Old Fella,
For others who might wish to read it, the report is public domain and can be downloaded from the ATSB WWW site. I know the senior aviation psychologist on that investigation (the ATSB does not identify "leads", as some other organisations do).
You say
Originally Posted by Old Fella
The "accident" .... was the result of a totally inadequate appreciation of the problems likely to be encountered and no thought, apparently, to the use of Full flap and Max reverse on landing
I think that it is fair to point out that that list of active failures and latent failures identified in the report is rather longer than your two. They have seven "significant active failures" relating to crew behavior, one relating to runway condition and one technical (PA system failure). In addition, there were nine "significant latent failures" associated with Quantas Flight Operations Branch activities, three associated with CASA's oversight activity, and one with the design of the aircraft itself (placement of components of the PA system).
So I think your summary understates the complexity of the causal factors leading to the accident, as identified by the ATSB. You focus exclusively on the pilots, whereas the ATSB spends considerable space on the context in which the pilots did what they did.
Your "totally inadequate appreciation of the problems" corresponds to the ATSB's first active failure, "The flight crew did not use an adequate risk management strategy for the approach and landing". However, your "no one thought" about flaps Full and Max Reverse, is for me somewhat more problematic. The report does say that the crew neither selected nor noticed the absence of either idle or full reverse thrust, but there is no mention of flap setting in the list of active failures. [Edit: I now understand that Old Fella was referring to the choice during the approach of Flaps 25/idle reverse, which the ATSB characterised as "not appropriate for operations on to water-affected runways", Report p vi, but which was Qantas standard at the time. In contrast, the ATSB considers Flaps 30/full reverse thrust as "appropriate". Below, I refer to deciding about use of reverse thrust when on the runway itself and it becomes apparent that decel is not what it should be.]
Sometimes it is very hard to understand exactly why people did what they did. The crew undertook substantial interviews with the ATSB HF people, who are world-leading, and the results of those interviews do not appear to have yielded a definitive answer to the "why", otherwise it would have been in the report.
It does seem to me odd to suggest that, in a large jet, "no one thought" about reverse thrust. I think it more likely that at the point of landing they fixated on other things: one pilot was in a go-around mind set; the other decided to continue with the landing, and at that point of opposing conceptions of the situation they probably "lost the bubble" in a number of ways.
"Having the bubble"/"losing the bubble" are concepts highlighted by Gene Rochlin in his study of the shootdown of Iran Air 655 by the Aegis cruiser USS Vincennes (Iran Air Flight 655 and the USS Vincennes, in Todd R, La Porte, ed., Social Responses to Large Technical Systems, Kluwer Academic Publishers 1991.) The closest I can come to it on-line is a precis in Rochlin's book "Trapped in the Net", of which the relevant
Chapter 9 is on-line. There is no mention of the "bubble".
Here is what Rochlin says:
Originally Posted by Gene Rochlin, Iran Air Flight 655 and the USS Vincennes, 1991, pp116-7
Past and present TAOs [Tactical Action Officers] have characterized their sense of having proper command and integration of the information flows as "having the bubble." When you've got the bubble, all of the charts, the radar displays, the information from console operators, and the inputs from others and from the senior staff fall into place as part of a large, coherent picture. Given the large amount of information, and the critical nature of the task, keeping the bubble is a significant strain. On many ships, TAO shifts are held to no more than two hours. When for one reason or other the TAO loses the sense of coherence, or cannot integrate the data, he announces loudly to all that he has "lost the bubble" and needs either replacement or time to rebuild it. Losing the bubble is a serious, and ever-present, threat, and has become incorporated into the general conversation of TAOs as representing a state of incomprehension or misunderstanding even in an ambience of good information.
This notional "bubble" is one of the key elements in obtaining high and reliable systemic performance in [critical , complex, high-risk settings].....
Mathematicians, computer scientists and others in the UK sometimes speak of "grocking" something, which means something similar. The idea is that there is a distinct mental state in which you intuitively understand all the relevant features and phenomena in an active situation, and equally its opposite is a mental state in which you don't have such an understanding. The point of singling this out with a special word or phrase is to indicate that the mind can switch rather rapidly between the two. I think ATCOs know about this quite well. They come to a radar screen to start a shift, and spend a while "grocking" what could be a complex situation. When they "have" it, then they can take over. And when they think that they are in danger of "losing" it in the middle of a shift, there is a second person there to offload some of the work. I hope that gives some idea of what I am getting at. It means you do/don't have a complete cognitive grasp of all relevant features of the situation at a given time.
I think all of us have experienced this phemonenon at some point, when a situation we thought we cognitively understood suddenly feels foreign, strange, and we instinctively look for clues to help us regain our cognitive grasp.
It seems to me that in a state of indecision, in which one pilot is set on go-around and the other on continuing a landing, that both pilots could easily "lose the bubble", a crew could collectively fail to "grock" the situation. Some relevant phenomena become absent from attention, and it seems use of reverse thrust may well have been one of these.
I think "losing the bubble", or failing to grock, decribes a different cognitive phenomenon than that signified by "not giving thought to" something. I hope you will agree.
Seaching for the reasons why such a lack of understanding of the actual situation developed during the landing led the ATSB to their "significant latent failures", most of which were associated with Qantas Flight Ops, so I think it is fairer to mention this along with active failures of the crew. Causally, the latent failures are just as significant as the active failures.
PBL