1/ pretty much all the lessons should have been learned by then.
2/ HC, ISTR that you were a senior trainer - I don't know with which company - so why do you think two pilots made such glaring, yet BASIC, errors on a simple instrument approach? And if you were aware of similar shortcomings, what did you do about it?
3/ You have said they had adequate training and checks so what was the problem? A cultural issue perhaps? Pilots regarding themselves as superior because of the salaries they were able to demand?
4/ As much as HC bangs on about finding the reasons for the accident - neither the AAIB or the Inquiry have found anything except pilot error - sometimes the blame really does lie with the pilots.
1/ it will be a sad day when we think we know it all and all lessons have been learnt. For starters, that can’t possibly be the case until there have been no accidents in aviation for several years.
2/ Not the same company as I worked for so I can’t comment on their training or procedures, but the AAIB did in the bullet points referred to by DB. Clearly I couldn’t have done anything about it even if I was aware. But as also indicated earlier, one of the problems is that unlike the airlines, there is (or was) no standard way to operate. It was left to individuals like me, with no specific training on how to create operational procedures, to make it up as we went along. And in doing so one obviously tends to have “baggage” from experience on previous types.
We only had one L2, for which I wrote the OMB. To be honest I doubt it specifically said “don’t use VS mode near Vy unless you have IAS engaged”. In part, because it seems obvious to me and you can’t include every possible minutia in a part B. But clearly, it wasn’t obvious to numerous pilots who according to AAIB routinely flew non precision approaches coupled to VS and not to IAS. It was SOP to climb out in IAS mode set to something like Vy+20 and accept whatever VS you got, because to climb out in VS mode clearly invited falling off the back of the drag curve.
3. I did not say they had adequate training and checking, I said they had extensive training and checking. Due to the archaic attitudes of the regulator, much of this time was spent doing pointless stuff and not enough time spent doing relevant stuff. For example, one could do an entire type rating and operator conversion in the aircraft and never be exposed to acting as PM during an onshore instrument approach. How can that be adequate? And this is the main thrust of my argument, that training, especially in those days, was very formulaic, very focussed on PF role and not orientated to the actual job. With increasing use of simulators these days I think there is much more exposure to PM role but from a regulatory point of view it is still optional. During an OPC or LPC there is no requirement to demonstrate competence in PM role. It all goes back to the good old days when the captain was there to fly the aircraft and the copilot was there to shut up and make the coffee. The regulator hasn’t really moved on from then.
4. The AAIB are not particularly clever when it comes to that sort of thing. Indeed I had sight of the draft report and had to send an extensive note to them correcting the many mistakes they had made in describing how the L2 autopilot system worked, amongst other points.