Originally Posted by
WillowRun 6-3
Quote: various posters subsequent to the NTSB information release yesterday, professing various conclusions about crew acts or omissions, and consequences, relative to sanctions, and system component reforms, and even ... causation.
Forum 11th Commandment: Must Have investigation report and those odd, pesky things, known as facts.
There is just too much left to be uncovered by the investigation process, and then still too much needing to be done to integrate the various and several factual elements into a coherent whole picture of the incident, before many of the assertions being made here would be justified and warranted. True, compared to investigations a couple of decades or so ago, places like this forum provide lots of access to relevant information - all the more so with all the tech gizmos which can show position, time-stamp, and more. But the thread is not the investigation. And before ya'all throw FCOM books at me, just think for a minute: once the facts are indeed known and integrated into a coherent whole picture of the incident, there will be plenty, plenty of time and opportunity to discuss probably dozens of system and subsystem reforms and changes. Wasn't the point, or one of the points, of poster Ian W.'s tutorial on attentional tunneling, a/k/a target fixation, that this could happen to anyone manning the flight controls? But let's hang the crew on suppositions here, heck, it's just the internet.
As an outsider with some knowledge of aviation this real issue is possibly clearer to me than to those closer to things. The AC pilots are surely fine pilots and representative of their profession. The guys in the waiting planes, likewise. But literally everyone was asleep here. The entire system nodded off. Why?
Routine. There is so little freedom of action, and the the long day is so overgrown with necessary actions performed almost as an automaton would, that given a certain hour of the day, condition of lighting, etc. the truth can hide in plain sight. That can't be a plane coming at me - planes don't line up on taxiways! They are for taxiing! And those runway lights sure look strange - shrug. Can't wait to get down and get some sleep.
So much of the visual stimulus at night is hard to make out, even if colored like a Christmas tree. It must seem a wash of pretty lights sometimes, moving with hypnotic slowness. Every pattern has a significance, but maybe there are too many of them to keep immediately in mind because you are tired or just bored after a long day being a part of the machine. There are numerous cases of "how on Earth did they not hear that alarm? Why didn't they set the flaps? How can you mistake a frequency for an altitude?"
I don't know what you can do other than to make life more interesting for pilots so that they remain engaged. Let them - no require them - to do some hand flying. That's a start.