Much discussion and speculation on ‘what’ happened or ‘what’ the crew did not do, but to learn from this accident we should consider – speculatively if necessary – the many aspects of ‘why’ things did or did not happen.
The technical aspects should evolve as the investigation progresses and they should be fairly simple, but the crew’s activities and thoughts might only be assumptions based on FDR and CVR data.
The initial approach appears to have been ‘crisp’, perhaps hot and high, but something which we all might encounter in normal operations; but for a training flight, the higher workload and need for good situation awareness – thinking ahead – could stretch the Captains mental capacity reducing attention resources to spot malfunctions or mistakes.
The erroneous RA triggered a ‘gear-not-down’ warning (there is no evidence that the crew or maintenance knew of previous problems, nor that they should have done).
Was the FO (PF) distracted by the gear warning, believing that he might have missed a call, a point of procedure, or misjudged the situation; i.e. did he think that he was at ‘fault’ for not lowering the gear. The Capt (PNF/PM), also surprised by the gear alert, commences the landing checklist or calls for a gear selection earlier than normal. Thus some of the crew’s attention is ‘elsewhere’ (all 3 pilots).
These activities and subsequent checklist action mask the RA fault. Who actually pattern-scans the RA, isn’t it more usual to make a spot check (RA live 2500', <1000’ ~ 3nm, 100 above, etc). Similarly who scans the FMA; do we only occasionally check for ‘expected’ changes or rely on flashing alerts to identify the unusual.
Thus the retard annunciation was probably not seen and the thrust lever movement could have been what was required in the situation – it was the expectation that the AT would continue to control speed. The FO may have reduced the airspeed demand as required by flap selection – most likely, thus the AT would move in the retard direction … everything, or at least most of the situation appeared normal.
The landing checklist was progressed by the Capt – a period where his capacity to monitor both the aircraft and the ‘under training’ FO is reduced, perhaps more than normal by the distracting gear alert, a the tight approach, late GS capture, and perhaps expecting but not seeing a dual AP FMA (trng purposes).
Hands on thrust levers? Not always possible when selecting flaps / gear or AP mode change, setting DH, pointing to checked items, etc.
The time line has moved well into the ‘100 sec’ period; flaps are selected and the aircraft is decelerating as expected, AP engaged, possibly the FD still indicating GS/LOC on the FO PFD. No warning flags, RA 1 was still indicating valid, although not showing the correct value – do we always perceive these indications. We have yet to learn if the fault was intermittent or not.
The role of jump seat pilot is not yet clear. Was he another FO under training, possibly to fly the return leg? Did he have a specific checking role; if so what was it; probably to observe/monitor the crew. Thus during the landing checks his attention might have been on the check list actions, possible reading a duplicate QRH. Could this pilot see all of the instruments - possibly not RA1 display? Why should he specifically look at the FMA, was he also confused by the gear alert? Latterly he could have sensed and seen low airspeed, but what do you say and too whom ... cultural aspects cannot be overlooked, particularly in this ex-military situation.
By the time that the Captain (possible the pilot with most workload) had understood the rapidly changing situation (deceleration ~ 3 kts /sec), the situation and feel of aircraft were non standard requiring even more attention.
This wasn’t a sim training stall on the approach. The aircraft was mis trimmed nose up by the AP, thus the feel of the stall recovery would be alien, not expected, a surprise. How do you perceive and then fly a mis trimmed aircraft; compare this with Airbus test flight accident thread.
There could have been need to apply a push force in order to ‘respect’ the stall waning – if indeed the aircraft ever recovered from the stalled condition before it hit the ground. Try flying accurately, smoothly with 30kts+ of mis trim force.
It may not be possible to verify any of the above, but we might learn from the issues and perhaps improve safety by considering what changes could be made – turning hindsight into foresight.
Do we fly smart/tight arrivals too often and too close to a safety boundary, thus removing some of the spare capacity for dealing with the non normal occurrence or particularly for a training flight?
Are we really well trained – sufficiently experienced in dealing with surprise, even with small abnormities do we manage our attention appropriately – do we practice this.
We could consider the role of an additional pilot on training flights; is s/he there to observe/learn or oversee/monitor the operation. Differing roles require different qualification or experience. It might be better to off-load the checklist reading from the PNF (Trng Capt) to the observer enabling improved PNF monitoring and time to ‘train’ the PF to monitor the flight path / automatics – an objective of the flight.
Do we really respect the stabilised approach criteria? How often is the 1000ft IMC stretched to … say 700 ft because that’s the cloud base, or even the 500ft VMC check point because we ‘will’ be visual? And who, or how often would we go-around?
Most of these fixes are aspects of organisational or operational systems thus they could be addressed with safety audits / TEM. This requires people (everyone) to think about their operations, not necessarily specific what ifs, but what margin there would be for any minor abnormality in a range of situations. We should ask if we are operating too close to the boundary of safety, too much in a tactical - a reactive ‘they wouldn’t make that mistake' role, as opposed to a strategic, proactive role where aspects of operations are thought through considering the limitations of human performance.