Nepal Plane Crash
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https://www.tourism.gov.np/files/1/9...L%20Report.pdf
Final Report is Out .
Alternate Link: https://we.tl/t-39xcRO1Bl6
Final Report is Out .
Alternate Link: https://we.tl/t-39xcRO1Bl6
Last edited by Yo_You_Not_You_you; 28th Dec 2023 at 11:55.
Thanks for the link to the report.
Quick overview:
No contributing mechanical issue with 'plane.
Two captains in the cockpit, one under training for the airport in question. PF ~6000hrs PM ~22000hrs. PM had been into this aerodrome 2 x previously.
On approach PF called for flaps 30, PM feathered props instead. Lack of 'power' noted by PF, PM stated to continue when questioned, power increased (still in feather), flaps eventually lowered. PM took over and held stick back in shake.
Report discusses workload + stress amongst other factors that include poor CRM, lack of checklist use, poor training. Difference in headsets noted (I mention this because of earlier discussions around ANR).
Personal observation: the questioning by the PF and the responses from the PM, and the age+gender of the people concerned, leads me to wonder whether there may have been a culture factor involved in the outcome? I want to be clear that this is a question in my mind, not a statement; I know next to nothing about this part of the world, nor this airline, but as such things have contributed to similar events in the past it raises a flag to me that I should try to learn more about these [possible] issues.
FP.
Quick overview:
No contributing mechanical issue with 'plane.
Two captains in the cockpit, one under training for the airport in question. PF ~6000hrs PM ~22000hrs. PM had been into this aerodrome 2 x previously.
On approach PF called for flaps 30, PM feathered props instead. Lack of 'power' noted by PF, PM stated to continue when questioned, power increased (still in feather), flaps eventually lowered. PM took over and held stick back in shake.
Report discusses workload + stress amongst other factors that include poor CRM, lack of checklist use, poor training. Difference in headsets noted (I mention this because of earlier discussions around ANR).
Personal observation: the questioning by the PF and the responses from the PM, and the age+gender of the people concerned, leads me to wonder whether there may have been a culture factor involved in the outcome? I want to be clear that this is a question in my mind, not a statement; I know next to nothing about this part of the world, nor this airline, but as such things have contributed to similar events in the past it raises a flag to me that I should try to learn more about these [possible] issues.
FP.
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Almost nothing said about possible fatigue in that report, other than "Previous rest period" -- "As per CAAN requirements" and a fleeting reference to a "SHELL model" for Human Factors.
The hours flown in the previous 7 days, 30 days, 3 months and 12 months are all given, but nothing about the work patterns for those hours, especially over the week and month before the crash. It will all no doubt be "As per CAAN requirements", but do those 'requirements' make sense in those circumstances? A training captain training a new captain means both of them sitting in seats that they are not 'every day' familiar with. The cumulative fatigue of that can be significant. How many sectors had they flown that week? Were they all early starts? That was their third sector that day, what time did they start that day? That was a very short sector with obviously very high workloads and the two previous sectors were very similar, had they all been like that in the preceding few days?
The report says: "The CVR transcript captured a flight deck environment rich with discussion on the appropriate way to fly a visual approach into the new Pokhara Airport. Both pilots were experiencing high workload, distractions to the external environment, and may have impacted on effective CRM within the cockpit. This may have lead them to not follow the checklist properly in critical phases of flight. The crew were most probably distracted due to excessive conversation in cockpit because the flight was first for the PF and the PM was occupied with providing instructions and was not focused on the PM duties." Yes, it was a training flight!! You teach by talking!!!
There is not enough information given about the fatigue possibilities as a contribution to this crash, other than a fleeting comment that some computer model does not consider that to be a factor: "A 72-hour history of both crewmembers indicated that fatigue ... [was] not a factor prior to the accident. Both pilots were reported to have eaten routine foods, went to bed, and rose at routine hours.". From personal experience in very similar circumstances, I feel that fatigue is a very, very valid factor in this crash and the report does not look into that aspect in anywhere enough detail.
The hours flown in the previous 7 days, 30 days, 3 months and 12 months are all given, but nothing about the work patterns for those hours, especially over the week and month before the crash. It will all no doubt be "As per CAAN requirements", but do those 'requirements' make sense in those circumstances? A training captain training a new captain means both of them sitting in seats that they are not 'every day' familiar with. The cumulative fatigue of that can be significant. How many sectors had they flown that week? Were they all early starts? That was their third sector that day, what time did they start that day? That was a very short sector with obviously very high workloads and the two previous sectors were very similar, had they all been like that in the preceding few days?
The report says: "The CVR transcript captured a flight deck environment rich with discussion on the appropriate way to fly a visual approach into the new Pokhara Airport. Both pilots were experiencing high workload, distractions to the external environment, and may have impacted on effective CRM within the cockpit. This may have lead them to not follow the checklist properly in critical phases of flight. The crew were most probably distracted due to excessive conversation in cockpit because the flight was first for the PF and the PM was occupied with providing instructions and was not focused on the PM duties." Yes, it was a training flight!! You teach by talking!!!
There is not enough information given about the fatigue possibilities as a contribution to this crash, other than a fleeting comment that some computer model does not consider that to be a factor: "A 72-hour history of both crewmembers indicated that fatigue ... [was] not a factor prior to the accident. Both pilots were reported to have eaten routine foods, went to bed, and rose at routine hours.". From personal experience in very similar circumstances, I feel that fatigue is a very, very valid factor in this crash and the report does not look into that aspect in anywhere enough detail.
How on earth do you mistake the condition levers for the flaps in an ATR? You almost couldn’t do that if you tried. There are two condition levers and one flap, the condition levers are bigger, longer, different shape entirely. It’s an astounding mistake.
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Bottom line, the pilot made a huge mistake and we should not try to cover it up with the fatigue excuse again. We should learn from it. Look then activate at a normal pace.
I still remember my memory items for an emergency in skydiving in order to deploy the reserve chute when the main parachute does not deploy: LOOK-REACH-PULL. And that no doubt came from the fact that people died because they were pulling on something other than the reserve handle for the rest of their life.
The fatigue thing is irrelevant. I suspect I know exactly what happened. Why? Because I once reached for the wrong lever(and tried to operate it) when landing flaps was called(damn good thing what I tried to activate didn't activate). Why did this happen? Because I didn't look before touching, which is something all pilots should do. And instead of making a deliberate action at moderate speed, I reached out quickly and grabbed.
Bottom line, the pilot made a huge mistake and we should not try to cover it up with the fatigue excuse again. We should learn from it. Look then activate at a normal pace.
I still remember my memory items for an emergency in skydiving in order to deploy the reserve chute when the main parachute does not deploy: LOOK-REACH-PULL. And that no doubt came from the fact that people died because they were pulling on something other than the reserve handle for the rest of their life.
Bottom line, the pilot made a huge mistake and we should not try to cover it up with the fatigue excuse again. We should learn from it. Look then activate at a normal pace.
I still remember my memory items for an emergency in skydiving in order to deploy the reserve chute when the main parachute does not deploy: LOOK-REACH-PULL. And that no doubt came from the fact that people died because they were pulling on something other than the reserve handle for the rest of their life.
It’s and absolutely shocking error.
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Fatigue might have played a role , but on the list of contributing factors ( pages 68/69) points 9 to 12 are the real external contributing factors.
As to why a Captain with so many hours on type would confuse a single Flaps lever with two conditions ones is a mystery and can probably only be explained by a neuro-Psychiatrist. : What the brain can do during high stress.
As to why a Captain with so many hours on type would confuse a single Flaps lever with two conditions ones is a mystery and can probably only be explained by a neuro-Psychiatrist. : What the brain can do during high stress.
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the pilot made a huge mistake
This is miles beyond a simple mistake.
we should not try to cover it up with the fatigue excuse again
Refusing to accept that fatigue is a possible cause of bad mistakes will simply result in these sort of bad mistakes repeating themselves over and over again.
That pilot did not want to make that bad mistake. So what caused that bad mistake.
Have any of you sat in the right seat of a turbo-prop training a new captain towards the end of a run of tiring (early!) duties? Both of you are in seats that are unfamiliar to you. That had been a very short sector so a very high workload. Add fatigue onto that 'pile' of problems and you run the risk of exactly this sort of disaster. To deny that fatigue can be a very significant factor is a refusal to look at reality.
This report has not sufficiently considered this problem.
What the brain can do during high stress.
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I was always trained (by multiple Captains) once you have the control knob in your hand (whether you looked to get there or not) pause, identify the control to yourself, or co crew member if two crew, and confirm - then move it as needed. More modern airplanes try to help the pilot keep this all straight with requirements for control location, motion, knob colour and shape. Earlier airplanes, less so. I was reminded of this flying two different deHavilland Beavers last summer, where the engine controls of the older one were original, and therefore in a different order, and knob shape to the more recent rebuilt one I had flown weeks before.
I cannot imagine how two condition levers are mistaken for one flap lever! Everything is different! As a person who approves cockpit control design, what more can I do to consider defeating such errors in better design?
I cannot imagine how two condition levers are mistaken for one flap lever! Everything is different! As a person who approves cockpit control design, what more can I do to consider defeating such errors in better design?
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Would Fatigued Pilots do a new approach to RW12 that is uncommon and hard on their own , not directed by Airliner or authority .
Increased Workload on the new approach, sure . this approach is rather familiar for them who just few week back used to land on the Old Airport . The Base leg on NEW airport looks like the final on the OLD airport that they are quite familiar with . It does involve one extra turn at low altitude .
Is 186 hours on Type for PF and 3300 Hour on Type for PM , considered a steep cockpit gradient ?
Where is PF getting Information about No Torque , No Power ? Where will PM look first to verify the No Torque , No Power or do to mitigate it ?
Increased Workload on the new approach, sure . this approach is rather familiar for them who just few week back used to land on the Old Airport . The Base leg on NEW airport looks like the final on the OLD airport that they are quite familiar with . It does involve one extra turn at low altitude .
Is 186 hours on Type for PF and 3300 Hour on Type for PM , considered a steep cockpit gradient ?
Where is PF getting Information about No Torque , No Power ? Where will PM look first to verify the No Torque , No Power or do to mitigate it ?
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Agreed.
Agreed, we should not "cover it up". But refusing to accept that fatigue could have played a part is a "cover up" on its own!! Fatigue is not an "excuse", if it is a factor it is a reason.
Refusing to accept that fatigue is a possible cause of bad mistakes will simply result in these sort of bad mistakes repeating themselves over and over again.
That pilot did not want to make that bad mistake. So what caused that bad mistake.
Have any of you sat in the right seat of a turbo-prop training a new captain towards the end of a run of tiring (early!) duties? Both of you are in seats that are unfamiliar to you. That had been a very short sector so a very high workload. Add fatigue onto that 'pile' of problems and you run the risk of exactly this sort of disaster. To deny that fatigue can be a very significant factor is a refusal to look at reality.
This report has not sufficiently considered this problem.
What a fatigued brain can do during high stress.
Agreed, we should not "cover it up". But refusing to accept that fatigue could have played a part is a "cover up" on its own!! Fatigue is not an "excuse", if it is a factor it is a reason.
Refusing to accept that fatigue is a possible cause of bad mistakes will simply result in these sort of bad mistakes repeating themselves over and over again.
That pilot did not want to make that bad mistake. So what caused that bad mistake.
Have any of you sat in the right seat of a turbo-prop training a new captain towards the end of a run of tiring (early!) duties? Both of you are in seats that are unfamiliar to you. That had been a very short sector so a very high workload. Add fatigue onto that 'pile' of problems and you run the risk of exactly this sort of disaster. To deny that fatigue can be a very significant factor is a refusal to look at reality.
This report has not sufficiently considered this problem.
What a fatigued brain can do during high stress.
But if a fatigued pilot looks before activating a lever, they are unlikely to do what happened on this ATR. Meanwhile, a non-fatigued pilot activating without looking is quite likely to create a problem. Yes, the flap lever and the condition levers are quite different on the ATR but the flap lever and the gust lock lever on the HS-748 are quite different as well, yet I pulled on the gust lock lever once instead of flaps(fortunately, it has to be pulled straight initially instead of aft). Grabbing and pulling quickly without confirming can cause major issues.
Sometimes, I suspect the people wanting a better schedule like to blame fatigue. I mean seriously.....we are told that it was their third sector of the day. I used to do 8 sectors overnight on one type I flew.
Now don't get me wrong, I believe that fatigue can cause accidents. But one needs to look before activating, whether wide awake or dead tired.
Last edited by punkalouver; 30th Dec 2023 at 11:47.
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First thing I noticed is 821 hours flown by PM in previous 12 month and its a lot for this kind of airplane and environment. With short legs and routine predictability you are using muscle memory instead of brain. Probably they were both looking outside to find new runway and were in a rush. So when he accidentally grabbed condition levers his hands played trick on him and feathered props without him noticing - yes, both levers are protected by a mechanical lock but its a simple spring lift switch. It would be interesting to see their post landing SOP's to find out who and when feathers props on a parking stand and if they have a callout for that. In my airline only captain had a tiller and he would taxi to stand and then feather both engines without a callout, but later is was changed when they introduced one engine taxi.
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