@@naknaksdadn572 The PM moving the condition levers to feather is not complacency. The definition is «a feeling of smug or uncritical satisfaction with oneself or one's achievements». Looking at the CVR transcript, PM was alert and awake to what was going on, showing clear signs that he knew this was an unusual and challenging approach. Its more likely that he had an instance of high stress. That would explain why he did the mistake of moving the condition levers instead of the flap.
@@MrGyngve What's so challenging about a clear weather left hand visual pattern approach ? He was so alert and awake that he ended up actually moving the flaps to 30 apparently without bothering thinking about what lever he moved when he previously said "flaps 30" and feathered the props, and never noticed that he did even after noticing they had no torque
@@FoxMikeHotel I agree that he was alert. High alertness is a stress indicator. What one finds challenging and stressfull is on an individual basis and subjective. But I would not argue that a visual approach into a new airport surrounded by high terrain is easy. They were stressed, and this is indicated by several things, amongst them the complete failure of both pilots to not catch that flaps were still 15 as PM read the before landing-checklist. I find it unlikely that this was complacency, because both pilots were quite on the job the way I read the CVR transcript. Ofcourse I can be wrong here. They might have been as complacent and relaxed as ever, but the CVR does not convince me of that. What makes a highly experienced captain set props in feather instead of flaps 30, is mind boggling, but not surprising to me. Having worked with HMI-systems in HMS relations for so long in both aviation and other industries, I have seen, read and heard about humans doing incredible and unbelievable mistakes so many times, Ive stopped raising my eyebrows. And while others here are convinced that an aural warning of engines in feather would have saved the day, I doubt that. Its not easy nor cheap to implement such a system in an aircraft already in production, and considering that this mistake had happened before in both DASH8s and ATRs, and engineers still have not installed such a system, says it all. The REAL SOLUTION it do make the prop levers like the Fokker 50. That WOULD have made a difference IMHO.
I don't understand why in the ATR, feathering the prop in the air doesn't trigger a master warning. The only reason I could see a pilot feathering an engine in the air is due to an engine failure, in which case you would expect a master warning. It seems like a fairly simple but life saving modification.
I was about to ask if there is any likely scenario that would require feathering both propellers in-flight, as I am only aware of the procedure to feather one on engine failure. Therefore, having the plane yell at the cockpit crew that they made a huge mistake instead of just having all the errors that are caused by the loss of ACW pop up, might have saved their lives. Especially in a stressful approach situation like this one, I can imagine it being way more helpful to sound the loudest alert and show "BOTH PROPS FEATHERED" instead of the simple warning that there is an electrical issue. As the indication they got requires you to think back to what could cause the error, and during an approach like this, where you even have to get a Terrain, Terrain EGPWS warning, this is just too much for most human brains. But I'd guess that a message that both props are feathered would focus their attention immediately on the condition levers.
I completely agree with you. I suppose feathering both props during the take off and landing even after knowing that to get to max torque after engaging max thrust requires minutes is unsafe. Hence a poka-yoke (en.wikipedia.org/wiki/Poka-yoke ) of a confirmation from the non-flying pilot -by pressing an approve button - in this case the captain on the RH should be incorporated in the design. I personally travelled in an ATR with Deccan airways. I must say the flight experience is not as pleasant as in the A320s or 737s. I can't explain it. The climb is steep. The banks more severe.
In these dire conditions you want the alert system to switch from observational alerts to being instructive. You want to instruct the crew to set the pitch for torque. (Action)(Target)(Setting) I e set-pitch-to maximum
Should not need a warning. Configuration changes like this are fairly easy to detect by sound alone and feel if you are the pilot flying. This is what happens with airline pilots who have been trained to be system managers rather than stick and rudder pilots.
@LTVoyager the problem is these pilots were flying the plane and not monitoring the systems, so that goes against your logic. You need warnings for a reason because it is easy to get overloaded with information in a high pressure environment. Most crashes are due to pilot error, so whilst I agree that training is pertinent, it seems perverse that there is no warning or safeguard when you accidently put the aircraft in a dangerous configuration, which unless detected quickly can have such disastrous consequences. As stated in this video this is not an isolated incident.
Thank you. As a trainer of science teachers, I was a passenger in Nepal in 2003, flying into and out of Tribhuvan Airport, Kathmandu in an Airbus A320, as well as in and out of the old cramped domestic terminal in a Buddha Air Beechcraft 1900D which gave one a pretty good view of the tree covered ridges on departure and during the approach. In such challenging terrain, adding unscheduled in-flight briefing to already high cockpit workloads is, as sadly shown by this crash, asking for trouble.
It doesn't even seem possible that someone with allegedly 21,900 total flight hours with 3,300 on type could mistake the condition levers for the flap lever! After he feathered the prop, neither one noticed the sound change? I've flown several turboprops and jets and even with noise-canceling headsets the engines give aural cues to significant engine or prop changes. Un-be-freaking-lievable.
He wasn't paying attention to what he was doing. His entire focus was on teaching the pilot flying how to fly this previously unbriefed approach, when they should have just made a straight-in landing. It was compounded by his sitting in the FO chair, so he was manipulating the controls with his left hand instead of the right hand he was used to.
@@stephenj4937 The unfortunate thing is till the end, the dude did not recognize the problem. When he moved the flaps to 30 the second time, how could he miss that he already had acknowledged movement earlier. If something was "deja vu" he must have realized that he had moved some other lever. I think the whole sequence went by too fast for them to be in memory.
@@sred5856 Yes, it really looks like this. His last words were: "What happened?" That is telling. - It was very enlightening from Magnar to play this in real Time, so it is understandable how quick it happened in reality.
Great video and explanation, Captain. I listened to the unofficially released cockpit recording and felt the crew rushed through the checklist items. I highly doubt they confirmed the selections and indications and this must have been their practice.
I've watched a dozen of crash videos and here is what I've learned: 1) When Autopilot disengages, always pull up for no reason and ignore the height controls 2) When stall warning comes up, always pull up as well while never have a look at your speed 3) When Engine fails, always shut down the other working one, to ensure zero thrust
One thing I really don't understand, is that the pilot monitoring DID eventually move the flaps to 15, so he must have realised he had not done so before. So my question is, did he not think "I definitely moved two levers earlier, wonder which ones they were"? Baffling incompetence from a so called professional pilot.
What I feel like is that, when he PF called for "flaps 30", the speed was higher, so he must have tried to pull the power lever down, incidently pulling the conditional lever down. After the speed was nominal, he pulled flaps 30 and hoped that the PF had managed the power lever, well, he could def see the PF using the Power lever so that might have been the cause. Its just my own thinking, idk if its true or not.
@@threeuniquefingers Nah. Not really possible. You need to unlock the gates to move the condition levers. I don't know if you also need to lift the flap lever to get it to move, so the similar sensation might have just made them cross it in their head. But you can't accidentally move the condition levers by brushing them or something. You'd think it would be hard to move two levers side-by-side expecting only one, but...
@@rynovoski I understand what you mean, but i still think its kinda possible looking at the workload and cockpit pressure. He was on conctsnt lookout for terrain and waypoints so, i think its kinda still possible.
A few factors at play from a CRM standpoint: workload management is a big factor here. Given the short flight, a thorough briefing for the approach done at the gate during preflight setup, including a threat briefing of a runway change could have helped mitigate this. It was obvious that both crew members were on the "overload" side of the stress bell curve. The first sense that leaves us when in that state is our hearing, which could explain why they didn't pick up on the master caution chime until very late.
Maybe they need an automated pilot voice stating “engine number feathered” when moved to that position. So many bleeps and dings when they are also overwhelmed with navigating and piloting the aircraft. There seems to be a lot of accidents from feathering the wrong engine too.
@@stephenj4937 There's a distinction between the overwhelm of an unfolding incident and a sound alert during an otherwise normal approach. When the engines were feathered, both pilots were focused intently on their work but things were under control. I think it's likely at least one, if not both, of the pilots would have heard a single "engine feathered" audio cue. It even may have registered more quickly than the warning lights, because it can be understood immediately regardless of whether the pilot is looking at their instruments.
Recently discovered your channel, really great work. It’s great to learn from someone as knowledgeable as yourself on this aircraft type - I’ve never known much about props. Keep going - you’re on the path to success!
Agree. They both had tunnel-vision. Or, were looking outside during the turn. Cockpit needs AI to monitor all the parameters and tell the pilots what corrective action to take.
Agreed. They were most likely startled by these warnings. That combined with the LH pilot constantly waiting for the RH pilot's orders. Even though he was monitoring and was the one who caused the loss of torque.
They flew 55 seconds with propellers feathered and they had 20 seconds between the first "no power" call to the first stall warning. They saw the 0 torque indication, they heard the engines but they did not check the only lever that control the torque. Avoiding a spin on the turn to final is expected from all GA pilots and surely you won't have 20 seconds in a small aircraft. Great job of finding the root cause: the authorities enabling a culture of disregard of safety and procedures. You can see her understanding that they don't follow procedures but being eager to learn how to manage this from the more experienced pilot as it was a good thing.
The root cause was the confusing similarity of the ATR's prop and flap levers (next to each other and similar feel). The root cause was not the poorly trained crew. The inability of the crew to quickly recognise the feathered props condition was a secondary cause.
They put full power also in the last 15-20 seconds..Isn't the power lever right next to condition lever.. They also confirm that flaps are at 30 twice, once PM then PF during checklist
@@howardgraff4084 No, check at 3:20 when Magnar use them and see they are different and also they have a safety that you have to pull in order to move them. Their positioning is common to many other types. Your car has also brake and throttle pedals similar and next to each other.
Exactly. But nevertheless: After all and finally 72 human beings died because a weird Pilot Error was made and not picked up by both of them. That´s not an accusation, just a statement. May they Rest in Peace - Anju and Kamal and the seventy other Human Beings who died in this Crash.
Ok, redo. The fact that the propeller controls are TOTALY different in construction and operation compared to the flap control lever, and yet the FO still feathered BOTH engines is incomprehensible.
@@adb012 Yes, that part was not worded well, but undoubtedly the OP is trying to make the point that they're shaped totally differently to AVOID accidents like this. The right seater (pilot monitoring) should have briefly glanced down at whatever lever(s) he was adjusting, but even if he didn't, the shape of the handles should clue the pilot into what he/she is adjusting.
Incompetence is right. It's hard to believe that someone with 3,300 hours on type and 21,900 total could make one grave mistake after another without recognizing and correcting any of them. Fake logbook? Or is it just a case of automatically passing every sim proficiency check with a wave of the hand and some quick signatures? No wonder the EU and ICAO are concerned.
@@cargopilot747 You may think they're totally different but when your mind is busy with something else your brain may miss that. To me they aren't TOTALLY different. They have different sizes and somewhat different shapes, but they both go forward and backward on a track and the end is shaped differently than the shaft. So they have some similarities as well. A few years back a Minnesota police woman pulled her gun instead of her taser and killed someone instead of tasing him. You can argue that a taser feels totally different than a gun, but they have similarities too. They're not different in the way that a pencil and a shoe are different. But when your mind is engaged in something else that is very demanding (in that case her partner was in danger) the mistake is made anyway.
I love your structured, sensible and far-reaching approach and thinking. The outro is also very nice. Kind of relaxing after all the reality terror of the accident. -Perhaps you could digest a little your script entered in the description under video, because I consider it normal to read the description first and then watch the video, and then it's a little disappointing to have all that just repeated. Will be watching more!
The outro?! If we're being kind, that was rather poor! Wasted literally half of the runway before touching down! Imagine you lose brakes or the reversers fail, once you have weight on wheels and lift is dumped, you're not going around, you're getting dragged out of the mud. Barely got it stopped before the bars. While it might look nice, it was more in the realms of 'how to fail your competency check ride'
As an aviation enthusiast and former private pilot I greatly appreciate this video. Prior to this video, I believed the accident was caused by severe icing but I now have a better understanding.
This is a different accident my man. This isn't the one in Brazil, that one was most likely icing. This was one a few years back where the FO feathered both props on base and neither pilot realized it. It crashed on final.
@@raymarshall6721 Exactly. This Video is dealing with the Crash of Yeti Airlines Flight 691 in Nepal on January 15th, 2023. Beyond the issue that both Aircrafts were ATR 72-500 it has nothing to do with the Crash in Brazil last week.
what an ENGREGIOUS level of HORRIBLE airmanship WOW. It should have been SO obvious that the engines were feathered! It would have only taken a second to unfeather them and instantly have torque + power again and recover! they had SO MANY SECONDS compared to that to figure it out, based off allllllllllll the super obvious indications available to them. What I genuinely don't understand is how he could have made the mistake in the first place, as your video proves that u need to pull UP on the safety lockouts before moving them to the feathered position, so how could he make that mistake, moving them thinking it was the flap lever, since the flap lever DOESNT have that safety lockout? Wouldn't it just not have moved since he wouldn't be pulling up expecting a lockout to be there? also, if he was really going for the flap lever, wouldn't he expect it to be ONE flap lever, and not TWO? What would explain him feeling the larger width shape of TWO LEVERS AND PULLING UP on the safety lockout for BOTH to move BOTH to feathered?
And beyond that, after moving the condition levers instead of the flaps, he did eventually move the flaps lever to 30, did he already forget that he had indeed operated a lever he thought to be the flaps already a few seconds ago ?
Gidday Magnar. I fly an ATR for work and your videos and patter is the best out there. Congrats on just having the words via text and not verballed that was very thoughtful. A great insight and breakdown of the cockpit and importantly the regulatory issues that stood behind this. Thankyou.
@@saito125 sir I'm not a pilot, my line of work is different. So you're right that I'm incompetent in being a pilot/aviation. That was a genuine question though, fyi.
They were both expecting a warning that should be ignored (the ground proximity one), that maybe helped them not giving importance to other sound alerts as well
I personally think that an approach route that gives you a "Terrain, Terrain" warning is a good idea in the first place. Not going to lie, if I was a passenger on that flight, seated close to the front of the aircraft and I heard that from the cockpit, I'd need a new set of underwear. I remember my only flight on a Dash-8 as a kid, i was seated in row 2, they were flying with the cockpit door open (it was pre 9/11 and also not a scheduled flight, but an event organized by the airline where a friend of my parents was a high-ranked pilot, so this was no big deal). Not knowing much about automatic announcements on the flight deck, I totally freaked out when I heard the "Minimums" call-out. Of course, today I know that this is absolutely normal and nothing to worry about. But a "Terrain, Terrain" is a totally different thing.
If that's really the cause then thats not the first time an accident has happened due to inadverted feathering. Maybe the should separate the flaps and feather levers a bit more or change the position or something.
For me there are two key ''flaws''. There were two pilots flying and no monitoring pilots (As RH Commanding Officer was guiding the LH pilot losing awareness of what was going inside the cockpit). Suddenly losing all power on a twin engine airplane is extremely rare and should immediately lead to check all power control lever positions, even more being that close to the ground. Unfortunately to err is human. Rip Captains Kamal KC and Anju Khatiwada.
When the pilot knew there was no thrust in the engines, he should have known that the propellers might be in feathering position and should have immediately corrected the mistake.
I've heard many times the expression "so many thousand hours of experience" and "so many years of experience". But either statement convey if the experience in hours and time were good proficient experience. Sometimes there are assumptions that meeting the bare minimum requirements is sufficient. Anytime the human factor is involved there is an inherent risk for error on just about anything that is operated by a human regardless of "experience".
Pilot error during landing almost always is a death sentence, especially in an ATR 72. The plane does not have a margin for error, so any mistake can result in a deadly stall which cannot be recovered.
Totally disagree. Super forgiving aircraft and very docile aircraft to fly. Lack of SOP, lack of SA, and an instructor that was having a hard time of “letting go!” He stopped being the PM (pilot monitoring), NFP (non flying pilot), whatever you want to call it. Even screwing up and pulling CLs back, a MC (master caution) light needs attention. Read it, call it out. Continue or go around and figure it out. If he had just said “Master caution”, “Hyd, Anti Ice, Elec”, maybe the other pilot might’ve realized what had just happened, Or, triggered himself and fixed the issue. When you grab the flap handle, (technique only), you come from underneath and look at what you’re grabbing. Flap handle has to be lifted up, then moved aft. Condition levers have triggers, come from over the top, then moved aft. It’s a different movement. Lastly, fly the airplane. It’s better to keep the aircraft flying than stall it into the ground. Airspeed is life in those situations. Watching the video (great video btw, love your stuff), once they realized there was no power, they were over the old airport. It would’ve been a beeline for me. Fly it to the pavement. I know, it’s easier said than done. It’s hard to not “Monday Night Quarterback” these things. You’re not there. You’re not in the situation. Could you have made a difference? I don’t know, and I don’t want to find out. EVERY AVIATOR strives to do things right and get home. I believe this crew was no different. Though this was a tragic event, its findings will have a significant impact and save lives down the road. RIP Yeti Flight 691!
Feathering the props when wanting to drop the flaps is like taking a dump when all you wanted to do was piss...in short -distraction & lack of concentration.
Excellent video Captain....thanks! I assume from FTR position to full TO power lever movement will put the props back to thrust pitch? It seems that happened but I guess to late to prevent the slow flight and excessive AOA to cause stall?
Thank you very much for picking this up and explaining it in this enlightening, but also disturbing way! It makes clear how rapid the Crash happened and how few time remained in fact to pick up the Mistake. And how easy it was to not recognizing him. It´s very, very sad to hear those last words: "What happened?" It is really horrible. Thank you very much, too, for the reference to "Admiral Cloudberg". She really got to the heart of the whole context of this Crash. But nevertheless: After all and finally it was a weird case of Pilot Error. They made one mistake too much, payed for it with their Lives and caused the Death of 70 other Human Beings. RIP to Anju Khatiwada and Kamal KC. RIP to all who lost their Lives. Again my deepest Condolences to their Families and Friends.
Similar to retracting flaps instead of gear on Tu154 on initial climb. There were several crashes back in the days. P. S. Wy no direct feathering indication / sound alarm?..
Excellent video and very clear coverage of the whole sequence of events. The pilot flying didn't have very many hours on the type, so without abbreviated briefing and things happening quickly, she missed the crucial SOP and the likelihood of accidentally feathering the props. Horrible last few seconds. Having no knowledge of the type of aircraft, I do wonder why there is no attention-grabbing indicator of feathering of the props.
Great Video as usual Captain! "Self Preservation Instincts" have steadily declined in the last 30 years and seems to be at an all time low. Back in 1983 as a brand new First Officer my attitude was if my captain moved his Big Toe I HAD to see it!! In other words I must see any movement of the one sitting next to me that could kill me! Using long checklists repeatedly creates "Parroting" where we say what we are accustomed to say instead of what is. The word "Checked" should be banned from checklist, instead the Flying pilot says what he SEES. Saying "Flap 15" instead of "checked" is more likely to prompt the pilot to actually check the flap indicator than saying "checked". We changed that decades ago in the airline I flew with.
They reacted how thousands of unfortunate pilots before them have reacted to something unexpected. By temporarily becoming task saturated and suffering cognitive lock up. Humans, not computers. Also we would need to see the airline’s operating procedures before we could say they didn’t follow SOP.
Captain Nordal, my congrats from Brazil to your great knowledge about the flight environment, and i respectfully ask you: Why the alert panel hasn't a "feather" light to indicate this condition?
From a human factors point of view I think it's a terrible design that the propeller control which only has three positions has two levers right next to the power controls. It would make much more sense to have switched or buttons that are out of the way - after all how frequently does the pilot need to access the propeller controls?
every engine start..................... every tarmac op. so american eagle when they ran the atr back in the day would do a lot of caribbean ops. they would run engines while stopped and would feather the props during unloading and loading. LIAT did the same with their dhc8s.. it is a very useful feature and it's unfortunate 2 "qualified" pilots 1. did this 2. did not realize it. it tells you on the gauges and you can easily look at the levers too. its akin to forgetting to lower your landing gear! thats the level of incompetence here. sad for the passengers, 0 pity for the pilots who caused this. should not have been in control of a bike!
@@johndonovan7018 I recommend looking up Ergonomics as a concept of Human Factors in Aviation good sir! It explains why some accidents are caused by certain "flawed" or "error-inducing" designs of, in this context, an aircraft especially when the human (the pilots or aircrew) are subject to extremely high workloads which often results to loss of situational awareness. A lot to talk about here on principles of Aviation Safety and this is a really insightful case study on Human Factors! :)
Airbus was able to make the propeller control in the form of usual Airbus engine master switch on their A400M. They should adapt it to their ATR lineup. Eliminating the risk of this kind of accident. The 100% NP OVRD then can be changed into push button form.
As always, very interesting summary and analysis of the event. To simplify it for non pilots, it's like switching off your ignition on your car while going flat out on a highway.. I wonder why there is no security mechanism for the levers to go into that position like moving it slightly to the right (like in a car for reverse gear)
@@christiangavrilato some extent. It’s more of that you select manual mode on automatic and forget that you are on low torque setting when u need it more. So can be misunderstood when you didn’t even realise hitting the lever. I feel ergonomic on ATR are way poor compared to other aircraft’s… they have caused too many disasters… can’t blame pilots always 😢
If you look around 14:21, it looks as if you already have to pull up on two knobs on the outside of the condition levers to move them. So a zig-zag pattern wouldn't add much to it. I am more wondering why there is no alarm going off if you feather both props, as I don't see any reason to do such in flight. (Feathering one upon engine failure, okay. But both? I don't know...)
@@bbgun061 In which case an additional alert could also be helpful, as it could be seen as a confirmation that you actually did feather both props. And I am confident that it's more likely to accidentally feather both props as happened here than a real dual engine failure.
Last August in Malaysia, a private jet co-pilot made a similar mistake when they accidentally pulled the lift dump lever instead of the fuel dump lever during the approach.
Cockpit should be designed for pilots under stress and 70% focus. Current cockpit design requires zero stress and 100% focus. Too demanding. Make the cockpit less demanding.
@@manikyum It is a mixed bag. If certain operations arenot automated one should at least design the lay out of instruments in such a matter that “foreseeable mistakes” can be prevented. That doesn’t make pilots dumber but prevents mistakes as in this case. Example: if you are operating a machine which has a “stop movement” switch next to an emergency button, one might think that pushing the esd button would do the same thing as said “ stop movement” button. In reality this ESD may cause morevital systems to stop, making the machine slightly unsafer ( because all power incl lights will also be switched off). In a day to day operation it is not a problem untill one day work needs to be carried out at night. Then suddenly, when lights go out, it becomes dangerous to step out of the machine safely. It is random made up example. Design matters.
Oh wow Magnar, I’m sure glad I came across your channel! You’ve got such a great way of delivering your content. It really helps me in understanding some of these aviation concepts. Thanks so much for the time, effort, energy and passion you put into what you do. It’s evident in your final product. Thanks again! Cheers mate.🛩️🫡
It seems to me that the ATR series is very unforgiving in stall situations and tends to roll into a spin very violently when stalled. I have seen many different stall/ spin/ roll accidents with the ATR series now, so something needs to be done here.
I can tell you what needs to be done, it’s very simple, Pilots should NEVER let it get that far! That’s one reason why there is 2 Pilots in the Cockpit, it’s to monitor what’s going on with your aircraft ALL the time and if one doesn’t catch something, the other one will.
@@user-kb8gh5jv9t I fully agree, but all pilots need to know that the ATR is a b.tch close to stall... She rolls and spins right away, this is not a STOL aircraft.
Very good video. As I learned of them having feathered the engines, I had no doubt that this was a case of crew being overloaded. Especially when they are flying into a new airport plus having training on the flight. When you get stressed, muscles memory is one of the back ups you have. In this case it could seem that the Traing Captain had the wrong muscles memory activated and therefor feathered the engines. Especially in nothern countries you normally don´t feather both engines at the same time, as in winter, having slippery aprons, this could result in the aircraft moving forward, even with parking brake on. But I suspect it could normal for this captain to feathering both engines as standard, and therefor having this muscles memory. Following this accident, I tried having both engines feathered during app in the simulator and if you are doing a visual APP and only looking out, the only thing you hear is a SINGLE CHIME. And if you are stressed/overloaded then the first thing you loose is you hearing. And yes they should have been looking in for the before landing C/L but again they are focused on the Visual Pattern. And actually the PF noticed something was wrong, so it seemed she wasnt that much overloaded. So for me I dont see much mystery about what happened, BUT I might be wrong. It wouldn't be the first time. We will see when the report comes out. I also think these were two very qualified pilots, that just got caught on the wrong leg on the wrong day. Something that probably can happen to all of us.
I think they didn't notice the indicators because they were trying a stressful approach without adequate briefing. When under stress, expectatoin bias becomes a much bigger nightmare (and in fact I use expectation bias errors as a way of gauging the stress of those around me). The stress was sufficient for both pilots to be fixated on the flight path for the approach procedure and miss other things. Also I wasn't aware of the two incidents involving feathered propellers. This indicates that this is a recurring problem with these airliners though not a fatal one. I think it is also likely that a sort of subtle spacial disorientation within the cockpit may have affected the RH captain since he would have been used to flying in the LH seat and that may have been the source of the feathering error especially under stress. Last minute changes can be deadly and this transcript shows one particular way in which this can happen. RIP all involved.
I hadn't considered the possibility of distraction contributing to the RH pilot grabbing the wrong lever. The CVR suggests that the workload as unnecessarily high for a challenging landing. The RH last comment of "what happened?" strikes me as absolutely tragic. The breakdown of SOPs strikes me here as a workload-related issue. They should have taken the decision on which runway to use on the ground and fully briefed it rather than trying to improvise in the air.
Very good insight of the last few minutes with the timeline, well done Magnar. In my opinion, the main contributing factor of the pilot is to be submissive and trust the incompetent pilot monitoring (validation flight). Work hierarchy and cultural hierarchy within this country's system plays a huge roll in this accident. The pilot in command was not in command, she allowed herself to be lead.. The pilot overly trusted the monitoring pilot , letting herself being lead through the approach instead of flying it. The monitoring pilot( validating instructor) is mostly at fault by meddling into the pilots role in addition to not briefing prior to the flight and allowing the aircraft/flight procedures get ahead of him during the flight. This is the reason procedures were rushed ( not following SOP) . Again , all my opinion. Magnar, Is it possible to post the flight recording? The tone of the voices can determine authority or submissiveness.
I heard it on other UA-cam Channels, too. Because most of the Conversation was done in Nepalese Language (only the Communication with ATC in English) you will understand nothing. Both voices sounded calm and focused nearly up to the end. The last remarks of Anju Khatiwada were made with an audible increasing panic. His last words sounded irritated and astonished.
I don't know how do you pilot a plane, but when I run any kind of machine that responds abnormally, the first thing I do is visually check the main control's positions. One person mislead the flap lever and pull the propeller lever is already a big mistake, and both haven't seen those levers in the wrong position is worst. But reflection and analysis of that kind of facts based on blinking lamps and beeping alarms, instead of watching to main controls, is too much insane...
It's called CRM. Crew Resource Management. This is 110% on the crew. Not the aircraft. When I flew corporate ages ago, no matter who was pilot in command, both pilots would double check the proper action was taken including a verbal response. Pilot in command calls gear up, pilot monitoring verbally responds gear up, then raises the gear handle, then pilot in command visually checks the gear handle was up. Pilot monitoring responds gear up lights out (indicating they aren't hung up in retraction), pilot in command visually checks the lights and confirms verbally. People are complacent these days. And instead of others admitting it's a problem. They blame the equipment.
Ok, CRM failed. After that, at that altitude, the pilot was alone and should be capable to simply pilot: look at controls, correct the propellers and corrected the flaps, while talk the official speech "fly, beauty, fly!". If ok, then, complete CRM checklist: "I ask you flaps, idiot!" Exclamations are optional.
The "crash airplane" levers may be located very close to the "anti crash airplane" levers, but if the pilots adhere to the SOPs, then it's not an issue.
it is always such a small thing. But holes aligned again. phew... make me appreciate that tiny flap lever in small GA planes. I was never into flying large buses not even in sims, so this is bit new to me. It is really surprising now that is googled couple of layouts, that airliners make it in such a similar shape, height and travel way as power levers. In stress situations it seems like asking for it. Everyone of us i raised on basic design three lever console. Throttle / Prop / Mix. With flaps being either to the side of the console or close to where gear handle is on front panel.
Well, a bounch of yellow buttons is not the best way to say "why did you feather both engines when they still working" An aural warning "both featered" will be much more effective espessialy during high stress situations.
All those people died because the crew did not take the 2 seconds needed to follow the flaps setting checklist because they were both 100% focussed on the visual approach profile. Yet another lesson on the importance of following checklists regardless of how experienced you are !
was that the one where they feathered the props and didnt look at their gauges to figure it out, or even look at the throttle stack... who trained that crew
Those levers are there on any other aircraft because they're needed for operations and those condition levers have safety triggers to prevent accidental movement. But I'll do you one better, imagine putting in charge of operating an aircraft people who are properly trained on them, that pay attention to what they are doing, and that are not excessively challenged by a simple visual left hand landing pattern (very basic skills that are used by general aviation pilots everytime they go fly).
@@sebastien1174 The different form/feel of the lever should prevent this kind of accident. Especially the detent on the thrust lever that requires finger lifts to go through(!). Still, somehow they managed to make this mistake. Hopefully, things can be learned from the accident that will prevent it from being repeated in the future.
I don't understand why there's a single "chime" along with a somewhat generic looking "caution" light relating to a feathered propeller during flight. Two feathered propellers definitely should be worth a red blinking light and a ringing bell (or two). Seriously, everything indicated an aircraft that was in a relatively normal phase of flight beginning with its reduced speed and altitude. Unfortunately the same two people that got in this situation weren't able to recognize the simple solution for getting out. Maybe some other information can be displayed on the master warning panel with an appropriate aural tone denoting its importance.
One of the worst pilot negligence incidents ever. How did the instructor not know about the feathering? It's more understandable for the pilot because she was still training, but the instructor should've immediately diagnosed the situation and corrected. This accident should never have happened.
Criticising the flying pilot (left seat) for non-standard checklist terminology! Her co-pilot (right seat) feathered the props on her instead of selecting flaps 30! Somewhere in heaven she is screaming WTF!! I feel very sorry for her and the passengers.
With the propellers moved to feather was the flight savable in flight in this case? I’m commenting before I forget but still have a few minutes left of this video in case you answer in video and I don’t delete this first. Thanks!
This mistake, by such a senior pilot and also an instructor should not have happend. How tragic for that girl as well who did everything right and then the senior caused the crash.
The problem is, that in a low power approach, feathering the props would not create a lot of decceleration as the engines where at low power anyways. Why can props be feathered in flight anyways with a running engine?
Low and slow, and then shutting off power............how pilots with a combined 27000 hours can make that mistake is truly stunning.
Complacency!
@@naknaksdadn572 The PM moving the condition levers to feather is not complacency.
The definition is «a feeling of smug or uncritical satisfaction with oneself or one's achievements».
Looking at the CVR transcript, PM was alert and awake to what was going on, showing clear signs that he knew this was an unusual and challenging approach.
Its more likely that he had an instance of high stress. That would explain why he did the mistake of moving the condition levers instead of the flap.
@@MrGyngve What's so challenging about a clear weather left hand visual pattern approach ? He was so alert and awake that he ended up actually moving the flaps to 30 apparently without bothering thinking about what lever he moved when he previously said "flaps 30" and feathered the props, and never noticed that he did even after noticing they had no torque
@@FoxMikeHotel I agree that he was alert. High alertness is a stress indicator. What one finds challenging and stressfull is on an individual basis and subjective. But I would not argue that a visual approach into a new airport surrounded by high terrain is easy.
They were stressed, and this is indicated by several things, amongst them the complete failure of both pilots to not catch that flaps were still 15 as PM read the before landing-checklist. I find it unlikely that this was complacency, because both pilots were quite on the job the way I read the CVR transcript.
Ofcourse I can be wrong here. They might have been as complacent and relaxed as ever, but the CVR does not convince me of that.
What makes a highly experienced captain set props in feather instead of flaps 30, is mind boggling, but not surprising to me. Having worked with HMI-systems in HMS relations for so long in both aviation and other industries, I have seen, read and heard about humans doing incredible and unbelievable mistakes so many times, Ive stopped raising my eyebrows.
And while others here are convinced that an aural warning of engines in feather would have saved the day, I doubt that.
Its not easy nor cheap to implement such a system in an aircraft already in production, and considering that this mistake had happened before in both DASH8s and ATRs, and engineers still have not installed such a system, says it all.
The REAL SOLUTION it do make the prop levers like the Fokker 50. That WOULD have made a difference IMHO.
Lack of proficiency, which is different from experience.
I don't understand why in the ATR, feathering the prop in the air doesn't trigger a master warning. The only reason I could see a pilot feathering an engine in the air is due to an engine failure, in which case you would expect a master warning. It seems like a fairly simple but life saving modification.
I was about to ask if there is any likely scenario that would require feathering both propellers in-flight, as I am only aware of the procedure to feather one on engine failure. Therefore, having the plane yell at the cockpit crew that they made a huge mistake instead of just having all the errors that are caused by the loss of ACW pop up, might have saved their lives. Especially in a stressful approach situation like this one, I can imagine it being way more helpful to sound the loudest alert and show "BOTH PROPS FEATHERED" instead of the simple warning that there is an electrical issue. As the indication they got requires you to think back to what could cause the error, and during an approach like this, where you even have to get a Terrain, Terrain EGPWS warning, this is just too much for most human brains. But I'd guess that a message that both props are feathered would focus their attention immediately on the condition levers.
I completely agree with you. I suppose feathering both props during the take off and landing even after knowing that to get to max torque after engaging max thrust requires minutes is unsafe. Hence a poka-yoke (en.wikipedia.org/wiki/Poka-yoke ) of a confirmation from the non-flying pilot -by pressing an approve button - in this case the captain on the RH should be incorporated in the design. I personally travelled in an ATR with Deccan airways. I must say the flight experience is not as pleasant as in the A320s or 737s. I can't explain it. The climb is steep. The banks more severe.
In these dire conditions you want the alert system to switch from observational alerts to being instructive. You want to instruct the crew to set the pitch for torque. (Action)(Target)(Setting) I e set-pitch-to maximum
Should not need a warning. Configuration changes like this are fairly easy to detect by sound alone and feel if you are the pilot flying. This is what happens with airline pilots who have been trained to be system managers rather than stick and rudder pilots.
@LTVoyager the problem is these pilots were flying the plane and not monitoring the systems, so that goes against your logic. You need warnings for a reason because it is easy to get overloaded with information in a high pressure environment. Most crashes are due to pilot error, so whilst I agree that training is pertinent, it seems perverse that there is no warning or safeguard when you accidently put the aircraft in a dangerous configuration, which unless detected quickly can have such disastrous consequences. As stated in this video this is not an isolated incident.
Thank you. As a trainer of science teachers, I was a passenger in Nepal in 2003, flying into and out of Tribhuvan Airport, Kathmandu in an Airbus A320, as well as in and out of the old cramped domestic terminal in a Buddha Air Beechcraft 1900D which gave one a pretty good view of the tree covered ridges on departure and during the approach. In such challenging terrain, adding unscheduled in-flight briefing to already high cockpit workloads is, as sadly shown by this crash, asking for trouble.
Indeed. Approaching spontaneously the other Runway was a very bad Idea.
Well, that was interesting to read. Great video yet again Magnar!
Anju's husband was a pilot who perished in a crash... she decided to become a pilot and she made it to captain until she... perished in a crash :(
its like an episode in final destination, you can never cheat the reaper, he wants what is due to him.
lol
Yes, it´s a very sad and tragic Story.
@@StanfordJohnsey Could you try not being a racist or sexist asshole?
@@jonyjoe8464 this is why i never take loans from reapers
It doesn't even seem possible that someone with allegedly 21,900 total flight hours with 3,300 on type could mistake the condition levers for the flap lever! After he feathered the prop, neither one noticed the sound change? I've flown several turboprops and jets and even with noise-canceling headsets the engines give aural cues to significant engine or prop changes. Un-be-freaking-lievable.
He wasn't paying attention to what he was doing. His entire focus was on teaching the pilot flying how to fly this previously unbriefed approach, when they should have just made a straight-in landing. It was compounded by his sitting in the FO chair, so he was manipulating the controls with his left hand instead of the right hand he was used to.
@@stephenj4937 The unfortunate thing is till the end, the dude did not recognize the problem. When he moved the flaps to 30 the second time, how could he miss that he already had acknowledged movement earlier. If something was "deja vu" he must have realized that he had moved some other lever. I think the whole sequence went by too fast for them to be in memory.
@@stephenj4937 Indeed, exactly.
@@sred5856 Yes, it really looks like this. His last words were: "What happened?" That is telling. - It was very enlightening from Magnar to play this in real Time, so it is understandable how quick it happened in reality.
@@NicolaW72Yeh they were far too close to the ground to have time to fix it or even work it out. He said what happened? Then boom 💥 gone. RIP
Great video and explanation, Captain. I listened to the unofficially released cockpit recording and felt the crew rushed through the checklist items. I highly doubt they confirmed the selections and indications and this must have been their practice.
I've watched a dozen of crash videos and here is what I've learned:
1) When Autopilot disengages, always pull up for no reason and ignore the height controls
2) When stall warning comes up, always pull up as well while never have a look at your speed
3) When Engine fails, always shut down the other working one, to ensure zero thrust
One thing I really don't understand, is that the pilot monitoring DID eventually move the flaps to 15, so he must have realised he had not done so before. So my question is, did he not think "I definitely moved two levers earlier, wonder which ones they were"? Baffling incompetence from a so called professional pilot.
Exactly! This was a let-down on his skill. Or maybe he has a short memory. BTW, it was flaps 30.
What I feel like is that, when he PF called for "flaps 30", the speed was higher, so he must have tried to pull the power lever down, incidently pulling the conditional lever down. After the speed was nominal, he pulled flaps 30 and hoped that the PF had managed the power lever, well, he could def see the PF using the Power lever so that might have been the cause.
Its just my own thinking, idk if its true or not.
@@threeuniquefingers Nah. Not really possible. You need to unlock the gates to move the condition levers. I don't know if you also need to lift the flap lever to get it to move, so the similar sensation might have just made them cross it in their head. But you can't accidentally move the condition levers by brushing them or something. You'd think it would be hard to move two levers side-by-side expecting only one, but...
@@rynovoski I understand what you mean, but i still think its kinda possible looking at the workload and cockpit pressure. He was on conctsnt lookout for terrain and waypoints so, i think its kinda still possible.
he was probably under high workload
A few factors at play from a CRM standpoint: workload management is a big factor here. Given the short flight, a thorough briefing for the approach done at the gate during preflight setup, including a threat briefing of a runway change could have helped mitigate this. It was obvious that both crew members were on the "overload" side of the stress bell curve. The first sense that leaves us when in that state is our hearing, which could explain why they didn't pick up on the master caution chime until very late.
Indeed, exactly.
Maybe they need an automated pilot voice stating “engine number feathered” when moved to that position. So many bleeps and dings when they are also overwhelmed with navigating and piloting the aircraft. There seems to be a lot of accidents from feathering the wrong engine too.
Ahhh no
@@virgilhilts3924 what a helpful reply 🤣🤣🤣
More automated voices won't help. It is proven that when people get stressed and overwhelmed the brain ignores auditory inputs.
@@stephenj4937 There's a distinction between the overwhelm of an unfolding incident and a sound alert during an otherwise normal approach. When the engines were feathered, both pilots were focused intently on their work but things were under control.
I think it's likely at least one, if not both, of the pilots would have heard a single "engine feathered" audio cue. It even may have registered more quickly than the warning lights, because it can be understood immediately regardless of whether the pilot is looking at their instruments.
@@stephenj4937
Quite correct 👍
Excellent review and video. Thank you very much. Your points at the end were well taken.
A well presented, calm, and balanced analysis
I'm glad you're covering other writers who are able to pinpoint the underlying issues
Thank you
Mental illness flag
Recently discovered your channel, really great work. It’s great to learn from someone as knowledgeable as yourself on this aircraft type - I’ve never known much about props. Keep going - you’re on the path to success!
They didn't see or hear the warnings because the were so focused and overwhelmed by the tight turn to land at whats a dangerous airport
Agree. They both had tunnel-vision. Or, were looking outside during the turn. Cockpit needs AI to monitor all the parameters and tell the pilots what corrective action to take.
Airport is not dangerous! It was a new airport that was just inaugurated a week earlier. So the landing approach was new for them.
@@mickdonedee1 no one is going to add ai to planes, stupid idea
The turn is not tight. The airport is not dangerous. What do you base your statement on?
Agreed. They were most likely startled by these warnings. That combined with the LH pilot constantly waiting for the RH pilot's orders. Even though he was monitoring and was the one who caused the loss of torque.
They flew 55 seconds with propellers feathered and they had 20 seconds between the first "no power" call to the first stall warning. They saw the 0 torque indication, they heard the engines but they did not check the only lever that control the torque. Avoiding a spin on the turn to final is expected from all GA pilots and surely you won't have 20 seconds in a small aircraft.
Great job of finding the root cause: the authorities enabling a culture of disregard of safety and procedures. You can see her understanding that they don't follow procedures but being eager to learn how to manage this from the more experienced pilot as it was a good thing.
The root cause was the confusing similarity of the ATR's prop and flap levers (next to each other and similar feel). The root cause was not the poorly trained crew. The inability of the crew to quickly recognise the feathered props condition was a secondary cause.
They put full power also in the last 15-20 seconds..Isn't the power lever right next to condition lever.. They also confirm that flaps are at 30 twice, once PM then PF during checklist
@@howardgraff4084 No, check at 3:20 when Magnar use them and see they are different and also they have a safety that you have to pull in order to move them. Their positioning is common to many other types. Your car has also brake and throttle pedals similar and next to each other.
Exactly. But nevertheless: After all and finally 72 human beings died because a weird Pilot Error was made and not picked up by both of them.
That´s not an accusation, just a statement.
May they Rest in Peace - Anju and Kamal and the seventy other Human Beings who died in this Crash.
Ok, redo.
The fact that the propeller controls are TOTALY different in construction and operation compared to the flap control lever, and yet the FO still feathered BOTH engines is incomprehensible.
Am I missing something (joke, sarcasm)? How can you say that the cause of the accident is the prop control and flap control being totally different?
@@adb012 Yes, that part was not worded well, but undoubtedly the OP is trying to make the point that they're shaped totally differently to AVOID accidents like this. The right seater (pilot monitoring) should have briefly glanced down at whatever lever(s) he was adjusting, but even if he didn't, the shape of the handles should clue the pilot into what he/she is adjusting.
Incompetence is right. It's hard to believe that someone with 3,300 hours on type and 21,900 total could make one grave mistake after another without recognizing and correcting any of them. Fake logbook? Or is it just a case of automatically passing every sim proficiency check with a wave of the hand and some quick signatures? No wonder the EU and ICAO are concerned.
So the entire mistake was pulling the lever back too far? 😮
@@cargopilot747 You may think they're totally different but when your mind is busy with something else your brain may miss that. To me they aren't TOTALLY different. They have different sizes and somewhat different shapes, but they both go forward and backward on a track and the end is shaped differently than the shaft. So they have some similarities as well. A few years back a Minnesota police woman pulled her gun instead of her taser and killed someone instead of tasing him. You can argue that a taser feels totally different than a gun, but they have similarities too. They're not different in the way that a pencil and a shoe are different. But when your mind is engaged in something else that is very demanding (in that case her partner was in danger) the mistake is made anyway.
I love your structured, sensible and far-reaching approach and thinking. The outro is also very nice. Kind of relaxing after all the reality terror of the accident. -Perhaps you could digest a little your script entered in the description under video, because I consider it normal to read the description first and then watch the video, and then it's a little disappointing to have all that just repeated.
Will be watching more!
The outro?! If we're being kind, that was rather poor! Wasted literally half of the runway before touching down! Imagine you lose brakes or the reversers fail, once you have weight on wheels and lift is dumped, you're not going around, you're getting dragged out of the mud. Barely got it stopped before the bars. While it might look nice, it was more in the realms of 'how to fail your competency check ride'
@@nohandleleft good that you mention, I noticed it, but I meant "visually nice"... approach view.
Thank you Capt.
Come on ATR!.. A loud voice warning saying "Propeller feathered" 3 times when it happens while airborne should have been easy integrate... Serioulsy!
agree .. its so critical it needs an audible call out .. they need to impliment this asap .
Thank you for the review, Magnar.
Very well done sir, thank you for the video!
As an aviation enthusiast and former private pilot I greatly appreciate this video. Prior to this video, I believed the accident was caused by severe icing but I now have a better understanding.
This is a different accident my man. This isn't the one in Brazil, that one was most likely icing. This was one a few years back where the FO feathered both props on base and neither pilot realized it. It crashed on final.
@@raymarshall6721 Exactly. This Video is dealing with the Crash of Yeti Airlines Flight 691 in Nepal on January 15th, 2023. Beyond the issue that both Aircrafts were ATR 72-500 it has nothing to do with the Crash in Brazil last week.
Excellent video, very well spoken and described. Happy to sub.
what an ENGREGIOUS level of HORRIBLE airmanship WOW. It should have been SO obvious that the engines were feathered! It would have only taken a second to unfeather them and instantly have torque + power again and recover! they had SO MANY SECONDS compared to that to figure it out, based off allllllllllll the super obvious indications available to them. What I genuinely don't understand is how he could have made the mistake in the first place, as your video proves that u need to pull UP on the safety lockouts before moving them to the feathered position, so how could he make that mistake, moving them thinking it was the flap lever, since the flap lever DOESNT have that safety lockout? Wouldn't it just not have moved since he wouldn't be pulling up expecting a lockout to be there? also, if he was really going for the flap lever, wouldn't he expect it to be ONE flap lever, and not TWO? What would explain him feeling the larger width shape of TWO LEVERS AND PULLING UP on the safety lockout for BOTH to move BOTH to feathered?
And beyond that, after moving the condition levers instead of the flaps, he did eventually move the flaps lever to 30, did he already forget that he had indeed operated a lever he thought to be the flaps already a few seconds ago ?
Gidday Magnar. I fly an ATR for work and your videos and patter is the best out there. Congrats on just having the words via text and not verballed that was very thoughtful. A great insight and breakdown of the cockpit and importantly the regulatory issues that stood behind this. Thankyou.
Fly with Magnar, great video dude
So many holes in the Swiss cheese. Tragic incompetence.
Where was the incompetence?
@@manikyumJeezuzzz... if you have to ask, you must be just as incompetent!
@@saito125 sir I'm not a pilot, my line of work is different. So you're right that I'm incompetent in being a pilot/aviation. That was a genuine question though, fyi.
yes. no yet ready for that training . either or one
@@manikyumjust wait until all the DEI PILOTS get in there from the U.S.
They were both expecting a warning that should be ignored (the ground proximity one), that maybe helped them not giving importance to other sound alerts as well
I personally think that an approach route that gives you a "Terrain, Terrain" warning is a good idea in the first place. Not going to lie, if I was a passenger on that flight, seated close to the front of the aircraft and I heard that from the cockpit, I'd need a new set of underwear. I remember my only flight on a Dash-8 as a kid, i was seated in row 2, they were flying with the cockpit door open (it was pre 9/11 and also not a scheduled flight, but an event organized by the airline where a friend of my parents was a high-ranked pilot, so this was no big deal). Not knowing much about automatic announcements on the flight deck, I totally freaked out when I heard the "Minimums" call-out. Of course, today I know that this is absolutely normal and nothing to worry about. But a "Terrain, Terrain" is a totally different thing.
I agree. Flying an approach where you expect a GPWS Terrain Warning is not normally done.
If that's really the cause then thats not the first time an accident has happened due to inadverted feathering. Maybe the should separate the flaps and feather levers a bit more or change the position or something.
So sad. Well done for you for taking the effort to provide txt and respecting the pilots.
Your videos are some of the best on YT, at explaining commercial flight. The diagrams and visual aids make for an informative presentation.
For me there are two key ''flaws''. There were two pilots flying and no monitoring pilots (As RH Commanding Officer was guiding the LH pilot losing awareness of what was going inside the cockpit). Suddenly losing all power on a twin engine airplane is extremely rare and should immediately lead to check all power control lever positions, even more being that close to the ground.
Unfortunately to err is human. Rip Captains Kamal KC and Anju Khatiwada.
Even without any power a competent pilot would not stall.
That´s exactly the crucial point - it was the decisive Mistake of all the Mistakes which happened here.
RIP to Anju and Kamal.
When the pilot knew there was no thrust in the engines, he should have known that the propellers might be in feathering position and should have immediately corrected the mistake.
I've heard many times the expression "so many thousand hours of experience" and "so many years of experience". But either statement convey if the experience in hours and time were good proficient experience. Sometimes there are assumptions that meeting the bare minimum requirements is sufficient. Anytime the human factor is involved there is an inherent risk for error on just about anything that is operated by a human regardless of "experience".
Fly with Magnar, this is sick
Hello. High cockpit workload, uncomfortable conditions, rest, distractions,……
Pilot error during landing almost always is a death sentence, especially in an ATR 72. The plane does not have a margin for error, so any mistake can result in a deadly stall which cannot be recovered.
Totally disagree. Super forgiving aircraft and very docile aircraft to fly. Lack of SOP, lack of SA, and an instructor that was having a hard time of “letting go!”
He stopped being the PM (pilot monitoring), NFP (non flying pilot), whatever you want to call it. Even screwing up and pulling CLs back, a MC (master caution) light needs attention. Read it, call it out. Continue or go around and figure it out. If he had just said “Master caution”, “Hyd, Anti Ice, Elec”, maybe the other pilot might’ve realized what had just happened, Or, triggered himself and fixed the issue.
When you grab the flap handle, (technique only), you come from underneath and look at what you’re grabbing. Flap handle has to be lifted up, then moved aft. Condition levers have triggers, come from over the top, then moved aft. It’s a different movement.
Lastly, fly the airplane. It’s better to keep the aircraft flying than stall it into the ground. Airspeed is life in those situations. Watching the video (great video btw, love your stuff), once they realized there was no power, they were over the old airport. It would’ve been a beeline for me. Fly it to the pavement. I know, it’s easier said than done.
It’s hard to not “Monday Night Quarterback” these things. You’re not there. You’re not in the situation. Could you have made a difference? I don’t know, and I don’t want to find out. EVERY AVIATOR strives to do things right and get home. I believe this crew was no different. Though this was a tragic event, its findings will have a significant impact and save lives down the road. RIP Yeti Flight 691!
excellent video i'm trying to understand why they switched at the last few minutes to landing at the more difficult runway
That´s a really good question. It made no sense.
Many Thanks for your work and this crystal clear explanation 👍👍👍
Very Well Explained Once again. Many thanks Captain!! Be Well.
Admiral Cloudberg's writeups are extremely detailed and great reading. Highly recommended.
Indeed. And she really got to the heart of the whole context of this Crash.
A very good video. Very informative.
Thank you sir we love your video 👍🏼🙇🏽♂️
Feathering the props when wanting to drop the flaps is like taking a dump when all you wanted to do was piss...in short -distraction & lack of concentration.
Excellent video Captain....thanks! I assume from FTR position to full TO power lever movement will put the props back to thrust pitch? It seems that happened but I guess to late to prevent the slow flight and excessive AOA to cause stall?
No. To unfeather the propeller, you move the condition lever to AUTO. The engine can only deliver power when the propeller is up to speed.
I honestly can't believe how this could have happened...I'm still shaking my head in disbelief.
Thanks for your video !!!
That was an absolutely great way to depict the incident.
Thank you very much for picking this up and explaining it in this enlightening, but also disturbing way! It makes clear how rapid the Crash happened and how few time remained in fact to pick up the Mistake. And how easy it was to not recognizing him.
It´s very, very sad to hear those last words: "What happened?" It is really horrible.
Thank you very much, too, for the reference to "Admiral Cloudberg". She really got to the heart of the whole context of this Crash.
But nevertheless: After all and finally it was a weird case of Pilot Error. They made one mistake too much, payed for it with their Lives and caused the Death of 70 other Human Beings.
RIP to Anju Khatiwada and Kamal KC.
RIP to all who lost their Lives.
Again my deepest Condolences to their Families and Friends.
It is like when the car engine lacks oil, but the message appears: Danger - Battery charge
Yes.
inattention to indicators and settings is beyond inexcusable. It's not even acceptable when driving a car.
fly safe captain!!!! nice video
Thank you for your insight Captain.
May these poor souls RIP 🙏
OMG, the closing sequence seems to have been quite a challenging landing!
Similar to retracting flaps instead of gear on Tu154 on initial climb. There were several crashes back in the days.
P. S. Wy no direct feathering indication / sound alarm?..
Excellent video and very clear coverage of the whole sequence of events. The pilot flying didn't have very many hours on the type, so without abbreviated briefing and things happening quickly, she missed the crucial SOP and the likelihood of accidentally feathering the props. Horrible last few seconds. Having no knowledge of the type of aircraft, I do wonder why there is no attention-grabbing indicator of feathering of the props.
Great Video as usual Captain!
"Self Preservation Instincts" have steadily declined in the last 30 years and seems to be at an all time low. Back in 1983 as a brand new First Officer my attitude was if my captain moved his Big Toe I HAD to see it!!
In other words I must see any movement of the one sitting next to me that could kill me!
Using long checklists repeatedly creates "Parroting" where we say what we are accustomed to say instead of what is.
The word "Checked" should be banned from checklist, instead the Flying pilot says what he SEES. Saying "Flap 15" instead of "checked" is more likely to prompt the pilot to actually check the flap indicator than saying "checked".
We changed that decades ago in the airline I flew with.
Very unfortunate accident, wonder if fatigue could have been a contributing factor, as well as airline culture. May all souls rest in peace.
Every analysis of this incident I've heard says it 100% was a factor.
Where is the link about detailed information concerning propeller as stated on part 4:14
In the description below.
They reacted how thousands of unfortunate pilots before them have reacted to something unexpected. By temporarily becoming task saturated and suffering cognitive lock up.
Humans, not computers.
Also we would need to see the airline’s operating procedures before we could say they didn’t follow SOP.
Captain Nordal, my congrats from Brazil to your great knowledge about the flight environment, and i respectfully ask you: Why the alert panel hasn't a "feather" light to indicate this condition?
Imagine seeing the runway and you wont let even reach it
What a complete screw up.
From a human factors point of view I think it's a terrible design that the propeller control which only has three positions has two levers right next to the power controls.
It would make much more sense to have switched or buttons that are out of the way - after all how frequently does the pilot need to access the propeller controls?
For engine start and engine shutdown in normal operation, also in case of engine failure of fire.
I agree good sir!
every engine start..................... every tarmac op. so american eagle when they ran the atr back in the day would do a lot of caribbean ops. they would run engines while stopped and would feather the props during unloading and loading. LIAT did the same with their dhc8s.. it is a very useful feature and it's unfortunate 2 "qualified" pilots 1. did this 2. did not realize it. it tells you on the gauges and you can easily look at the levers too. its akin to forgetting to lower your landing gear! thats the level of incompetence here. sad for the passengers, 0 pity for the pilots who caused this. should not have been in control of a bike!
@@johndonovan7018 I recommend looking up Ergonomics as a concept of Human Factors in Aviation good sir! It explains why some accidents are caused by certain "flawed" or "error-inducing" designs of, in this context, an aircraft especially when the human (the pilots or aircrew) are subject to extremely high workloads which often results to loss of situational awareness. A lot to talk about here on principles of Aviation Safety and this is a really insightful case study on Human Factors! :)
Airbus was able to make the propeller control in the form of usual Airbus engine master switch on their A400M. They should adapt it to their ATR lineup. Eliminating the risk of this kind of accident. The 100% NP OVRD then can be changed into push button form.
Magnar, thanks for the clear explanation. To which Dash 8 incident were you refering? Thanks. BR Rob
As always, very interesting summary and analysis of the event. To simplify it for non pilots, it's like switching off your ignition on your car while going flat out on a highway..
I wonder why there is no security mechanism for the levers to go into that position like moving it slightly to the right (like in a car for reverse gear)
It is more like setting the gearbox on neutral and wondering why there is no torque when you press the throttle.
@@christiangavrilato some extent. It’s more of that you select manual mode on automatic and forget that you are on low torque setting when u need it more. So can be misunderstood when you didn’t even realise hitting the lever. I feel ergonomic on ATR are way poor compared to other aircraft’s… they have caused too many disasters… can’t blame pilots always 😢
If you look around 14:21, it looks as if you already have to pull up on two knobs on the outside of the condition levers to move them. So a zig-zag pattern wouldn't add much to it. I am more wondering why there is no alarm going off if you feather both props, as I don't see any reason to do such in flight. (Feathering one upon engine failure, okay. But both? I don't know...)
@@Colaholiker Only in case of dual engine failure...
@@bbgun061 In which case an additional alert could also be helpful, as it could be seen as a confirmation that you actually did feather both props. And I am confident that it's more likely to accidentally feather both props as happened here than a real dual engine failure.
Last August in Malaysia, a private jet co-pilot made a similar mistake when they accidentally pulled the lift dump lever instead of the fuel dump lever during the approach.
Cockpit should be designed for pilots under stress and 70% focus. Current cockpit design requires zero stress and 100% focus. Too demanding. Make the cockpit less demanding.
i have been thinking that a long time; however what is missing is good ideas what to change.
@@HarryFortyTwo move the prop levers to the centre aft of the ceiling (roof); it doesn't look like you need to touch them that much during flight
So you want dumber and dumber pilots
@@manikyumwe're getting them regardless
@@manikyum
It is a mixed bag. If certain operations arenot automated one should at least design the lay out of instruments in such a matter that “foreseeable mistakes” can be prevented. That doesn’t make pilots dumber but prevents mistakes as in this case.
Example: if you are operating a machine which has a “stop movement” switch next to an emergency button, one might think that pushing the esd button would do the same thing as said “ stop movement” button. In reality this ESD may cause morevital systems to stop, making the machine slightly unsafer ( because all power incl lights will also be switched off). In a day to day operation it is not a problem untill one day work needs to be carried out at night. Then suddenly, when lights go out, it becomes dangerous to step out of the machine safely.
It is random made up example.
Design matters.
Oh wow Magnar, I’m sure glad I came across your channel! You’ve got such a great way of delivering your content. It really helps me in understanding some of these aviation concepts. Thanks so much for the time, effort, energy and passion you put into what you do. It’s evident in your final product. Thanks again! Cheers mate.🛩️🫡
How the hell was the guy in the left seat a captain? He sounded like a complete student. The right seater was telling him how to fly the approach.
It seems to me that the ATR series is very unforgiving in stall situations and tends to roll into a spin very violently when stalled. I have seen many different stall/ spin/ roll accidents with the ATR series now, so something needs to be done here.
Don't stall!
In the recent ATR crash in Brazil the stall developed into a full flat spin straight to the ground. All recorded on video.
@@saito125 More incorrectly feathered props I think I read...
I can tell you what needs to be done, it’s very simple, Pilots should NEVER let it get that far! That’s one reason why there is 2 Pilots in the Cockpit, it’s to monitor what’s going on with your aircraft ALL the time and if one doesn’t catch something, the other one will.
@@user-kb8gh5jv9t I fully agree, but all pilots need to know that the ATR is a b.tch close to stall... She rolls and spins right away, this is not a STOL aircraft.
Very good video.
As I learned of them having feathered the engines, I had no doubt that this was a case of crew being overloaded. Especially when they are flying into a new airport plus having training on the flight. When you get stressed, muscles memory is one of the back ups you have. In this case it could seem that the Traing Captain had the wrong muscles memory activated and therefor feathered the engines. Especially in nothern countries you normally don´t feather both engines at the same time, as in winter, having slippery aprons, this could result in the aircraft moving forward, even with parking brake on. But I suspect it could normal for this captain to feathering both engines as standard, and therefor having this muscles memory.
Following this accident, I tried having both engines feathered during app in the simulator and if you are doing a visual APP and only looking out, the only thing you hear is a SINGLE CHIME. And if you are stressed/overloaded then the first thing you loose is you hearing. And yes they should have been looking in for the before landing C/L but again they are focused on the Visual Pattern. And actually the PF noticed something was wrong, so it seemed she wasnt that much overloaded. So for me I dont see much mystery about what happened, BUT I might be wrong. It wouldn't be the first time. We will see when the report comes out.
I also think these were two very qualified pilots, that just got caught on the wrong leg on the wrong day. Something that probably can happen to all of us.
I think they didn't notice the indicators because they were trying a stressful approach without adequate briefing. When under stress, expectatoin bias becomes a much bigger nightmare (and in fact I use expectation bias errors as a way of gauging the stress of those around me). The stress was sufficient for both pilots to be fixated on the flight path for the approach procedure and miss other things.
Also I wasn't aware of the two incidents involving feathered propellers. This indicates that this is a recurring problem with these airliners though not a fatal one. I think it is also likely that a sort of subtle spacial disorientation within the cockpit may have affected the RH captain since he would have been used to flying in the LH seat and that may have been the source of the feathering error especially under stress.
Last minute changes can be deadly and this transcript shows one particular way in which this can happen. RIP all involved.
I hadn't considered the possibility of distraction contributing to the RH pilot grabbing the wrong lever. The CVR suggests that the workload as unnecessarily high for a challenging landing. The RH last comment of "what happened?" strikes me as absolutely tragic.
The breakdown of SOPs strikes me here as a workload-related issue. They should have taken the decision on which runway to use on the ground and fully briefed it rather than trying to improvise in the air.
Very good insight of the last few minutes with the timeline, well done Magnar. In my opinion, the main contributing factor of the pilot is to be submissive and trust the incompetent pilot monitoring (validation flight). Work hierarchy and cultural hierarchy within this country's system plays a huge roll in this accident. The pilot in command was not in command, she allowed herself to be lead.. The pilot overly trusted the monitoring pilot , letting herself being lead through the approach instead of flying it. The monitoring pilot( validating instructor) is mostly at fault by meddling into the pilots role in addition to not briefing prior to the flight and allowing the aircraft/flight procedures get ahead of him during the flight. This is the reason procedures were rushed ( not following SOP) . Again , all my opinion. Magnar, Is it possible to post the flight recording? The tone of the voices can determine authority or submissiveness.
The CVR recording is available elsewhere on UA-cam. I heard it a few days ago.
I heard it on other UA-cam Channels, too. Because most of the Conversation was done in Nepalese Language (only the Communication with ATC in English) you will understand nothing. Both voices sounded calm and focused nearly up to the end. The last remarks of Anju Khatiwada were made with an audible increasing panic. His last words sounded irritated and astonished.
I don't know how do you pilot a plane, but when I run any kind of machine that responds abnormally, the first thing I do is visually check the main control's positions. One person mislead the flap lever and pull the propeller lever is already a big mistake, and both haven't seen those levers in the wrong position is worst. But reflection and analysis of that kind of facts based on blinking lamps and beeping alarms, instead of watching to main controls, is too much insane...
It's called CRM. Crew Resource Management. This is 110% on the crew. Not the aircraft. When I flew corporate ages ago, no matter who was pilot in command, both pilots would double check the proper action was taken including a verbal response. Pilot in command calls gear up, pilot monitoring verbally responds gear up, then raises the gear handle, then pilot in command visually checks the gear handle was up. Pilot monitoring responds gear up lights out (indicating they aren't hung up in retraction), pilot in command visually checks the lights and confirms verbally. People are complacent these days. And instead of others admitting it's a problem. They blame the equipment.
Ok, CRM failed. After that, at that altitude, the pilot was alone and should be capable to simply pilot: look at controls, correct the propellers and corrected the flaps, while talk the official speech "fly, beauty, fly!". If ok, then, complete CRM checklist: "I ask you flaps, idiot!" Exclamations are optional.
For sure this is a perfect landing capt magna 🔥 17:33
Make the feathering levers look exactly like a flaps lever and watch the confusion.
My UA-cam friends said that this CVR is fake, but I think that they have envy for me because I was the first person to see it, I know that is real
The "crash airplane" levers may be located very close to the "anti crash airplane" levers, but if the pilots adhere to the SOPs, then it's not an issue.
it is always such a small thing. But holes aligned again.
phew... make me appreciate that tiny flap lever in small GA planes.
I was never into flying large buses not even in sims, so this is bit new to me. It is really surprising now that is googled couple of layouts, that airliners make it in such a similar shape, height and travel way as power levers. In stress situations it seems like asking for it.
Everyone of us i raised on basic design three lever console. Throttle / Prop / Mix. With flaps being either to the side of the console or close to where gear handle is on front panel.
Adding power should automatically remove the feather condition. The pilot wants to go up.
Well, a bounch of yellow buttons is not the best way to say "why did you feather both engines when they still working" An aural warning "both featered" will be much more effective espessialy during high stress situations.
Indeed, exactly.
Amazing how many commentators did not watch the video, think its a plane fault
Did I undertstand correctly? Did the pilot set propellers on "feather" instead of setting flaps 30? Did she just move the wrong lever?
Nice landing. :) Thank you Captain.
All those people died because the crew did not take the 2 seconds needed to follow the flaps setting checklist because they were both 100% focussed on the visual approach profile. Yet another lesson on the importance of following checklists regardless of how experienced you are !
was that the one where they feathered the props and didnt look at their gauges to figure it out, or even look at the throttle stack... who trained that crew
Imagine designing an airplane and put the death lever right next to the flaps lever pilots use when in demanding situations
Most transport aircraft have the flap lever next to the thrust levers.
@@4ndroidG yeah that’s kind of weird but hey who am I to judge lol
Those levers are there on any other aircraft because they're needed for operations and those condition levers have safety triggers to prevent accidental movement. But I'll do you one better, imagine putting in charge of operating an aircraft people who are properly trained on them, that pay attention to what they are doing, and that are not excessively challenged by a simple visual left hand landing pattern (very basic skills that are used by general aviation pilots everytime they go fly).
@@sebastien1174 The different form/feel of the lever should prevent this kind of accident. Especially the detent on the thrust lever that requires finger lifts to go through(!). Still, somehow they managed to make this mistake. Hopefully, things can be learned from the accident that will prevent it from being repeated in the future.
Thanks.
I don't understand why there's a single "chime" along with a somewhat generic looking "caution" light relating to a feathered propeller during flight. Two feathered propellers definitely should be worth a red blinking light and a ringing bell (or two). Seriously, everything indicated an aircraft that was in a relatively normal phase of flight beginning with its reduced speed and altitude. Unfortunately the same two people that got in this situation weren't able to recognize the simple solution for getting out. Maybe some other information can be displayed on the master warning panel with an appropriate aural tone denoting its importance.
One of the worst pilot negligence incidents ever. How did the instructor not know about the feathering? It's more understandable for the pilot because she was still training, but the instructor should've immediately diagnosed the situation and corrected. This accident should never have happened.
So the veteran pilot pulled the wrong lever?
Yes. And both Pilots didn´t recognized that.
@@NicolaW72 how tragic. All those souls lost.
@@hardsayings2400 Indeed 72 Fatalities caused by a weird Mistake, but as a result of a chain of events.
Were they wearing ANR headsets?
Criticising the flying pilot (left seat) for non-standard checklist terminology! Her co-pilot (right seat) feathered the props on her instead of selecting flaps 30! Somewhere in heaven she is screaming WTF!! I feel very sorry for her and the passengers.
The first rule of flying is "Don't stall!"
Yeah this is a joke 😮
With the propellers moved to feather was the flight savable in flight in this case? I’m commenting before I forget but still have a few minutes left of this video in case you answer in video and I don’t delete this first. Thanks!
It takes about 30 seconds to recover a feathered propeller. So, if they had discovered the error when it happened, they would have had enough time.
@@FlywithMagnar that’s all disappointing. Thank you for answering ❤️😭
question: There's no way to recognize the propeller condition by the sound they produce?
EDIT ok you answered further down in the video.
This mistake, by such a senior pilot and also an instructor should not have happend. How tragic for that girl as well who did everything right and then the senior caused the crash.
The problem is, that in a low power approach, feathering the props would not create a lot of decceleration as the engines where at low power anyways. Why can props be feathered in flight anyways with a running engine?
Because an engine can catch fire.