An unbelievable mistake | Yeti Airlines flight 691 

You should not censure people’s opinions. The point of accident investigations is to prevent future occurrences. I don’t know how you expect to do this when you are spoon feeding your our personal narrative.

I have deleted libelous comments targeting individuals. There's a clear line between discussing what has happened, and harassing people.

I'm from Nepal and you clear us why this accident happened thank you very much

@@FlywithMagnar Keep in mind that not all disputes are destructive. “Malicious compliance” is an actual thing. 90% of accidents could have been prevented by someone just speaking up, and your censorship does not help this at all.

@@mike48084, let me make this clear: I do not censor opinions. I remove comments that are attacking individuals as persons. This includes racism and hate messages.

Hey, besides Yeti, had you taken any airlines or not? If you have, which airline in Nepal do you recommend?

U mean tara air

😊😊😊😊😊😊

They thought they engine power is a thruster

Pete, I bet you had a few "butterflies", with this incident fresh in your mind?

Perhaps making the feathering level into a wheel like a trim wheel will help with muscle memory? In low speed and low altitude trying to stay conscious of levers seem like it could go wrong somehow. Having a totally different feel and mechanism might help unconsciously differentiate controls.

@@manofcultura I think the levers are quite different enough. Humans do some crazy things under pressure. I though maybe adding an audible warning as in "Levers - Feather" would help, but there's no guarantee of that helping since hearing is one of the first things to go and numerous accident reports have noted pilots not hearing audible alarms when in a very stressful live or die situation.

@@pfsantos007 I agree with you. Some folks go completely "brainless" in high stress situations.

@@guitarhillbilly1482 This was not a stressful situation. Excellent weather conditions, light wind, good weather, excellent visibility.

Vielen Dank!

Thank you for your contribution and feedback! I have heard about a similar incident with a Dash 8. And as in your case, the mistake was discovered within seconds.

Yes pilot decreased condition lever instead of flaps to 30° Engine turned off fuel supply due to that plane crashed - Cockpit Recorder

159,000 ?

@@jonathanhermansson4553 😂😂

​@@jonathanhermansson4553it's still fu.cking 10 bucks who were giftet. Humans are stupid these days.

It´s indeed obvious that more than one mistake was made during this short time of only 60 seconds.

Hi...Do you think it is normal thing to do to change the flight duties in the final moment when PF became the PM and PM became the PF ? Shouldn't the PF continue flying until Landing or Go Around Procedure is complete?

@@SurajUpadhyaya-kj8zi I believe they switched control to the more experienced pilot when it had already become obvious that there was some kind of problem. Remember the left seat was on a familiarization flight.

@@jerryweirdspeed8943 Indeed. But nevertheless it´s at least a point to discuss if this was a sensefull decision - both pilots had to find themselves in that new roles for what no time remained - and so far as I read the Preliminary Report no Control Inputs were made during the final 14 seconds of the flight.

@@NicolaW72 instructor did not check prop lever upon finally setting flaps. easy mistake to make even if it sounds unusual to have 4 occasions to miss the fact that the props are feathered and still not check the levers consciously. neither pilot did that in the end, it appears. and this is the tragedy of this incident. they did not perform checklists correctly nor did they show presence of mind when troubleshooting the issue. nor did they have much time at all whilst executing an approach to a new airport. and i'm not judging whether it was sufficient time. this is not up to me.

Vanligvis tar det et halvt år før den første rapporten publiseres. Så dette er faktisk ganske så unikt at rapporten kommer så tidlig. Desverre mangler mange detaljer.

Tudor, for not being a pilot well said!

One word can bring you down... Complacency 😮

Both are captains and they are overconfident I guess

Very well said. Makes a lot of sense. Helps one understand how an experience pilot could make such a basic error. I was wondering how that could have happened.

So...props feathered...and therefore no thrust...therefore.. speed decayed....stall and spin..

Thank you so much! Highly appreciated!

@@FlywithMagnar Yes pilot decreased condition lever instead of flaws to 30° Engine turned off fuel supply due to that plane crashed - Cockpit Recorder

After a couple of month: Yes, indeed, exactly. And the "missing links" between what we know so far could contain some more bad surprises in this direction. It was really a very sad event.

Can you explain further..with example

Thank you for this information! - Yes, this is plausible.

Point.

Good catch

Why is it not possible to take a quick glance at the lever before you pull it?

Muscle memory from the seat ?

​@@DearMe247 things you were doing with your right hand, you now do with your left

I am not a pilot but in the work I do there is a saying "familiarity breeds contempt" and perhaps this played a part. God Bless the poor souls who perished

@@Johnlee0513 Both Pilots were of course familiar with the ATR 72 - the Pilot Instructor even very familiar. But the Approach they flew was new, therefore two Captains were seated on the Flight Deck, and the Pilot Flying did this particular Approach probably for the first time. As Magnar stated in the video: Both Pilots were probably looking out of the window for exact this reason and this contributed to the Crash. The Sequence of this Event is nevertheless disturbing if you take a closer look. I hope the Final Report will answer the open Questions - and there´re still a couple of important ones. It seems to be a really important investigation, not only one for this special case.

@timemachine194 Of course we don´t know if the Preliminary Report really contains everything what the FDR and the CVR are containing, as Magnar stated in the Video. But let´s take it for a moment as if everything is published what they´re containing. The FDR than shows that between the switches of roles between the Pilot Flying and the Pilot Monitoring (10:57:18) and the Impact (10:57:33) there happened not a pull back of the Yoke instead of a move forward as it was the case in the Colgan Air - there was simply no Control Input at all - NOTHING! Even nothing when the Stick Shaker was going (at 10:57:24). THAT has to be explained. The Aircraft was performing a difficult and for the Pilots NEW CIRCLE APPROACH. The Aircraft just turned from Base to Final and the Pilots tried to line it up with the Runway. Following the River was in this situation no option for them. Then: This Aircraft stalled because the Propellers were - obviously unrecognized - in the Feathered Position - NOT because the Pilot Flying pulled the Yoke back instead of moving him forward, to repeat this! Short before the Role Switch of PF and PM the Power Levers were even set to Full Thrust - what would have been the absolutely right action in this situation - but what was useless with the Condition Levers in the Feathered Position. Magnar explains this in great details. Please watch his video again. This is a very different Story compared to the Colgan Air Crash.

@timemachine194 Thank you very much for your Work which you made yourself with this Post. Not Loss of Engines - the Engines were in the Feathered Position. They were flying low and slow in the last turn from base to final when the stall happened. The Autopilot was off. Flaps 30 were only done at 10:56:56, not when the PF (left seat) called for it twenty seconds earlier. Did you anything read about Control Inputs between 10:57:18 and 10:57:32 in the quoted part of the text? Of course we must wait in this context for the Final Report as mentioned because we don´t know so far if the Preliminary Report really contains every available information about the Crash Sequence. But if we take for a moment as a complete description of that Crash Sequence what the Preliminary Report contains - because why should the investigators hide necessery informations for the understanding what happened? - then there was no control input from the IP at all when he became again PF, so no Nose Down, too - and that was of course another very serious mistake, adding up to all his other mistakes he made before. The Pitching up happened between 10:57:17 and 10:57.24, what matches perfectly to the Ground Observer Video and what happens when you´re turning with the Propellers in Feathered Position. With no control inputs => no nose down, gliding was impossible. When the Stick Shaker was going at 10:57:24, there were 2 seconds left - two! - before the Aircraft stalled. So at this Point the Game was probably anyway over: Too much too serious failure´s. Openly said: I got the impression when reading the Preliminary Report that they could have glided two more hours, they wouldn´t had detected that the Condition Levers were in the Feathered Position. How much more best occasions did they needed to recognize this? Maybe the Final Report will contain some more bad Surprises. He will surely deal much with Human Factors and will probably be from broader importance for Air Safety.

@timemachine194 That´s indeed possible, yes.

A comercial pilot flyies not just once a day or every vew days. If you fly like 5 different routes a day, you are in greater danger to become victim to a routine and so you maybe miss something. Most people are very carefull with everything that they don't do on a daily base b.c. they know that they can make misstakes and wan't to prevent them but if you do things regularly, you start to miss things b.c. the tension will become less each time.

@@friendlyreptile9931 in this case that is bad really specially when they know the life of many souls is in their hands.

@@noneNone-mw1px Yeah that's true.

@@friendlyreptile9931 That`s so true my friend. As the old saying goes, familiarity breeds contempt.

I call that good airmanship from your part. That is why piloting isn't for everyone. Equipments are getting better and better. Systems are put in place to assist pilots throught all stages of flight. Pilots need to be adamant towards check list and OPF. The ATR 72 is an awesome piece of equipment, which has achieved it's purpose 100%.

It's pathetic

pilots dont want to be filmed when they consume cocaine or play with the stewardess.

The data recorders can be upgraded to record what levers were pulled and buttons pushed without recording video. Pilots are resistant to video recording for various reasons. One thing I've heard mentioned is that in worst cases, they don't want the video of their final moments to be circulated in the internet. They also don't want hourly micromanaging and micropunishing of their performance.

Yep. Anyone who drives a stick knows that one can put it into 4th gear instead of 2nd very easily because theyre side by side. I liken it to this. One has to be alert to the feel, the sound, or the instrument panel indication, to catch the error cuz it isnt obvious at first glance of the shifter.

is it possible that the investigation report was scripted to favour the airline and other stake holders. I mean its always a custom to blame the dead pilots rather taking any responsibility.

@@_-HaKooNa.MaTaTa- Absolutely not

Sabotage?

​@@_-HaKooNa.MaTaTa- This Is The Report Of Nepal Investigator, there Is Still French Investigators are Ingestigating.

relative to your post he stated that the job of the "right seat" was to keep eyes on the controls and indicators for anything not normal....it was apparent you "saved the day" not the case here

A very interesting Hypothesis. The Final Report is out now.

And read the altitude and squat switch for an immediate terse audio warning, ATR needs to alert pilots that make these deadly mistakes.

Perhaps not to the stage of flap warning, but yes it would not be easy to program in the backend with a rule. If aircraft is airborne and prop goes to feather, then audible warning in the likes of “feather” should be triggered. Same as in a simple piston like the baron, if flaps are down and throttle is reduced below a certain point it will alert for gear if not down.

It's really not necessary. Would compicate an already busy environment during a critical stage of flight

It doesn't help. People ignore it. Listen to the Air France 447 crash. The stall warning was shouting "stall, stall" over 50 times and all three pilots ignored the fact it was stalling.

Engineers need to be aware of a thing called " nuisance information " which could be distracting to "trained" pilots.

Indeed. And here a couple of serious mistakes were made in the short time of only 60 seconds.

I can totally see myself making a mistake like this. Sometimes the mind just does weird things, especially when you're new (like on of the pilots was). Your mind gets blurred with too much stuff and you move the wrong lever. But that's the point of having 2 pilots. The other person should say: "What are you doing?" And the mistake is corrected. Trust but verify.

They should not put levers that are that important to be that similar and together. It's insane that you can even make that mistake

New video on police activity shows a shooting in Albuquerque grocery store and a one of the cops runs in on body cam wifj their taser out. Then realized after trying to pull the trigger and switched the pistol and starting shooting at suspect.

Thank you so much! Highly appreciated!

I'm surprised there isn't an indicator and a warning alarm when the props are feathered! Would make sense surely!

I'm wondering why the plane should even allow you to feather props mid-flight when there is power to the engines. I understand the desire to feather a prop if there is a stalled or dead engine, but the plane shouldn't even allow you to feather engines in flight that are receiving power from the turbine. Maybe i'm missing a situation where you would want this?

@@2760adeAn alarm sounds reasonable until you have a real engine failure. The you want the propeller to be feathered. The indication that this has been achieved is Np is zero. It must be therefore possible to cancel such an alarm however the propellor will still have been feathered.

@@robmausserOne such situation might be when you have a jammed engine control, a EEC/PEC failure resulting in a runaway engine/propellor, loss of oil pressure or an engine fire.

If you are correct then this is the start of the investigation, not the end. Mashing up or totally ignoring SOP’s should not result in the aircraft being placed in a dangerous configuration.

@@Trevor_Austin Hey Trevor. I would have to respectfully disagree. There are many fatal accidents that have been caused as a result of the crew not following SOP’s. By drifting away from standard procedures, what you’re doing is exposing yourself to potentially dangerous errors that could adversely affect overall safety. Check out Mentor Pilot’s channel. He has several examples.

@@faganfit572 Hi...but I think we all are taught about the swiss cheese model....Fatal accidents happen due to series of mistakes. Just one mistake should not cause the crash to happen?

@@SurajUpadhyaya-kj8zi Very true Suraj. We can just aim to do our best as aviators.

could be watching tiktok instead of concentrating on the flight

I don’t think it will happen, it is a perfect position, human stupidity will defeat any system

Same here. Even in a case such as this, where it seems glaringly obvious that the pilot made a “stupid” mistake, I hesitate to use that word, since it is so human to be momentarily distracted and then do something completely different from what you intended to do.

Very valid point.

I have heard the design criticized on other videos

@@johngreydanus2033nothing wrong with the design, every aircraft type with condition levers has exact same configuration

@@johngreydanus2033 ATR is the most successful aircraft with most advance systems specially its propeller system. Mechanical failure or human factor could lead to such disaster. I will be very keen to know the actual position of CLs found after crash in final investigation report.

My condolences.

I agree. Bringing both propellers into feather is so bizarre as to be suspicious of being an intentional act. But then later, the flaps were set to 30, so I suspect the pilot monitoring quietly tried to correct (or hide) his mistake?

@@m.f.m.67 Then why not restore the condition levers back to auto at that point also?

@@earthb67 That's the biggest question in my opinion. He must have realised he hadn't set the flaps to 30, but he must have ALSO realised that he had earlier accidentally moved something else? Makes no sense to me!

@@2760ade It´s indeed so that after the "basic" mistake of confusing Flaps Lever with Condition Lever five or six more crucial mistakes were made in just 42 seconds: 1.) The "basic" mistake was not cleared when the Pilots worked the Before-Landing-Checklist. 2.) When the Flaps were finally set to 30 there was no Call-Out made by the Pilot Monitoring (at least I readed the Preliminary Report in this way), so that the Pilot Flying stayed unaware of this action at that time. 3.) When the Flaps were eventually setted to 30 the mistake that the Condition Levers were in the Feathered Position stayed undetected - or at least uncorrected. 4.) When the Power Levers were moved first to 62% and then to Full Power the mistake of the Condition Levers being in the Feathered-Position was also not detected or at least not corrected by BOTH Pilots . 5.) The Pilots switched the Roles of Pilot Flying and Pilot Monitoring in that now very dangerous situation, so that they wasted time with accomodating to their new Roles instead of FLYING THE AIRCRAFT. 6.) That all happened during an unstabilized approach (= Checklists were not completed and Landing Configuration was not finished above 500 feet AGL), so that the Pilots were during this whole Accident Sequence always behind their Aircraft. And then finally - again: at least I readed the Preliminary Report in this way - the former Pilot Monitoring and now Pilot Flying made no Control Inputs during the final 14 seconds of the Flight, even not when eventually the Stick Shaker was going. That means, he was NOT flying the Aircraft when he became Pilot Flying. To type all of this mistakes in lasted nearly half an hour - the real Crash Sequence lasted only 60 seconds all-in-all. That is to remember. But nevertheless: There was seldom a Crash were in such a short time such an amount of really crucial and weird mistakes were made. So there remains really the need for the ongoing investigation to find an answer to the question: Why?

I've been saying that ever since the report came out, there's no way he mistakenly moved the lever instead of the flaps!!!!! It seems he was an experienced pilot.

You absolutely have to have full control over the Props at all times. In the unlikely event you suffer a double engine failure, then you would NEED to feather both props if the auto-feathering failed to operate, otherwise you will lose control of the aircraft. I hear what you’re saying, but it’s just not feasible. I’ve got thousands of hours flying ATR’s such as this, all be it many years ago now. Had an engine failure of my own on take off in one as well with an associated fire. Since flown most of the heavy jets and still do, but the ATR was a real handful at times, especially in strong cross wind. This is a tragic accident, but it isn’t the first time in aviation history where mistakingly moving the wrong lever has caused a catastrophic accident, and sadly, it won’t be the last either.

@@GeeBeeMike in that case there should be a warning of "feathered props," once the leavers are moved or yellow warning light on the torque meters to highlight the prop condition.

@@shug831 You cant miss the props being feathered or unfeathered. The noise in the cockpit is unmistakable when you either feather or disc-out the props.

@@GeeBeeMike well two experienced captain's failed to hear the difference. 😢

@@shug831 Yes, indeed.

Prop noise on a turboprop is definitely the prominent sound. Feathered engines produce considerably less noise but it is the same pitch, frequency or whatever. It would become suddenly quieter but with sound canceling headphones it might not be noticed as much.

@@thomasmaughan4798 I think for many pilots like myself the notion that the props were unexpectedly feathered in flight and NOT immediately noticed by either or both pilots is frankly perplexing. Noise cancelling headset would be irrelevant. As Capt. Magnar points out one does not easily confuse the prop condition levers with the flap lever, certainly not experienced pilots. This configuration of prop and flap lever is not unique to this airplane, on the contrary, it is very common. Feathered props would be noticed right away, it would sound different and would feel different, noticeably so on both counts not to mention that the airplane would fly differently. There were a lot of holes of the Swiss cheese model that lined up that day or in more modern terms the airplane quickly got into an undesirable (indeed unsafe) state and they did not notice much less correct it. Really bizarre.

”Point and call out” has proven to be surprisingly effective. Even bus drivers in Japan use it when they come to a traffic light.

Point culture should be applied worldwide.

Could you quickly describe how it happens irl please? Thanks

Point and call is also implemented on some railroads in North America for example for approaching switches in the track - I can confirm it helps, especially if there is some fatigue issue.

Indeed, exactly.

I've never seen a first-world Airline that didn't explicitly train ACTUALLY verifying and confirming that all checklist items are performed correctly and the criticality of not becoming complacent. Especially so after all the high profile takeoff crashes of the 70s-90s that were the result of NOT performing critical checklists correctly. The takeoff/landing checklists in particular have the PM repeat command, visually confirm change, with the PF also verifying it afterwards. This is a huge part of training and has been a point of emphasis for decades now, and every cockpit video I've ever seen has the PM and PF both verifying checklist items