[bumby]

The main reason I don’t consider it pilot error is because the pilots did not get training on the system. So the proper mitigation required quick understanding of a system they did not know about, which is incredibly difficult with an intermittent failure like MCAS. If it was identified too late, the force required for trim was too great to be applied manually. Expecting that knowledge and timing to be in place is why it’s not a reliable mitigation when there is no training.

There are lots of proximate causes, but the lack of training to avoid a new airframe certification is a huge one.