One thing to keep in mind that as much as we'd like to think otherwise, all humans are NOT created equal. We have people with above average skills and cognitive abilities, and people below average. The top 75 percentile will pass any exam designed for the average, the pilot profession is no different. Automation, SOPs and CRM have made enormous advances towards ensuring that the real-life performance of those with above and below average skills are not that far apart anymore. However there always be the odd unexpected situation where superior skills save the day (Sully) and below average skills lose it (AF or this one).
The direct cause in this case was the PF reacting subconsciously to one piece of information, which was seeing a big and increasing piece of blue of the PFD, no doubt the result of many hours of training and conditioning to follow the ADI regardless any sensory illusions. It would have required that extra touch of superior skills given the circumstances to grasp that if speed, altitude and power setting did not change, the indication must be false.
Given the rarity and unforseeable nature of such failures, it is very difficult to effectively train for them, as by their very nature the required action goes contrary to what one was prmarily trained to do. On the other hand, I'm sure everyone who have read the report will sit on their hands for a few seconds in a similar situation. It is a matter of learning from and avoiding other's mistakes.
Last edited by andrasz; 13th Dec 2016 at 10:19.