The men are utterly failing to engage in an important process known as crew resource management, or CRM. They are failing, essentially, to cooperate. It is not clear to either one of them who is responsible for what, and who is doing what.
I have read a few other transcripts from crashed planes and this seems to be the most common and significant contributor.
I see variations of this problem almost daily in my day to day work. It strikes me so many times that people flat out refuse to communicate or do do in an extremely ambiguous fashion, people violate responsibility boundaries all the time (faux-technical people forcing technical decisions for e.g.) and that directly results in losses far greater than they should have been if there was any notion of discipline and communication.
CRM is interesting stuff. It got popular in aviation after the crash of United 173,[0] where the crew was so involved in a serious landing gear problem that the only one who noticed that they were running out of fuel apparently didn’t want to be rude enough to insist on dealing with it before it was too late. In that case, it was generally interpreted as too much respect for authority: the junior crew member didn’t want to distract the captain by raising the fuel problem too often. So that can go both ways.
United 173 was only a particularly good example of exactly what you point out: many plane crashes happen when individual crew members miss simple things that others could easily correct but don’t. After flight crews got CRM-based training, the incidence of this kind of thing went down measurably. But as I was reading this transcript, it was eerie to see how little they were applying it. Why were they practically silent? If they’d each volunteered a little more information about observations, intentions, and actions (“I’m leaving the stick full forward”), they’d have been fine.
Anyway, I think CRM has some pretty clear applications to normal business environments, but especially to startups. The jumbled panorama of interlocking and quickly developing options confronting a small team of coders is not unlike an aviation emergency, though at a slower pace.
I don't want to in any way refute the referenced article or the findings of the air crash investigators, because clearly the pilots here behaved incorrectly and I am just an outsider.
However I think it's worth at least mentioning that both airlines and aircraft manufacturers have a vested interest and significantly more resources to put behind demonstrating that pilot error is the primary cause of any accident.
For instance in this case you have...
• poor training (pilots unprepared for alternate law)
• possibly poor UI (de-coupling of controls, insufficient communication that aircraft had lapsed to alternate law)
• small-scale systems failure (pitots)
vs
• incorrect response and continued failure to understand aircraft attitude (in turbulence, with no visual cues, in a situation which 'fooled' three pilots)
...which makes it an interesting one for manufacturer and airline to definitively defend, but I would guess that they can and will absolve themselves from liability.
In one of Malcolm Gladwell's books he talks about air crash scenarios, citing several cases where copilots were 'scared' of pointing out errors that they thought were being made by their captains. I think it was Korean airlines that lost a few planes this way, essentially through a lack of communication.
They brought in some guy to retrain the pilots and they never had the problem again.
This was also one of the points of Malcom Gladwell in one of his book ("the Tipping point"), where he talked about what went wrong in several examples of air crashes: lack of human cooperation at its best.
I have read a few other transcripts from crashed planes and this seems to be the most common and significant contributor.
I see variations of this problem almost daily in my day to day work. It strikes me so many times that people flat out refuse to communicate or do do in an extremely ambiguous fashion, people violate responsibility boundaries all the time (faux-technical people forcing technical decisions for e.g.) and that directly results in losses far greater than they should have been if there was any notion of discipline and communication.