This was an accident stemming from a 'hazardous misleading display', which according to AMC 25.1302 2.1 requires that 'The probability of indication of dangerously incorrect information without a warning being given should be Extremely Remote'.
We might ask why the certification process involving the equipment manufacturers (IRS and EFIS), the airframe and simulator manufacturer, and various national regulatory authorities involved in certification did not identify this hazard. Was the probability proven by numbers, or risk assessed such as the crew were expected to notice (regulatory generated black swan).
The EFIS software appears to have been designed to remove the alerts, the accident was 'as designed'; thus how did the various checking processes fail to meet the safety requirement.
The above questions are easy to ask with hindsight, but how might these aspects be turned into foresight.
Is the current emphasis on LoC training, immediate action, and SOPs now biasing pilots to react with little thought, no crosschecking, particularly in surprising situations.
Is the industry generating this type of accident, misunderstanding or seeking to address the difference between what is assumed to happen against the reality of rare accidents, with unrepresentative regulation.
Can the current safety and regulatory processes be expected to identify and manage events beyond the certification boundaries.
There are many approaches to safety, all necessary for achieving the current high level of safety, but is their more recent application now endangering future safety. Regulatory restraint, 'SOP for everything', and train for 'everything', except that not everything can be foreseen, offers diminishing safety return. There is greater need for the interpretation of requirements for training, emphasis on a checking mentality vs educating and understanding, which if misapplied decrease the opportunity for experience further weakening crews' ability to manage the unforeseen. This accident may have been foreseen, but it was parked the other side of a regulatory line 'of assumption' to become 'unforeseeable', yet still expecting crews to manage the surprise when it happens.
Time to change the way we think about safety.