The discussion drifts back to fatigue, a single focus. Although important, it isn’t the dominant or overriding issue in this accident; that is about how it is possible for all of the factors to come together at that time.
#62 titled GA, could equally be titled fatigue, or system design, or SOPs, etc; the quote below still applies. Perhaps this viewpoint is the better item to debate.
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
Consider how each of the agencies cited in the reports recommendations might act:- the airline, the regulator, the manufacturer, ICAO. At best, individually, they might “consider” the issues.
And anything that they or we might consider would be ineffective without action; thus the prime questions are what to act on, and who, and how is this to be actioned, what do we change - joined up thinking.
Thinking …
https://ta-tutor.com/sites/ta-tutor....ts/thinkng.pdf