tdracer, you approach the point of assuming that no one would overlook all of the available cues. Furthermore, it would be inappropriate to assume that something prevented the crew recognising the situation. Thus as you conclude we need to understand the mental process, but, BUT, many very experienced researches still seek a usable answer.
The metal processes which create success or failure are the same – the way in which we think; it’s only circumstance (outcome) which distinguishes between them.
Many posters would be well served by reading articles by James Reason and heeding the risk of bias (#582). The errors which the crew suffered (only determined by hindsight) – the processes, inabilities, assumptions, are no different than the manner in which many of the views above are stated. We are our own worst enemy – or at least our thinking is; #523 attempts to show this.
In the absence of knowing the crew’s thoughts, any understanding this accident depends on supposition. There has been significant technical analysis above, part supposition and part unverified ‘fact’ more often based on assumption; we must take care to define and acknowledge the line between them.
There is still great opportunity for supposition about the crew’s thoughts and behaviour. The VF article touches on this, but I suspect that most people are uncomfortable with this approach – too personal, whereas it’s much more satisfying to blame someone (which the report avoids).
In search of a solution, the industry needs to improve individual understanding of behaviour (behaviour is triggered by thought) – HF training (not necessarily CRM). Also review situations to minimise opportunity for error, and if encountered, how to recover or reduce the effects of the outcome – not stall recovery, the situations which lead up to it, the flight path, the procedures, training. Each might be seen as small and insignificant (bias), but together at a critical time there is great hazard.
The roots of this accident might be found well before this flight started.