777fly re 2271 “the failure of both the flight crew and the maintenance staff to fully consider why certain system abnormalities were indicated and what would be the consequential effects of the maintenance actions that were carried out.”
It was not so much the lack of lateral thinking as the lack of direct thinking – consideration of the consequences of work on any system that could result in the combination of errors.
If the combination of errors has to be considered, then why isn’t this done by someone higher up the management chain? The certification requirements shave the subject but fall short of hard defences. The manufacturer or FOEB (predominantly operators) who assemble the MMEL could have considered the possible errors and required a TOCW test after any work on adjacent systems. Are the FOEB qualified to think about the likelihood of error (human factors) or the consequences of error?
But this is all in hindsight, what we require is the foresight to avoid the next major accident, which most probably will not involve TOCW.