, applicable to many types, but specifically to the 737 in this accident.
Additionally, the reoccurring issues of trim awareness, assumptions about human contribution in abnormal situations, and design philosophy (737).
The regulators involved with the 737 Max recertification should read the last page of this report; paras 5.21, 5.24 and 5.25, and footnote #38.
And we're back to the 737!
What's with the obsession on this forum about "not blaming the pilots"? Hell yes, blame the pilots! Did you read the autopsy section? Did you read about what happened to those passengers? They found the highly fragmented remains of 63 people. Only 62 were on the manifest, they eventually identified the 63d as a foetus - one of the women on board was pregnant. 63 beautiful lives turned into mince meat.
The dead pilots are not with us anymore, and it doesn't matter what we say about them. They were the first to die. But it sure as hell should not be conceived by anyone that this was in any way an acceptable level of performance from a trained, professional flight crew. Illusions and fatigue are always going to be there - that is not an excuse to smash an airplane nose-first into the ground, along with all its contents.
On the contrary, we need to blame pilots a lot more, training and selection of crew should be a million times more restrictive and intense. It shouldn't be anyone who has money and can pass some ridiculous tests gets to be crew. Flying an airplane is not a joke.
The heavy burden of responsibility from flying living beings around at speeds generating energies massive enough to disintegrate their bodies cannot be overstated.
F/O should have yelled out "I HAVE CONTROL! LET GO OF EVERYTHING NOW!", worse case punched the Cap's lights out and immediately taken control. With 40 deg pitch down, speeding towards the ground with engines at full power is not a time to be giving advice and "no, no, no"ing or pulling half halfheartedly on the yoke at the same time the other guy is pushing down. It's time to knock out the dude that's going to kill us all, engines idle and pull out of the freaking dive.