Originally Posted by
ATC Watcher
Yes but according to
grizzled who posted this memo , it was leaked on Jan 30th , and we know now that the CVR/FDR were not read in Nepal and well after this date. reading it again , especially the first line of it :
The existing approach procedure for domestic air operators was critically reviewed ,,etc.. and continues saying : all airplanes in Nepal oerating in STOL airfields , etc..
On second toughts it looks like this satement was probably in pipeline before the accident and the Team used the accident to leak it , to show they were on top of things, but I doubbt it was written, at least not in its totality, especially for this Yeti ATR accident .But maybe it was , we;ll see when the final is out.
@Lookleft
Incredible seen the difference in shape, and operation. . I must revise my human factors list of ergonomics nightmares.stories ...
@Parkfell :
indeed and we could add Asiana 777 in SFO which also stalled with 3. But to be fair on many other incidents a 3rd or even 4th ( QF32 ) saved the day.
Given there are many examples in this thread alone of incorrect controls being operated, regardless of shape and location, the question we should perhaps be asking is: How ofter has a PM or PF for that matter, gone towards the wrong control but self corrected? IE no one but them would know about it. I am betting we would be amazed at how often it happens and has always happened. SOPs have been introduced to reduce the risk of it going unnoticed but even those could be susceptible to Conformation bias.( I think thats the bias i mean!) Increasingly complex aircraft and automation may indeed make it more likely.
I applied aviation principles to an IT environment a few years ago and once we had created a safe environment where team members felt comfortable to talk, we were all amazed at what came up at our 1st near miss meeting! This was all prompted by someone accidentally shutting down a production server instead of a test one. Out of 20 people in the meeting, 75% said they had nearly done the same thing! We also looked at factors at play when these near misses took place and the usual suspects were there but for a significant minority, we could not identify the potential 'why'...
Simply writing it off as stupidly, laziness, mind not on the job, unprofessional behaviour is, well stupidity IMHO.