I took the time to read the NTSC report in full, and generally believe that the investigation has been quite thorough.
What I take from it though, and what was not specifically mentioned in the report, is that we now have a generation of pilots (and engineers in some cases) who believe that any fault is simply a computer glitch, and that it can always be fixed with a reset.
In the past system health was measured by temperatures, pressures, voltages, etc (and by a flight engineer), but nowadays there is a mindset that "green is good" in system indications. Should there not be a green indication, then many pilots think that either
- it can be solved by a reset, or,
- it must be an indication problem.
Many pilots don't seem to consider that a component may in fact have failed.
I also see engineers (some at least) who try repeated resets or re-racks to try and resolve an issue. Some engineers seem also to be convinced that there is an indication problem, and are unwilling to consider that a component change may be necessary.
To some degree manufacturers have contributed to this, with most trouble-shooting carried out by computer.
What I found particularly scary in this report was the revelation that the fault had been reported 23 times, but no-one considered any "fix" other than a system reset.
The Captain involved in this accident had experienced the same problem in the same aircraft 3 days earlier, and had returned to the bay. An engineer then came on board and accomplished a reset successfully, after which the Captain enquired if he could pull and reset the relevant circuit breakers if the problem re-appeared. The engineer apparently suggested that he could, but my guess is that the engineer assumed (always a trap) that the Captain would only attempt this on the ground. On the subsequent push-back the problem did reoccur, and was apparently reset successfully by the Captain tripping and resetting the appropriate circuit breakers.
No doubt pleased with his ability to resolve (temporarily at least) the issue, I imagine that the Captain noted this "fix", and attempted it in the air on the accident flight.
I grew up learning that circuit breakers were/are designed
ONLY for circuit protection, and that they should
NEVER be used as a reset tool or a switch. Modern practice seems to be completely the opposite.
So too, apparently, does the practice of hand-flying the aircraft.
The report mentions the importance of the "startle" factor when confronted with the situation faced by the crew. It also touches on the fact that the limited amount of jet upset/unusual attitude training done in the simulator is always accomplished at low altitude, in the approach configuration, and
with the prior knowledge of the crew under training/check. This is a whole different ball-game to an unexpected upset at high altitude in convective weather.
Perhaps there is merit in introducing jet upset training in simulator sessions without advising the crew ahead of time. Whilst I do not want to see a return to the days where crews arrived at the sim without any foreknowledge of what was to come, this particular scenario cannot be properly trained for if it is run to a script.
Looking forward to reading Centaurus' views on this.