Nepal Plane Crash

[Lookleft]

Too many pilots will operate a control be it flaps or gear without actually checking what they have their hand on. Many times an Airbus has landed with the park brake on when the crew thought they had selected the flaps.

[ATC Watcher]

Originally Posted by Lookleft

Too many pilots will operate a control be it flaps or gear without actually checking what they have their hand on. Many times an Airbus has landed with the park brake on when the crew thought they had selected the flaps.

Surely you mean the speed brakes, not the parking brake . because seen the position , the form of the knob and the mechanism to activate ( turn instead of up/down movement) I would find this highly improbable. But Ok there might be a first in everything.

@ Michaelbinary :

For 2 pilots, both captains, to have made such stupid and elmentary errors and then not recognise the results of their actions and cause a perfectly servicable aircraft to crash is unforgivable.
Enough of people saying they were tired, or fatigued or stressed, flying the bloody plane was their job and between them they screwed up.

Before hanging up high the pilots here 2 facts to remember:
1- The prelim report said the props were feathered nothing else, what you say is probable but is still a speculation . Remember there are families and friends behind those pilots that may read or shown messages like yours .
2- Nobody here said they were tired , fatigued or stressed. We did ( I was one of the first) raised the issue as one of the possible contributing causes, but only the report will establish if it played a role here.

Apportioning blame should not be part of any aviation investigation , which is basically what you just did , and worse not knowing all the facts

[Less Hair]

The leaked memo with the suggestions/ early lessons learned did mention fatigue and the need to improve duty hours. And it mentioned a need to check instructors to operate by manufacturer approved procedures and standards.

[Lookleft]

Surely you mean the speed brakes, not the parking brake . because seen the position , the form of the knob and the mechanism to activate ( turn instead of up/down movement) I would find this highly improbable. But Ok there might be a first in everything.

​​​​​​​Nope I mean park brakes and not just a first, its happened on at least 5 occasions. On an A320 the park brake is next to the flap handle.

[B888]

Safety Pilot

Not sure if this was suggested before, but when there’s training in the cockpit, normally there’s a safety pilot in the jump seat.
may have helped in this situation.

[parkfell]

Originally Posted by B888

Not sure if this was suggested before, but when there’s training in the cockpit, normally there’s a safety pilot in the jump seat.
may have helped in this situation.

A covering pilot in the jump seat would be present with a (new) FO line training until the LTC dispenses with the third pilot at some point.
With a FO being trained up as (new) Captain occupying the LHS on a type already qualified as a FO, unlikely to have a covering pilot.
They should be a third pair of eyes although that proved to be untrue on the Turkish 737-800 at AMS which stalled on final approach.

[airbow]

Originally Posted by B888

Not sure if this was suggested before, but when there’s training in the cockpit, normally there’s a safety pilot in the jump seat.
may have helped in this situation.

My understanding was that both captains were already qualified on the ATR 72, the captain on the left was taking an airport familiarization course however. There have been multiple events in the past where having additional pairs of eyes in the flightdeck proved useless as parkfell mentionned.

[ehwatezedoing]

Originally Posted by 9 lives

June 2019 in Canada, the PNF pulled the condition levers to shutdown on a cargo Basler DC-3T by mistake, and you have to pull them past a gate to do it! Splashed the plane.

Actually one of his arm/hand/coat caught both condition levers while operating gear up through a weird move is my understanding. The gate you mention is a simple metal corner to pass by moving those levers sideway before down/Stop. Those corners can be worn out enough not to do their job properly.
I'm pretty sure both Basler's guys knew right away what happened and just didn't have enough time to do a restart contrary to the obvious cockpit confusion in the Nepal crash.

I’m wondering was there a medical issue affecting PM?

Might as well call both of them on the medical issue then! Assuming the prop levers were pulled by mistake (Which as correctly mentioned by ATC Watcher we cannot yet)

[sycamore]

Do we actually have any current ATR pilots here to explain how the condition levers and flap levers are operated..?As I understand it the CLs have `release buttons underneath the `knobs`,which have to be lifted ,before moved,Does the flaplever have to be moved in a similar fashion between settings...? Was the prop setting at 100%,before the event,or is that only done on `finals`...?
I have watched Magnar`s training videos,but in-cockpit operations it is difficult to see if the PM actually `looks`before selecting either,flap or CL lever.

[ATC Watcher]

Originally Posted by Less Hair

The leaked memo with the suggestions/ early lessons learned did mention fatigue and the need to improve duty hours. And it mentioned a need to check instructors to operate by manufacturer approved procedures and standards.

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

​​​​​​​Nope I mean park brakes and not just a first, its happened on at least 5 occasions. On an A320 the park brake is next to the flap handle.

Incredible seen the difference in shape, and operation. . I must revise my human factors list of ergonomics nightmares.stories ...
@Parkfell :

​​​​​​​They should be a third pair of eyes although that proved to be untrue on the Turkish 737-800 at AMS which stalled on final approach.

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.

[Johntheo]

I'd say this wasn't the first time that the props were feathered but the mistake was spotted in time, I'm quite surprised that there isn't a audible warning that they have been feathered, looking at the position of those levers, especially with flaps 15 selected and when flaps 30 are called for then IMO its almost inevitible that someone will, under the "right" conditions, pull the wrong lever(s).

The Staines accident occured despite having three pilots, a P1 and a P2 plus additionally, a monitoring pilot, a P3 sitting back between them. After this accident a speed baulk was installed to prevent retraction of the droop lever until the speed was above the stall speed. BEA said that the likelihood of someone retracting the droops before the stall speed was exceeded was very low because the droop lever only became unguarded when the flap lever was moved, it then only took something like 10 secs for the speed to build up to exceed the stall limit.

[blind pew]

Originally Posted by Johntheo

I'd say this wasn't the first time that the props were feathered but the mistake was spotted in time, I'm quite surprised that there isn't a audible warning that they have been feathered, looking at the position of those levers, especially with flaps 15 selected and when flaps 30 are called for then IMO its almost inevitible that someone will, under the "right" conditions, pull the wrong lever(s).

The Staines accident occured despite having three pilots, a P1 and a P2 plus additionally, a monitoring pilot, a P3 sitting back between them. After this accident a speed baulk was installed to prevent retraction of the droop lever until the speed was above the stall speed. BEA said that the likelihood of someone retracting the droops before the stall speed was exceeded was very low because the droop lever only became unguarded when the flap lever was moved, it then only took something like 10 secs for the speed to build up to exceed the stall limit.

Unfortunately BEA had a procedure whereby all three pilots were required to write down ATC clearances which probably happened and as such both P1 and P3 were doing so when the droop was selected in.

[tfx]

Yes. Well if it was me I would've put the condition levers on opposite sides of the throttle box, outboard of the throttles. One on the left and one on the right.

[tfx]

And while I'm at it, can we have an end to this ridiculous term "Pilot Monitoring"? "Monitor" has a colour of policing, which is the last thing we want. The term should be "Support Pilot", and I marvel so many of us have got it so wrong for so long.

"Flying Pilot", "Support Pilot", okay?

[Grummaniser]

Not being a suitably qualified pilot, may I ask: are the condition levers moved to full feather as part of the normal post flight procedures? If so I wonder if a partial explanation of the erroneous selection of the condition levers was that the right seat pilot had already done that action twice that day so it would not feel as inappropriate as it otherwise would, muscle memory being another part of the equation.
All this assuming that the final report does indeed conclude that the feathering was manual and not due to some mechanical failure.

[FlexibleResponse]

@ATC Watcher

Quote:
Originally Posted by Lookleft View Post
Too many pilots will operate a control be it flaps or gear without actually checking what they have their hand on. Many times an Airbus has landed with the park brake on when the crew thought they had selected the flaps.
Surely you mean the speed brakes, not the parking brake . because seen the position , the form of the knob and the mechanism to activate ( turn instead of up/down movement) I would find this highly improbable. But Ok there might be a first in everything.

@ Michaelbinary :
Quote:
For 2 pilots, both captains, to have made such stupid and elmentary errors and then not recognise the results of their actions and cause a perfectly servicable aircraft to crash is unforgivable.
Enough of people saying they were tired, or fatigued or stressed, flying the bloody plane was their job and between them they screwed up.
Before hanging up high the pilots here 2 facts to remember:
1- The prelim report said the props were feathered nothing else, what you say is probable but is still a speculation . Remember there are families and friends behind those pilots that may read or shown messages like yours .
2- Nobody here said they were tired , fatigued or stressed. We did ( I was one of the first) raised the issue as one of the possible contributing causes, but only the report will establish if it played a role here.

Apportioning blame should not be part of any aviation investigation , which is basically what you just did , and worse not knowing all the facts
ATC Watcher is offline

Look at it from the reverse perspective...

On each and every flight, pilots make hundreds or even thousands of safe and correct selections and decisions that prevent a catastrophe and crash killing everybody.

This has to be performed to 100% on each and every flight to be a safe sector without hull loss.

It is only when one of these things is screwed up that an accident ensues...

[fdr]

Originally Posted by Lookleft

Too many pilots will operate a control be it flaps or gear without actually checking what they have their hand on. Many times an Airbus has landed with the park brake on when the crew thought they had selected the flaps.

Then the instructors, examiners and systems that accept that basic failure to occur as a routine need to be corrected in their processes. Have we devolved that far? We just plonked a F-35B in the brine with a ramp strike, as the JG was relying on modes that were not selected, and not monitoring the dynamics of his aircraft. Perhaps flight crew that want to play Nintendo so do so, away from aircraft that are dynamic, filled with lots of hydrocarbons and kinetic energy (well, supposed to be...) and filled with soft centered gooey stuff we tend to have affections for.

Is the design brilliant? Nope, when ah HS748 looks like an ergonomic miracle, it is time to revisit the Part 25 bits that surround HMI, but until then, would it not be nice for people to do pilots things when they dress up in fancy dress.

[fdr]

Originally Posted by FlexibleResponse

@ATC Watcher



Look at it from the reverse perspective...

On each and every flight, pilots make hundreds or even thousands of safe and correct selections and decisions that prevent a catastrophe and crash killing everybody.

This has to be performed to 100% on each and every flight to be a safe sector without hull loss.

It is only when one of these things is screwed up that an accident ensues...

Its better and worse than that. The potential for a bad day out exists on every flight, it is the human interest in the proceedings that has the potential to rectify issues that occur that were not able to be preprogrammed into a routine. The minor setback is the variability of human performance, and the potential for distraction, undetected errors etc to occur. It is this area that makes flying interesting, and the truth is, that to an extraordinary extent an aircraft with 400 people and cargo on board with immense kinetic energy gets to go from one part of the planet to another, dealing with the vagaries of birds, dogs, scooters, thunderstorms, fog, mechanical failure, computer errors (cosmic or earthly) and the complexity of air traffic management in a system that still has people yelling at each other on HF to get a message across. Humans make errors, many errors every hour of every day. The pilot is being paid to manage error, to review, and correct if mitigation didn't result in avoiding the errors. Selecting the engines to feather is a slip, that happens; realising that the flaps hadn't moved 42 seconds later and then reselecting the flaps, and not wondering what had been moved before is a total loss of SA. The first error is an SA 1 event, followed by an SA 2 event. It is pretty sad, and we keep on doing the same thing still.

Hours in the aircraft do not correlate linearly to safety, something that insurers should comprehend but do not.

[michaelbinary]

Originally Posted by tfx

And while I'm at it, can we have an end to this ridiculous term "Pilot Monitoring"? "Monitor" has a colour of policing, which is the last thing we want. The term should be "Support Pilot", and I marvel so many of us have got it so wrong for so long.

"Flying Pilot", "Support Pilot", okay?

Completely irrelevant. Its just a word, semantically it means the same. One pilot is flying the plane, one pilot is monitoring actions, controls, dials, levers, switches, whatever you want. Thats their job, call it support, monitoring, checking, whatever you want.They didnt do their job properly, they werent aware of what was going on, they didnt think hmmm, I selected full flaps before, how can I be doing it again, I wonder what I moved last time, etc etc.

[vilas]

Originally Posted by Lookleft

Nope I mean park brakes and not just a first, its happened on at least 5 occasions. On an A320 the park brake is next to the flap handle.

​​​​​​​In A320 putting parking brake on instead of selecting flaps is the dumbest thing any one can do. The brake lever is not in line with flap lever. Brake lever rotates, flap lever needs to be squeezed and extended.