Conventional safety analysis is based on 'most probable cause', which tends to focus on a single issue, e.g. Thrust levers, or rejected landing, or aircraft system.
Modern operations are increasingly complex and interactive, where rare accidents can have many (minor) contributing factors, which are only relevant when they come together in a particular situation or time frame.
The modern view of safety reflects modern operations, including the trend to evidenced based action, i.e. evidenced based training, which should avoid over-focus on a single event, or single issue.
Thus where is the 'strong' and convincing evidence for more training; given the extent of many successful flights vs this one accident?
The industry has identified problems with GAs, but these are more generic as discussed in the ASAGA report, where the dominant contributors involve complex situations which generate surprise and demand high mental workload; see 'defining the problem' p120 ASAGA "The crew must perform a number of actions and cross-check them in a short time. The induced cognitive overload may prevent the detection of deviations both by the PF, who is mainly concentrated on the PFD, and by the PM, who undertakes a set of tasks that divert his attention. Thus, a deviation, even in an important parameter or in the flight path, may not be detected by the crew."
It would be short sighted to require even more procedures which add to the situational complexity and increase workload; thus avoid adding SOPs or requiring more of the 'same' training in order to solve isolated problems.
Golden rules II, Educate, Communicate, Clarify, Simplify.
New safety thinking:- "the most probable cause was the conjunction of many apparently insignificant factors, which in isolation would not result in an accident, but together created a situation which momentarily exceeded the crew's ability to comprehend the situation and act accordingly". With apologies to J. Reason.
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Last edited by alf5071h; 21st Sep 2016 at 11:27.
Reason: Typo