For those who wish to regress to hindsight, or ask why did't they..., I don't' understand..., etc, see the links to documents from Griffith University:-
http://www.icao.int/Meetings/LOCI/Pr...Strategies.pdf
Surprise - Startle
'... an appraisal that a situation is threatening and is beyond the immediate control of the individual'
'... significant impairment in information processing for up to 30 seconds.
... tasks such as attention, perception, situational awareness, problem solving and decision making can be markedly impacted. Communication is often disorganised and incoherent for some time'.
If this crew were severely startled, as is most likely, then none of what was recorded on the CVR and inferred to be communication may be relevant; similarly any inference of action from the FDR. These might be seen as illogical to us now (hindsight bias), but for some unexplained reason they may made sense to the crew at the time. What were those reasons; training, experience, safety promotions, ...
Also in this event there appears to be more than one opportunity for startle. Unexpected engine oil warning, stab trim and bank angle alerts, over speed warning; perhaps a never ending startle effect or at least multiple distractions as to where to direct attention.
Note the aspects in the presentation about 'Individual differences and defences, and organisational problems and strategies, which relate to the industry's problems noted in earlier posts.
http://www98.griffith.edu.au/dspace/...pdf?sequence=1
'... pilots have been surprised or startled by some event, and have as a result either taken no action, or alternatively have taken the wrong action, which has created an undesired aircraft state,
... have been far from optimal in their handling of unexpected events and rather than utilizing their skills, training and knowledge, have underperformed at exactly the time when these skills were most needed'.
Note the latter point, which relates to regulatory assumptions that the pilot will be able to manage such situations, yet research indicates that inherent limited human performance prevents this.
Training is a central issue, not that trainers are underperforming, but that operators are increasingly constrained by regulatory 'ticks in the box'.
Also relating to this are the delays in instigating change partly due to reactive safety management which requires 'evidence' from accident events. Because there are so few extremely rare events, and that each differ in nature, evidence is lacking. Also, if some events are judged on outcome (what happened,) then false patterns can be found - loss of control, which can result in inappropriate safety activity.
Alternative analysis, to the point of speculation, could identify patters which relate to 'why' the accident occurred, considering the contributions of man-machine-environment, such as surprise, alerting system design, certification process and regulatory assumption.
The accident report makes a good effort to move from 'what' to 'why', but falls down with the recommendations; more calls and communication, perhaps because 'startle' is not an engineering 'fact'.
There is little value in individuals, trainers, or operators beating themselves up in forums like this without safety leadership from the top, the regulators. But these organisations appear to out of step with reality of operations; deciding to use reactive safety and looking for 'evidence' from rare events. Evidence which might be found in everyday operations, the normality of operations, expectancy of success, training requirements, overly standardised procedures, and safety by regulation.
Or are the regulators to surprised to realise?