From the ATSB website (my bold):
The operator conducted an investigation and determined that the following factors had contributed to the incident: incomplete approach brief, loss of situation awareness, improper coaching techniques and cognitive overload. As a result, the operator intends to:- provide the Captain and FO with a remedial training and coaching program
- conduct a review of their command upgrade training to ensure it focuses on the development of a positive cockpit authority gradient, and the command of flight capabilities
- incorporate this incident into the command upgrade training course as a case study
- conduct a review of their recurrent human factors training.
So we see the contributing factors listed as well as corrective measures, but are these items listed truly what you would define as 'root cause'?? Because the root casue is the most serious part of the incident.
a) Incomplete approach brief - Why? Was it a training issue, normalised deviance, error or violation, complacency, operational pressures, resource deficient, technologies, communication, fatigue, PIC/FO skills gradient?
b) Loss of situation awareness - Again,Why? Was it a training issue, normalised deviance, error or violation, complacency, operational pressures, resource deficient, technologies, communication, fatigue, PIC/FO skills gradient?
c) Improper coaching techniques and cognitive overload - Once more Why? Was it a training issue, normalised deviance, error or violation, complacency, operational pressures, resource deficient, technologies, communication, fatigue, PIC/FO skills and experience gradient?
Furthermore, are the root causes in this case related to just this crew or do they apply across the spectrum of this operator? Are we seeing an emerging pattern?
And yet again, where is the regulator in all of this? Do we even have one? Are the executive lawyers and out of touch former pilots running CASA even capable of managing these issues? Doesn't appear that way.
Over to you Senator Xenophon. Tick tock tick tock