They were incredibly busy so it would be hard for them to remember. This is a system related problem. A better checklisting system is needed. Or was needed. Probably fixed I assume!
Amazing how many crashes are from forgetting to set flaps and slats for takeoff. It seems so elemental and critical at the same time. The warning not working contributed to the crash only as a fail-safe, so if that was not working, they were doomed. This seemed at first like it would be ice on the wings.
I think the issue is that brains aren't perfect, and given enough time, someone will make every kind of possible mistake. It just so happens that forgetting to set the flaps alone is a big enough mistake to kill everyone on board. Usually a single mistake doesn't have such devastating consequences. While humans are definitely smarter than machines for now, we certainly aren't perfect, which is obvious given this and other incidents. I think that's why more and more automation goes into planes, because That's less and less possible mistakes people can make.
Well they did set the flaps, but then retracted them temporarily so ice wouldn't build up on them intending to reset them at takeoff. They forgot. They were distracted by the change in procedure.
Agree. Some other channels go into so many technical details it’s hard for me to understand what they are talking about and I get lost in these. But here it’s all concise, but still complete 💪
@@MiniAirCrashInvestigation hey Mini, I shared the video with my acquaintances at the Pan Am World Airways Museum in nyc... They said they liked the content but found the title to be offensive clickbait. Theres always a possibility thst one of the cutators knew a member of this crew, so I told them I'd reach out and see if you would consider changing the title to something mire descriptive and respectfully accurate?
I was thinking about ice from the beginning, or mainly, since he said that the plane waited for 45 minutes out in the cold. The actual clusterflak that went on there didn't even pass near me. He had it well hidden, and even threw another false hint in the ice direction when saying that the wing analysis found some parts stuck.
So a system that warns the pilot has forgotten to configure the aircraft for takeoff doesn't work in cold weather unless the pilot remembers to configure the warning as well. That's not great human factors engineering (though given that these systems were designed in the 50s I guess that's to be expected)
That was a fantastic video I was thinking you might have done this video before? But maybe I just read it or seen it on another channel anyway now I watched it I’m watching it again now that’s how much I like your work
The special something of Pan Am was that it captured the optimistic spirit of the USA of these times. Its very name underlined that it was both an American and a global airline. And so it was: I can remember how as a teenager I was waiting with my parents in Pan Am's futuristic and elegant JFK terminal, the Worldport, looking at the remark next to flight PA 001. It said "Round the World". Which encapsulated the spirit of Pan Am and of the USA of those times at large. And the romance of travel. Emirates will never come close to that, for all its oriental opulence.
I agree regarding Emirates. Pan Am set the standard and then upgrading it. It still remarkable that it has been gone for thirty years. Didn't think TWA would go as well, but the aviation industry has crushed many.
I disagree with that comparison. Emirates was not groundbreaking. True, they had showers, 150 a380s, and beautiful Flight Attendants... But PanAm was a PIONEER. They developed a majority of the systems of operating a global airline that are still in use today. And the flight attendants on PanAm were world class women, not simply pretty to look at. So yes, in some regards it is a valid comparison... But PanAm was so much more important to the industry than Emirates will ever be. Still enjoy all of your vids... Please keep them coming!
@@BobbyGeneric145 Pan Am was the pioneer - but not the best. Yes, Pan Am flight attendants were world-class - but so are Emirates flight attendants. Plus, in its 37-year history, EK has never had a single passenger fatality; the longest Pan Am ever went without a passenger fatality was 5 years. No matter how important Pan Am was - and they are very important - they definitely were not the best. Indeed, after a Pan Am crash, the captain wrote a book, The Myth of Aviation Safety, which was true for the entire airline industry during the "Golden Age" of air transport that never was. Seriously, Emirates (and, for that matter, Etihad, Singapore, and more airlines) offers first class products way above and beyond anything Pan Am ever had.
Non pilots will say, pilot error. And they were 90% guilty of that. But any pilot, especially pilots of complex aircraft will tell you that b4 take off is always a very busy time and without proper training and without following strict procedures this can and does happen. More than non pilots would want to believe. Being in a hurry to make dead lines or beat weather etc is usually the factor in making deadly or even non deadly mistakes.
As you have pointed out there are a few occasions, very few, that call for the flaps to be kept up until just before take off. One answer to the problem of forgetting them is to delay reading the Taxi Checklist until you put the flaps down. Unfortunately this could lead to the whole check list being forgotten at the last moment as If you don't put the flaps down the checklist doesn't get called for. My own answer (laughed at by some First Officers) was to write the word FLAPS in big letters on a large piece of paper and fix it to the instrument panel in such a way that it covered up most of the important flying instruments which worked on the basis that I was very unlikely to start the take off with the ASI covered! It always worked for me.
Another terrific video. As with most crashes, multiple issues combined to result in this crash. Really interesting research. Hard to believe that there wasn't one final flaps check on the checklist to save them and at least one other flight I can recall.
Right .. without all the personal baggage .. I like the straight to the point cause and effect but I miss some of the input by investigators putting the pieces together.
I was a 19 year old airman sound asleep near the end of the flight line. I heard these jet engines screaming louder than I have ever heard, and thought to myself, someone is crashing, the sky lite up orange from the fireball, horrible situation, I had horrible nightmares for months afterward. may they RIP.
I think the checklist was the biggest issue. The automatic systems in a plane can fail, like in this flight or on Northwest 255. But a checklist will never fail, as long as the pilots follow it. In this case, they were doing everything by the book, unfortunately this meant that they had to keep a mental note regarding the flaps. However, because they were distracted, this mental note was forgotten. A checklist can offload plenty of mental effort, such as needing to remember something relatively simple, like extending the flaps. I think the more mental effort you can offload, the better. That's why checklists exist in the first place, because although someone could theoretically fly a plane without them, that would involve relying on unreliable human brains to always remember everything every time. I think if there's ever a point where a pilot has to make a mental note of something, that means that it would be a good candidate for a checklist item. But there also should be some kind of procedure for when you need to make a mental note for something that isn't on a checklist, since a checklist can't possibly cover everything. There ought to be, if there isn't already, some kind of failsafe way to record some kind of information you have to keep track of, such as the fact that you need to extend the flaps later, and have it be impossible to skip over that before it's too late.
Well, at least as far as flaps are concerned, the solution was to include the flaps again in the takeoff checklist, just in case the pilots missed it the first time around during the taxi checklist.
I disagree with that. Humans perform way worse than a properly designed automation. Humans excel in thinking and intelligence, but very poor in executing autonomous task sequences at the same precision and care every time and at every circumstances. Extending the checklist just increases the load. If something is mentioned only once, at an inappropriate time, it might get forgotten. If something is mentioned too many times, one might skip through it, "yeah, I did it already". But this could be proven. Give one group of people checklists and a sequence of some administrative tasks. Give the other group a software which requires them same beahviour as the checklist. The software allowed to aid the work, but strictly disallow doing something if required conditions are not met. Then run the experiment for a week. I guarantee you that it will start very good, but then you will start observing increasing number of mistakes in the first group (they are getting to confident themselves and start neglecting the checklist which takes away time from the actual task) These sorts of things are easy to automate or make warning for. I am not a pilot, but it seems by all of the videos that aviation moves sooooo slowly with the development on the "user experience" side of things, everything seems so ancient and needlessly complicated. My first issue is, why the plane have to guess the takeoff intent instead of exactly selecting that mode by the pilots? And why based on the thrust levers angle? Wouldn't be more objective to enable the warning above certain airspeed? Certainly above taxi speed, but way before v1. The current implementation is similar to as if you would keop your eye on the exact gas pedal angle in your car based on the speed limit tables, instead of checking the spedometer. Checklists are good, but it should be a fallback, in case the automation does not work.
I've seen a lot of air accident videos on this youtube channel & others and a number of no-flaps-extended conditions. If I were flying again, I tell myself, I'd definitely remember those damn things, but I know how hard it is to recall something mentally that's not on a checklist and would probably be just as human as anyone else if put in the same position. Glad they added some addl checks after those two tragedies.
Even on my FSX always checking before TO: flaps, trims, heading & altitude settings (according to ATC commands) and at last throttle up. I think so after many flights pilots became bored and less vigilant, too much routine also kills.
Cameras looking at the wings and tails and engines and displaying the images in the cockpits would prevent a lot of mistakes and crashes. Then, instead of having to rely on instruments to tell you what was happening back there, you would be able to see for yourself. Just as you could in a Tiger Moth.
Of all the flights in my lifetime one on PAN AM from London to San Francisco was most memorable, it was huge, comfortable, lots of leg room, great food and great service. The best experience. Finnair was nr.2, would be possibly nr1 if it wasn't for a scare, fuel dumping and return to the airport after an hour of flying and being greeted by firetrucks but pilot landed perfectly. Another time our connecting plane from London to San Francisco (I don't remember which airline) didn't take off at all due to the storm in London at the time (it was in February), it was a great decision. They put us up in a 5 star Edwardian hotel in a luxurious room and with huge proper English breakfast. I didn't make it to work the next day but it was worth it. Conclusion, when the weather is bad and there are even small problems, stay put until you know it's safe...
The crash was a result of all of the reasons that you mentioned, hence the term "error chain." Inserting another flap check would have broken this chain. Another nicely done video.
As the video correctly points out, the pilots were very busy and had much to think about. Non-pilots want to put all the blame on the pilots, who had many complex variables taking up brain space. It seems like such a basic error today. But there are now improvements in checklists, as well as methods to use those checklists. I flew 727s in the 1990s. Our company checklists called for setting (or verifying) the flaps for takeoff 3 separate times, to ensure they weren't missed. If pilots are running a checklist and are interrupted for any reason, the crew member reading the checklist will either stop at the last verified step, or even start that particular checklist (Taxi, Descent, whatever) over from the beginning. We all benefit from improvements in technology and processes after these disasters. Sadly, as the video again points out, some improvements that could have been made after PanAm weren't done, until passengers were killed. Essentially the attitude in the industry is often "no humans were killed, only pilots, so let's not change anything yet."
I'll go with option 4... stress. The pressure to get up in the air in time. That's the kind of stuff that makes you forget things that you _know_ you should've done. That's the kind of stuff that can make someone miss (or skip) even multiple check lists.
Great video. I find it difficult to understand how pilots can forget flaps for take-off. Mostly it is a critical thing for a successful takeoff. I would on occasion, when the runway was short and we were heavy, start the roll with no flaps, but with my hand on the flap switch. This allows you to pick up speed quicker without the drag of the flaps. Then at an appropriate speed pop the flaps.
They had flaps out but their taxi checklist wanted them to retract them so ice wouldn't build up and so they did. If you always follow checklists and you are ready to take off with all checklists completed it's very easy to assume your plane's configured for takeoff.
There is a screw to adjust the horizontal stabilizer not the elevators. There is a specific setting for the stabilizer for takeoff depending on the weight and balance calculations.
Northwest 255 was a repeat of the same failure of the crew to follow the checklist, plus, they disabled the configuration warning. The FAA should have issued an order to all towers in the U.S., that prior to granting takeoff clearance, the controller verify with the aircrew that the aircraft is configured for takeoff. This would cause flight crews to have to verify the flaps and slats are properly extended.
Warning systems save lives, and so do checklists... It is important to realise that a warning system might not work properly, so the checklist should always be used for pre-flight...
It's a very intractable problem - checklists become so routine that pilots simply fill them out as if already accomplished. A similar problem almost caused Apollo 10 to end in disaster, when a critical switch was thrown twice, nullifying it, and the LM came within seconds of crashing on the Moon. There have been other examples of forgetting to set the flaps leading to catastrophe. I remember one crash of a commuter airliner where they forgot to remove the lock pins on the elevator and rudder!! Astounding. Anything my life depended on, I would check and recheck a 1000 times!
Thank you, always enjoying your content. I didn't see any link to JAL 8054 (10:17) on screen near the end of the video, maybe you could add this in the description ?
Pilots need to have a notepad in the cockpit where they can write ad-hoc notes to themselves of odd states - like when the pilot said "Let's not forget the flaps", he should have a place to write that and then reading that note pad will make up a sort of "Final Checklist" of things they have to do.
The warning system not working reminds me of One-Two-Go 269, where 40 knots of windshear and possible fatigue caused a them to forget TO/GA during go-around and they entered a stall, where controls were transferred without warning. There were 6 windshear sensors around the airport, but only 3 were working. The reason, was because they were solar powered, and the solar panels were blocked by clouds, where windshear would be most common.
You’ve got takeoff configuration warnings, and crashes where the warnings are disabled or otherwise fail. You’ve got multiple checklists that include the takeoff flaps position, and less rigorous or rushed pilots skip the step or entire checklists time and again. You’ve also got the crash where the takeoff warning sounded in flight (hint, it wasn’t a takeoff warning, it just used the same alert sound for an equally serious problem)... dunno if we want a weight-on-wheels airspeed > x-mph based warning... it’s pretty hard to judge what a pilot is thinking, but if you have a plane moving at speed on the ground, he’s probably taking off, landing, or in a hurricane. Landing’s easy to check - ‘brakes on?’. Catch here is the weight-on-wheels sensors can also fail (causing their own crashes), as can airspeed indicators... This flying thing is pretty complicated.
There are many crashes attributed to not deploying flaps. There are like 5 Air crash investigation episodes in which the crew didn't deploy flaps So whenever a plane crashes on takeoff I first think it probably is not deploying of flaps
Engine failure at takeoff is also a big killer. It is usually possible to recover from a single engine failure at takeoff, but very difficult, so even experienced can fail. In case it is a cargo plane loaded to the absolute max, a single engine failure just after rotation is mostly likely deadly (unless they have empty field in front of them, and can crash land).
If you consider how long ago this was, and all that the flight deck crew were trying to manage, I can’t help but feel that they were over tasked. The unfamiliar flight-line, weather, and the time pressures they felt was more than that 707 flight crew could deal with, ergo things got skipped over. Thanks for another great video, and take care, amigo.
The crew forgot to extend the flaps, for sure. The warning ⚠️ could have saved them. Their training assured them of a warning sound. So ... 🤷🏼♂️ Really liked your description of Pan Am at the beginning. Thanks for another well done and well expressed episode.
It just goes to show that humans have trouble when their brains are overloaded. That's why checklists are essential in "can't fail" situations. Those poor guys... We now have heavily automated aircraft, but then the challenge moves to the programmers to get everything perfect and anticipate every possible crazy situation. Then you have the "hours of boredom, and seconds of terror" problem that human pilots have trouble with. And then you have the "how does the computer behave in manual mode, Air France 445" problem. Piloting a jet in all situations is a pretty hard problem. Thanks for your efforts. I have a morbid curiosity in air crash investigations. You deliver in bite-sized segments. Watching on TV now, we seem to get that repetition that they use to pad out the show to 1 hour. It gets pretty annoying.
My opinion is that the fault was shared by the flight deck members, the weather, and the industry itself. Yes, had they followed the checklist, the accident would most likely not have happened. However, the primary thing to remember is that the jet age was still in its infancy, and that the criticality of certain things were not known yet in the industry, like the importance of immediately revising checklists after it was demonstrated necessary. In the end, it was naivety and fixation that killed these people; its extremely sad that it took another like disaster to wake up the industry. Laissez faire is still common in this industry, but we react, respond & remediate *much* quicker today, and future tragedies are averted as a result (mostly).
tbh, the main purpose of the checklist is to remind the pilots abt what they hv to do, everyone knows that the most critical stage in a plane journey is Take Off n Landing, its obvious that the pilots would be stressed, the checklist shud hv been planned properly, so that even if the pilots forget, they would be reminded again.
That’s wrong, the purpose of a normal checklist is to confirm the required steps are accomplished, not to remind pilots what they have to do, but obviously you are not a pilot or you would have known that.
Having cut my jet teeth in the little Learjet model 23, I developed my own before takeoff check. It was flaps, trim and spoilers. Those are the things that will kill you.
An accident is not usually caused by a single factor, but instead by a chain of single factors, that when are added together, lead up to it. Here we have an unfamiliar airport; winter weather and possible airframe icing; an air route clearance limit time and desired cruise altitude availability; before departure workload involving each crewmember in a different way (Captain -- taxiing at an unfamiliar icy airport; First Officer -- on radio with ATC; Flight Engineer -- dealing with aircraft weights, V-speeds, and altitude performance capability), which appears to have separated them during pre-takeoff preparation; preoccupation with dealing with Air Traffic Control and verifying route clearance and altitude during taxi; an inadequately-designed checklist (in which flaps are only mentioned one time); no memory aid/gouge that the flaps were retracted, after having been extended once already (the checklist put in the gap between the thrust levers worked for us); a takeoff warning system that would not warn of flaps being up during cold temperatures; and a desire to depart as soon as possible -- rushing(?). At my airline, a separate "Deicing/Anti-icing" checklist was implemented just to prevent this sort of thing from happening (flaps are not extended until deicing/anti-icing is complete, and only then, the flaps were set for takeoff and the "Before Takeoff" checklist performed, during which, both crewmembers had to point to the flap handle, flap gauge and takeoff setting display on the flight computer screen and verify aloud the flap setting, "Plan Flaps 5, set 5, indicating 5 [or whatever setting the flaps were supposed to be at -- either 1, 5, 10, 15, or 25, as appropriate], with a green light (verifying that the leading edge devices were extended into the proper position also). This was also before "Sterile Cockpit" procedures came into being -- which today, means no unnecessary conversation among crewmembers that is not related to the flight or safety of flight -- only business. It appears that there was no "safety net" that would catch errors before they would become critical. Lastly, CRM (Cockpit Resource Management), in which the input of all crewmembers, including the flight attendants, was considered important enough to the safety of flight to be taken into consideration might have been able to prevent this accident, because it encourages junior crewmembers to be more assertive with safety-of-flight issues.
Engineers: "Hey Boeing, the xyz system has issues that could cause a crash, that should be fixed." Boeing management: "That would cost $ to fix, leave it be." Sound familiar?
Bro, don't be stressing. We'll just install cheap computer software to make sure the flaps are extended when required, and have it all hooked up to a single sensor that is prone to failure. Airlines wont even need to provide updated training to pilots, that's how amazing it'll be. Nothing can possibly go wrong.
Bean counters often win the day. That's what led to the poor design of the Piper Cheyenne III. Engineers warned management of design flaws, but bean counters won the day.
@@richardjenkins4182 The same penny-pinching 'bean counting' helped to turn hundreds of DC-10 passengers into mincemeat* when McDonnell Douglas were allowed by the FAA to take their time retrofitting key safety mods into DC-10 hulls, in order that sales wouldn't be lost. * in1974
Just a heads up. I grew up in Anchorage. And some stories you'd cover come through here. Elmendorf is the military airfield, Ted Stevens is the civilian airfield!
These no flap takeoffs have been too frequent. Configuration warning circuit breakers switched off due to another nuicance or anomaly, 3 times in the checklist, but always towards the end and each time other communication interrupted the checklist procedure etc..
Elmendorf is in Anchorage. Elmendorf is the USAF base of operations in Alaska separated from the the Anchorage international airport by about 2 to 3 km. He would have you think the distance is so far as to be wearying rather than an annoyance.
N706PA was one of the first Pan-Am 707s. It was supposed to go to TWA, but they declined to buy it, so Pan-Am took it in 1960. Construction list #1 was Pan-Am N708PA, a model -121.
That 747 at 0:15 in that clean classic Pan Am livery is, to me, the most beautiful aircraft that ever existed. (That's Clipper Neptune's Car, btw. Delivered Mar. 2 1970, scrapped Aug. 1995. She was the 18th 747 ever built).
Well the PA logo has stood the test of time.Maybe the #1 airline logo ever. My 2nd favorite is the TWA twin globe. To dispense with it after just 15 years was a crime against liverity.
Ugh, human factor accidents are so tragic. I'm no pilot, but I have that gift of being able to instantly put supposed checklist items completely out of my mind, so no lack of empathy there. It's terrible that these talented people lost their lives, the only silver lining there were no passengers.
Yeah human factor accidents are unfortunately unavoidable. It’s easy to say “Oh I would never do that!” But think about it. How many times does the average person forget their phone, or their keys? How many times has someone forgotten to do something because they were tired or disoriented?
I lived 5 miles north of Detroit Metro airport when NW255 crashed. I was 19 years old and had been a travel agent for just about one year. It was devastating.
reminds me a bit of LAPA's 737 accident back 1996, in buenos aires. they forgot to deploy the flaps. the investigators found the pilots were talking with cabin crew about what to do next night
@Mini Air Crash Investigation - answering your question: to me, it's pretty clear the main cause of the crash was neither of things you mentioned. Those contributed, no doubt. But the main thing - that 1st officer was too careless and/or tired and/or incompetent. Whatever it is, his ability to fly that plane - was at the time nearly non-existant. Because it does not take any much experience nor any much brains to know that when you take off with cargo and crapton of fuel for the long haul - you wanna rotate later than papers say you should, and you wanna attack less than papers say you should. He didn't do that - you mention stall, and i assume he had perfectly fine engines' power there. This just doesn't happen back then with any proper 1st pilot, unless something is really, really wrong with him. Even when it's no flaps - he'd just rotate later, at higher speed, and would do just enough climb to clear ground, to maintain and increase speed, because he'd start climbing. Chances are, they'd also manage to retract gear. Back then, pilots were quick to react and i bet they knew extra drag from gear while going out that heavy - best be removed ASAP. Also, when they got the shake - that would be another urgent reason for them to retract gear, as doing so helps to go out of stall sooner / better, and pilots with their experience and back then - could hardly not know it. Back during those years, planes were not yet highly automated and digitized machines. A pilot - every pilot - had to be, well, able to fly in full sense of the word. But in this case, this 1st pilot - wasn't able to. In fact, we can't even excluse the chance that he did it on purpose. There are some few known cases when pilots crashed their planes on purpose, documented cases leaving no doubt about it. Further, if so - then we can't even be entirely sure that it was not a _noble_ _deed_ of purposefully crashing that plane, mind you! Those years, it was Cold War at its heights, and maybe, just maybe, there was something inside that plane which was really, really bad. Wrong. Best destroyed, for the good of the World. Maybe that 1st pilot crashed it on purpose? Heck, maybe it was whole crew's decision to do it? Maybe the crew was not supposed to know what they are transporting, but somehow they found out, for example? At very least, we know where that plane was flying, you know - and we know how many died in the country of its destination during and after the war (agent Orange, etc), and that great many of those deaths were really avoidable. Sadly, if something similar to previous paragraph was indeed the case - obviously, we won't find out about it from an NTSB investigation. If it was something seriously classified and yet carried by a Pan Am plane - then i'd say, chances are we'd _never_ find out about it anyhow, too.
Questions ? So are you able to safely deploy flaps and ailerons (if forgotten) at take-off while trying to gain altitude, any risk of damage? Does it all require configuration before take-off or can you deploy if needed ?
@@golson33 you can, but on a large jet it would be too late anyway since the flaps move really slow, of course if you were an airline pilot you would know that.
I always wonder how they can forget the flaps. I mean I understand how busy it gets and I also understand overlooking things, but I feel like every time you are ready to advance the throttles for take-off you would do a last 2 second visual check of the basics, and nothing is more basic than flaps, especially if you're in adverse conditions.
Smart people always knew, but later it became aknowledged by many that people aren't good at monitoring automated systems and the only good combination is when electronics is used to monitor people's actions to to somehow warn or intervene when people are making mistakes. This and some other episodes of yours show how poorly the systems can be designed. This includes the plane electronics in first place and the checklist too. I've been watching many channels on aviation disaster investigaions and like many if them but your videos are special in a way that they are very compact and at the same time as informative as the others or even better. Good job! Best wishes!
As I recall, the flight crew’s failure to set flaps for takeoff led to the crash of Northwest Airlines Flight 255 at Detroit Metro Airport in August 1987.
To busy to check flaps as your throttling up. Busy being busy is a priority issue. Stick and rudder baby. Less is more. Keep it simple. Easier said then done. Great vid clip. Thank you.
Well, I remember shortly after the Detroit crash of flight 255, I was flying with my professor boss from DTW to Atlantic City via Philly. We were to attend a science convention. Just before the takeoff I said to him semi-jokingly "I hope they extended flaps this time". And he replied: "Well, if it makes you feel any better, you may go to the cockpit and remind them". Needless to say, I didn't!
About 20+ years ago there was a crash on takeoff because “trim tabs” weren’t set properly, or at least that’s what was in the news. It was given so much coverage there was an incident of passenger rushing cockpit on takeoff cause he thought pilots forgot them.
I would expect the plane to have problems maintaining lift, but after takeoff, with the speed increasing, why did it lose lift? And why did the wing tip over? I don't understand.
I love your channel. Please make a detailed documentary on the crash of flight 5719 over Hibbing, Minnesota, killing everybody on board. There are pilot behaviorial issues involved and i feel it will have great dramatic elements which will be v.interesting to see n know. Please make a well researched video on the crash of flt 5719 over Hibbing
You can almost understand the industry and airlines not wanting to make safety changes that will cost millions of dollars. But how much does it cost to rework a checklist? Virtually nothing in the scheme of things.
It would seem all three things you mentioned played a part in the disaster. That being said, it is the responsibility of the Captain to keep his cockpit in proper working order. Pilot error seems the major part of the three potential causes. RIP to the crew.
Which is the heaviest factor for this crash? Well, as usual it is a chain of events, technical singularities, SOPs design and human vulnerability in such complex environment. So, the only question is how do we cut the fatal chain ? By improving the systems and the SOPs, developping the human factors (skills, knowledge, attitudes and competencies), the environment and the company culture, so that the risk is brought as low as possible.The job done so far is not bad, even if there are still some fails. All our colleagues that died deserve our respect by remembering them, investigating their fate, and learning, humbly, constantly from our own experiences, personal and corporate.
