Does this indicate that the ATSB think it better to make the machine smarter - rather than attempt to make the crew smarter ...? Had it have been QF/or other, might they have said something different?
ATSB is saying that it's impossible to 100% eliminate human error.
The Captain who made the initial data entry mistake had over 22,500 hrs. No matter how experienced you are, people must be
expected to make mistakes at some point. There must be cross-checks, and in this case human & automated cross-checks / procedures all failed.
While both pilots' performances were inadequate, there were also numerous issues with the Airbus system:
- When there's GPS and IRS disagreement, the GPS position is supposed to be invalidated and a GPS NAV FAULT warning should have appeared on ECAM. But this warning was never displayed.
- Similarly, upon entering the wrong IRS coordinates, a separate FMS/GPS POSITION DISAGREE warning should have activated. No evidence that it did.
- When takeoff thrust is applied and GPS PRIMARY is not active, the aircraft coordinate is supposed to auto-update based on the entered runway location. But this didn't happen either; the update just silently failed.
- And instead of flagging the bad data, the system displayed the wrong magnetic heading to the crew on the ND and PFD. After takeoff the displayed heading was 193 degrees when the actual heading was 155 degrees. So they turned left to intercept the SID instead of turning right like they were supposed to.
- On a couple of occasions there were warning chimes, but without any ECAM messages or indication of what (if anything) was actually in error
I'm sure software updates are being made...