US Summary Comments on Draft Final Report of Aircraft Accident Flash Airlines flight 604, Boeing 737-300, SU-ZCF 3 January 2004, Red Sea near Sharm El Sheikh, Egypt. Quote from page 5 of 7:
"Distraction. A few seconds before the captain called for the autopilot to be engaged, the aircraft's pitch began increasing and airspeed began decreasing. These deviations continued during and after the autopilot engagement/disengagement sequence. The captain ultimately allowed the airspeed to decrease to 35 knots below his commanded target airspeed of 220 knots and the climb pitch to reach 22°, which is 10° more than the standard climb pitch of about 12°. During this time, the captain also allowed the aircraft to enter a gradually steepening right bank, which was inconsistent with the flight crew's departure clearance to perform a climbing left turn. These pitch, airspeed and bank angle deviations indicated that the captain directed his attention away from monitoring the attitude indications during and after the autopilot disengagement process. Changes in the autoflight system's mode status offer the best explanation for the captain's distraction. The following changes occurred in the autoflight system's mode status shortly before the initiation of the right roll: (1) manual engagement of the autopilot, (2) automatic transition of roll guidance from heading select to control wheel steering-roll (CWS-R), (3) manual disengagement of the autopilot, and (4) manual reengagement of heading select for roll guidance. The transition to the CWS-R mode occurred in accordance with nominal system operation because the captain was not closely following the flight director guidance at the time of the autopilot engagement. The captain might not have expected the transition, and he might not have understood why it occurred. The captain was probably referring to the mode change from command mode to CWS-R when he stated, “see what the aircraft did?,” shortly after it occurred. The available evidence indicates that the unexpected mode change and the flight crew’s subsequent focus of attention on reestablishing roll guidance for the autoflight system were the most likely reasons for the captain’s distraction from monitoring the attitude".
[16]