Boards and Busts
The comments posted about the report and incident, including those which take a stab at stating larger questions raised by the incident in a general sense, impel me to ask:
1) If it is accepted as fact that the NTSB gave the incident too little emphasis - given the several potential extra-holey Swiss cheese scenarios implicated - do those knowledgeable about such investigatory safety boards think that the NTSB's broad mandate which includes railroads and pipelines is a root cause of its limited attention span? As the forum community includes a pretty extensive non-U.S. contingent, and other countries appear to have safety agencies for aviation as such . . .
2) I had always thought that take-off, climb-out and ascent toward cruise Flight Levels - while immensely mysterious to such as an SLF - were less challenging, to the aviators, than executing a successful and safe approach, at least in many instances. But here, the front-end of the operation was out of alignment . . . is it correct that a bust of a cleared altitude on ascent toward cruise Flight Level is not typical, even highly atypical?
What all the factors involved in this incident say about the need to change the nuts-and-bolts of R/T and charts and ATC procedures, I don't know. What these factors say about perceptions about a need to tighten up on training standards and procedures of air carriers, I also don't know. But hoping those who do know what they're talking about might comment further.
WR 6-3