ATR-72 crash at PKR, Nepal. Many fatalities feared.

[Gabriel]

The levers are very different: Different shapes, different colors, different heights, different operations (squeeze latch under the handle vs lift the full handle).

However, we need to understand 2 different kinds of brain fart: Bad aim (you aim for the right stuff but you miss) vs aiming for the wrong thing.
The features I mentioned above are very powerful to stop the first kind. If your brain is looking to lift a flap-shaped handle and your hand touches 2 square knobs with latches underneath your brain will jump at once. But if the flying pilot says "flaps 30" and the copilot's brain says "where are my square levers with the squeeze latches underneath", it will never detect the mistake. At least not initially. If the airplane's (or car, or boat) reaction is crisp and clear, at that point the pilot may connect the dots and see if it is because the thing he just did, and then realize.

When a 747 took off, the PM called "positive climb" and the PF called "gear up", all the difference in the world didn't stop the the PM from grabbing a flap-shaped handle and moving it forward, instead of garbing a round handle on the instrument panel, miles away from the correct one, and moving it up. It took the stickshaker to activate for the PM to say WTF and check what he had just did, discover his mistake in horror, and correct it, all the while the PF masterfully treaded the needle by lowering the nose just enough to prevent the stall and prevent contacting the ground at the same time, managing to keep the AOA at the onset of the stickshaker.

[xspeedy]

Should the aircraft call out audibly when certain controls are moved or selected? So when the prop levers were moved to feather, the aircraft could have followed with “props feathered”. Same for flaps or gear - “flaps thirty”, “gear down”. Obviously the A/C knows what was set better than the PM in this case.

[3WE]

Should the aircraft call out audibly when certain controls are moved or selected? So when the prop levers were moved to feather, the aircraft could have followed with “props feathered”. Same for flaps or gear - “flaps thirty”, “gear down”. Obviously the A/C knows what was set better than the PM in this case.

Yes.

[Evan]

Should both pilots call out audibly when certain controls are moved or selected?

Yes. It's called crosscheck.

[TeeVee]

i think evan missed the point and clearly cross-check would not help if the guy moving the control THOUGHT he moved the correct control, e.g., "PF: flaps 30. PM (after moving the CL) Flaps 30."

[Evan]

Okay, if the crosscheck doesn't involve any actual checking than you are right. Even if glancing down at the pedestal is too much to ask, there is a forward panel instrument to scan. Actually, while an audible flap position annunciation might be too intrusive, I think it would be a magnificent idea if there were an audible "prop feather left (right)" annunciation along with the amber warning lights and the master caution. And if both are feathered in flight, it should come after a master warning, cavalry charge kind of thing. Basically, both engines just fell off the airplane.

[Gabriel]

i think evan missed the point and clearly cross-check would not help if the guy moving the control THOUGHT he moved the correct control, e.g., "PF: flaps 30. PM (after moving the CL) Flaps 30."

Pilots should check that their actions have the intended consequence. Ok, I moved the flaps lever to 30 (or I think I did, that is was I intended to do and I did move something to accomplish that). Are the flaps moving? Did the flaps (not the lever) reach the 30 position?

And they should also check each other's action. Not to mention that the pilot flying should watch the airspeed and the pilot monitoring should monitor it. And I am still waiting to see what kind of bells and whistles they got when they feathered the propellers.

Remember the PIA accident that landed gear up?

[TeeVee]

i'm not a pilot. not even a sim pilot. i can find my way around a cockpit to a limited extent and have a rudimentary understanding of what does what. having said that, i have jump-seated on a number of challenger 300 flights with my friend and his #1. i dont remember ever seeing the PF double check what the PM said he did, though admittedly I wasnt watching for it. and having watched my fair share of real world cockpit youtube videos, it doesnt appear that way either. i mean, there has to be a degree of trust, right?

i suspect the result of this investigation is going to leave us as we were after AF447--absolutely dumbfounded and bewildered at how some experienced pilots totally flubbed-up. they paid the ultimate price for their errors, but ~68 others did as well.

[Evan]

Pilots should check that their actions have the intended consequence. Ok, I moved the flaps lever to 30 (or I think I did, that is was I intended to do and I did move something to accomplish that). Are the flaps moving? Did the flaps (not the lever) reach the 30 position?

And they should also check each other's action. Not to mention that the pilot flying should watch the airspeed and the pilot monitoring should monitor it. And I am still waiting to see what kind of bells and whistles they got when they feathered the propellers.

Remember the PIA accident that landed gear up?

Remember why?

Configuration should be done when it doesn't compete with other, seemingly more urgent things, like maneuvering and navigating and trying to save an approach. That's why we have stabilized approach criteria and nice, long finals with precision guidance. The only time to not take advantage of these things is when they are not available or unsafe for some reason.

One of the key products of three decades of air crash investigations is that we know pilot error happens for a reason. Finding that reason is as important as finding the pilot error.

[Gabriel]

Remember why?

Why what?

Configuration should be done when it doesn't compete with other, seemingly more urgent things, like maneuvering and navigating and trying to save an approach.

It looks to me the intended flaps 30 came at an appropriate time of the approach. Above 700ft, apparently before starting the turn, before performing the landing checklist (where they missed the flaps 30 again). At this point they completed the landing configuration, or so they thought.

[3WE]

You guys sure use a lot of words…there’s actually two checks…1. 30-SELECTED (visual confirmation of lever and 2 INDICATED- flap position indicator officially checked …yeah, type specific blah blah, but lumper man was thinking that’s a bit universal…


Just like 1. Gear down 2. Three green

[Gabriel]

You guys sure use a lot of words…there’s actually two checks…1. 30-SELECTED (visual confirmation of lever and 2 INDICATED- flap position indicator officially checked …yeah, type specific blah blah, but lumper man was thinking that’s a bit universal…


Just like 1. Gear down 2. Three green

Yes, well, but one more: Landing checklist.

Like you said, same as with the gear:

1. gear down
2. three green,
3. check 3 green again in landing checklist.

Landing checklist is also a bit universal.

[Evan]

Why what?


It looks to me the intended flaps 30 came at an appropriate time of the approach. Above 700ft, apparently before starting the turn, before performing the landing checklist (where they missed the flaps 30 again). At this point they completed the landing configuration, or so they thought.

The initial configuration was done correctly on the nice, long downwind. The landing configuration was done at around the right time but at a point in the approach that required too much concentration elsewhere. It wasn’t the timing, it is the dangerous nature of the compressed base leg and the unfamiliarity of the visual pattern.

PIA was trying to catch the glide slope from above at excessive speed. Unstable. Distracted. I think, from a human factors perspective, this was a similar trap.

[TeeVee]

evan, there are lots of airports around the world that do NOT have long, easy, straight in finals, and require substantial maneuvering up to very late. this is one of the reasons for having "captain only" take-offs and landings.

again, i'm pretty sure we are going to see that this terrible tragedy was related to the singular act of feathering, nothing else. yeah, i know you're all gonna jump on me and say to add their failure to realize the mistake....

[Gabriel]

i'm pretty sure we are going to see that this terrible tragedy was related to the singular act of feathering, nothing else. yeah, i know you're all gonna jump on me and say to add their failure to realize the mistake....

I am sure that if the investigation board does a serious investigation, they are going to look at a lot more. They should. "Pilot screwed up" was never a useful probable cause in itself, because what is the corrective action for that?

The investigation needs to look at:
- How the error happened.
- Why the error was not detected.
- CRM and what human factors were at play (tunnel vision, mission accomplishment, confirmation bias, fatigue, cognitive overload????).
- RIsk and threat management.
- Was the crew deviating from company policy / procedures and if so, voluntarily or involuntarily
- Are the policies / procedures themselves adequate? Especially if the pilots did things that were factors in the accident and at the same time were consistence with procedures / policies.
- The airline's safety culture (regarding discipline and compliance with policies and procedures).
- Pilots' training.
- Policies and requirements (proficiency and currency) for pilots that can fly from either seat, especially if they use one seat only seldom.
- Aviation authority oversight of the airline (hint: there is a reason why the airline is blacklisted from flying in Europe).