Originally Posted by
ptarmigan
I would say that that the concept of "root cause" is entirely a human construct. Accidents these days are a complex interaction of many components that are not possible to separate out. They are also not linear event sequences (the idea that it is layers of cheese as Jim Reason once used, but even he disavowed later) is really just a domino model. With complex and highly coupled systems we see interactions that are very difficult to anticipate using conventional methods. This was actually the topic of a talk I co-presented at the ISASI annual seminar a few weeks ago. The conference paper is available on the ISASI website, here
http://isasi.org/Documents/library/t...20Systems.docx
Equipped to comment from but one guy's perspective. Can only to describe the analysis attached as…comprehensively excellent. Could go on to detail circumstances (LCA/ASAP board/Pt.142/Pt.119) where FLCH & A/T interface may be in conflict with stabilized visual approaches but, it's all there really.
Returning to AF447 for a moment. Don't personally regard the known human factors as, a conclusion. Like so many others, just seek to better understand how what might have been for one crew, a readily solved anomaly yet for another, 7 mile dive into ghastly statistical record.