Re: “The report does not explain … …, it does show they were not proficient to execute one in complex circumstances.” #123
This covers many aspects of this incident;
The difficulty in explaining complex situations; - often it is impossible to explain human behaviour, there will not be a single view which satisfies everyone.
There was no ‘showing’ - reasoned argument about proficiency; only that actions (with hindsight), were not as expected for the situation.
It is very difficult to change the human condition, easier to change the situational circumstance, which is what the report concluded.
There will always be errors; their relevance depends on the consequences. Forgetting - unaware that the AP was disengaged is labeled ‘error’; a human limitation, which in isolation was not critical. However, the consequence of adjusting to the ‘error’ resulted in ‘an undesired state’ - Level Bust - the hazard.
The report recommends reviewing the ‘complex circumstances’ of the missed approach requirements - GA altitude and routing; not proficiency or training.
Tacitly the report recognises that there are limits to human performance, which in a very safe industry might defy intervention focused on the human, e.g. training; alternatively changing the situations to be managed could help avoid a similar incident.