Go Around
Humans are simple creatures in a complex world. We crave understanding, we simplify issues and discuss them in isolation (we are lazy - cognitive misers), and detesting uncertainty conclude ‘black or white’, not wishing to accept the reality of a grey world.
The report is ‘grey’ - a very good shade, without ‘definitive conclusion’, yet able to identify and discuss contributing factors which could have resulted in the observed behaviour (hindsight).
Factors were reviewed in isolation, enabling each to be examined for their potential to improve safety, but not excluding more realistic or unidentifiable combinations - a subjective task requiring skills of critical thought and acceptance that there is no single solution - systems thinking - foresight.
The first GA might not have been totally unexpected, but still surprising - different levels and duration of mental stress. A Wind-Shear GA is different, how often practiced vs a normal GA.
Aircraft with large thrust-pitch coupling may use reduced thrust for a ‘normal’ GA to reduce pitching tendency and trim effort, but for WSGA the SOP mandates max power, no matter what else - taught and trained by rote.
The second GA, 2 hrs less fuel, light weight aircraft, max thrust, overshoots the potentially misleading pitch target in the HUD. The HUD approved bypassing normal certification and by default accepted by other regulators. Forward stick is maintained until trim catches up; but in this aircraft stick force only reduces with opposite stick movement; it is possible to fly the aircraft with trim.
The HUD format changes with ‘excessive’ attitude to retain a horizon line, but unlike EFIS it compresses the pitch scale with potential for inducing false sense of pitch rate, also ‘upwards’ cues are presented, not related to pitch-roll convention (90deg) and might be misinterpreted as a roll indication.
We are unable - unwilling to consider a graduated response between GA and WSGA, too many variables, complexity - thus KISS (of death), ultimately resorting to the crews judgement, judged after the fact in a mandated SOP culture, with display information based on static format designs - not considering the dynamics of the situation, man, machine, and environment, all assumed (canned in SOPs) for simplicity.
Systems thinking starts by accepting that there is no ‘solution’ - we are challenged by a complex adaptive issue which at best might be contained, and with careful consideration and small interventions, safety might be improved - but we may never know.
In a highly reliable industry we must be careful not to disturbed the fine balance which has enabled this level of safety; don’t jump to conclusions or rush to yet more training; list and check assumptions.
Start with the individual, ourselves; would the issues affect us, if not why not.
There is opportunity in either viewpoint, the key is to think about the issues and form a viewpoint and understand why (you, not others).
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