Re
PJ2 ref to S Dekker # 49;
the very apt publication of Dekker's report below to the Dutch Authorities which the NYT cites as being dismissed following Boeing intervention, # 1.
Only read the summary so far, but … concluding …
"
A breakdown in CRM (Crew Resource Management) cannot be substantiated for TK1951."
"The length of B737 type training at THY, as well as procedural compliance at THY, appear to at least match industry standard."
"Post-accident manufacturer recommendations that, in effect, tell flight crews to mistrust their machine and to stare harder at it not only mismatch decades of human factors and automation research, but also leave a single failure pathway in place."
"
Shortly after the accident, Boeing issued a bulletin to all 737 operators and announced that it “will warn crews about fundamentals like flying the aircraft, monitoring airspeed, [and] monitoring altitude” (Learmount, 2009).
The only defense against a designed-in single-failure path, in other words, are the pilots who are warned to mistrust their machine and to stare at it harder. Such a reminder, oriented only at the human operator in the system, is hardly credible after three decades of in-depth research into automated airliner flying and the subtle and pervasive ways in which automation on the flight deck (and particularly its subtle failure) affects human performance (e.g. Wiener & Curry, 1980, Sarter et al., 1997). For flight crews of Boeing 737’s, like the crew of TK1951, there is no sufficient training, no written guidance or documentation, and no likelihood of line experience that would insulate them from the kind of automation surprise that happened near Amsterdam on the 25th of February."
https://www.onderzoeksraad.nl/nl/med...t_s_dekker.pdf