While most investigations find evidence suggesting why mistakes happened, in some cases it seems impossible to envisage why flight crew made the mistakes that they did. Two accidents are briefly described. In each of the cases it is difficult to envisage how the experienced crew could have made the catastrophic errors that they did, unless they were impaired in some way. It appears possible that this could have been the result of ingesting oil products.
This is a publication from the International Aircraft Cabin Air Conference 2021 (Online, 15-18 March 2021)