PJ, re #2613, you imply that the responsibilities of higher management are placed (unfairly) on the front line operational staff … I agree.
Too often accidents like this enable the industry via formal investigations, or this forum with considered debate, to identify reoccurring problems (patterns of failure), but rarely do we see implementation or even proposals for viable solutions.
Some might debate the necessity for better system warnings. It’s most probable that recent certifications would require a RA comparator during an approach; then why not retrofit all aircraft.
Grandfather rights provide a commercial balance – for older aircraft the risk is as low as reasonably possible in proportion to the cost.
Yet why should problems identified on older 737s be perpetuated in the latest variants? Does the manufacturer offer any advice in lieu of modification? The industry has accepted the status quo, again operating closer to the edge of safety; more often the defence is placed with the crew – be vigilant.
Yet the human does not (cannot) change (perhaps the greatest grandfather rights of all) and behaviour cannot be ‘certificated’, thus the system, in and with which the human operates, must accommodate less than optimum performance.
An operational view of the problem - operating too close to the edge of safety – suggests that it is extremely complex, one which might not respond to a big initiative; instead requiring a range of small efforts to improve the situation.
Perhaps ATM need not be so ‘helpful’ with continuous descents, high speed arrivals, or direct routings; yet they too have commercial pressures for traffic capacity and environmental niceties.
Operators could schedule training fights with a fully qualified jump seat ‘assistant’, yet this creates additional expense and crewing pressure.
Operators shouldn’t schedule training at busy international destinations, but without this how do new pilots learn; simulation is far from perfect in operational scenarios, or gaining the experience after qualification in line operations would unfairly pressure line captains with a ‘training’ task – again a risk to safety.
The operator, and the ‘players’ in the wider system have to recognise the risks, and on occasions expect that a training flight might require a bit more time, will slow down earlier, perhaps miss an approach. In other words the system has to have greater flexibility to accommodate a training flight. The training captain would have to plan and brief the approach with the risks in mind, the crew will have to communicate their intentions / requests, and the infrastructure will have to respond. All of these aspects require optimum human performance – a wiliness to help, not as a commercial necessity, but for safety.
Yet on occasions this even this panacea is untenable; there will be circumstances where the system cannot deliver and the risk remains high. The counter is to demand the highest levels of professionalism in every aspect from design to certification, from management to operations – a tall order, but necessary if the industry is to learn from these accidents and maintain a good safety record.