Sqwak7700, Re #369.
I don’t exclude those contributions which you list; there are many others. However it could be short sighted to exclude other aspects which, although appearing to be irrelevant, might have contributed to this accident or should be consider in avoiding a future accident.
A significant contribution appears to be mis managed attention, perhaps due to over focus on weather radar and the avoidance of storms.
It could be possible that some EFIS formats or the crew’s unfamiliarity with them, contribute to reduced attentional resources, e.g. if strip speed formats require greater concentration than a dial presentation or the crew has recently changed to strip speeds, then the crew might not appreciate the change in workload. Similarly with any change FMA location.
It is often the small and seemingly innocuous changes in operating situations which lead to error.
Re:-
- Pilots are taught to fly on instruments; but are the techniques / skills used in manual flight the same as those when the autopilot is used; what changes, when, and why.
- Pilots should be able to recover from unusual attitudes; however, this assumes that the abnormality has been identified and correctly interpreted, particularly when suffering acceleration based disorientations. Disorientation is a significant hazard – it is difficult to identify and all crew can be affected simultaneously.
- Pilots should be capable of operating the aircraft systems correctly, but due to human limitations and weaknesses, we all make ‘small and irrelevant’ mistakes; except that the relevance depends on the context of the situation which also may have been misjudged and then these errors become potential contributors to accidents.
I would agree that the conjunction of a weak crew and an adverse situation was central to the accident, but the basis of safety in our industry depends on defenses in depth which mitigate the extremes of these hazards. Thus, the interesting issues might be why these safety nets apparently failed.