Is this a dangerous design? | Yeti Airlines 691 accident 

Hello Captain Magnar. I believe that the accident in question involving two captains in the cockpit may have been what we call muscle memory of repetitive movements in daily operations, taking into account that one of the captains was not sitting in his usual position. I'm a pilot at Azul Linhas Aéreas Brasileiras, the largest ATR operator in the world, your videos are of great relevance for us ATR operators. Captain Magnar say hello to the Azul ATR pilots here in Brazil. Thanks!

I was a training captain on DC-9 aircraft. One day I had a brand new F/O on his first flight. We also had a supernumerary safety pilot. I was PF in left hand seat. After rotation, I called "Gear UP" and the new F/O moved the flap/slat lever from flaps 10deg (? memory is fading) all the way to SLAT Retract., Probably before anything had time to move, I returned flap/slat lever to flaps 10 and the supernumerary pilot retracted the gear. Exciting for a few seconds.

It would be interesting to do an anonymous survey of how many ATR instructors have made this mistake (even very briefly) while sitting in right seat.

There is another reason why Boeing ‘standardised’ the speedbrake-thrust lever-flap handle layout the way they did on the 707, 727, 737 etc. On those aircraft, engine thrust control, speed brake deployment and flap actuation are all achieved using cables driven by pulleys. It makes sense that the levers (and pulleys) controlling thrust, speed brakes and flaps would rotate on the same pivot point or axle for ease of design, construction and maintenance. Fly-by-wire aircraft, such as later Airbus aircraft are not constrained by the mechanics of pulleys and cables so they are free to be more creative with control lever position. In practice, however, once a configuration has become standard, aircraft designers are loath to change things too much in case this leads to the misidentification of controls.

Absolutely nothing wrong with the design in my humble opinion. I flew the Dash 8-300 first, then moved on to the ATR 72-600, and now the ATR 42-500. There is a reason why you should always try your best to stick to SOP’s. You move a lever, you check to see whether the result/indication makes sense for whatever action you’ve performed. I don’t care how experienced you are, we all make mistakes.

Thank you for the follow-up video. Microsoft often asks 'are you sure?' Unix assumes you know what you are doing and just does it, right or wrong. Maybe aircraft software could be programmed to spot and query unusual sequences of actions? Like for instance entering a very light all up weight into the system at the start of a long flight. The Yeti PF was low down, manouvering and presumably 'eyes out', so difficult to catch the PM's error.

There is a discipline that was focused upon when I became a multi-engine commercial pilot. ALL controls, must be identified, verified before any movement. No matter what!. Inadvertent manipulation of these controls can cause loss of control or performance and possibly a fatal accident depending on available altitude to recover.

I’m afraid that cockpit ergonomics often can’t save the day when the distraction is high enough. There was an incident of an A320 in the UK landing with the parking brake on because PM had selected it instead of the flaps - completely different shaped lever and movement. The key is to touch the control and verify it first before operating it.

I don't think it's the same phenomenom but this made me remember the time I taxied to hold short of runway of the wrong runway. I knew that small airport so much, I knew exactly where all the runways were, I even readback the taxi instructions correctly, but my mind just went on autopilot mode and while doing the instruments checks I didn't realize until I saw the runway sign....awkward moment when I had to tell Ground Control.. I learned that no matter how much you know an airport, you gotta be focus as if it was your first time..

Very well stated on the nature of human performance. Now in the nuclear power industry, one error reduction tool that Control Room operators use is to physically point and verbalize the control switch by name and the action they intend before even touching it.

This is "simple": It's in the statistics: -The more controls/tasks: the more can go wrong. you should go to a simulator and let a thousand of pilots perform actions with different cockpit interfaces and see what is more safe. What you in practice is that development of a interface goes in steps and in each iteration it's a bit better less complicated/more safe.

Dear Magnar, thank you for the detailed inside view into the cockpit designs and it’s potential impact to this accident-or not. You’re right that only the final report will unveil the root cause. Concerning the design: it is visible that the prop control is blocked by triggers which you have to actively unblock with your fingers before movement. The flap lever has to be pulled up before movement. What more can we expect from the designers? I think they did their best to avoid mistaken action. Very interesting is your statement about the mistakes which had happen and this is reality! Thanks again and always blue skies 👍🏻

For anyone with any level of competence it's a perfectly safe design, Fantastic Content 👊

Thanks!

They don’t need to be separated , there just needs to be a special movement to feather the engines - like some button that needs to be pressed at the same time or sleeve that needs pulling up ( like on a gear knob when you select reverse )

Hello Captain Magnar, I would like to point out an issue that I have always felt to be an inherently dangerous design with regards to the Airbus vertical speed/fpa selector mode and it's associated philosophy as I will try to explain. I am a retired Airbus pilot and I remember how uncomfortable I was trying to make sure I understood it and how easily one can make a terrible mistake by pushing one small button under the selector which assigns two distinct functions. The first is usually the most frequently used feature which is just the vertical speed and it is displayed in fpm (or some may have meters) climb and descend. The second feature that is SHARED is the fpa function which was used as a profile decent on a managed non-precision approach which as the name implies is a flight path angle and NOT fpm. FPA mode does not respect fpm therefore one cannot assume as such as the aircraft will now descend at the pre-programmed rate which can be dramatically different when the display indicates degrees up or down and not feet! This was demonstrated in the sim and if I remember correctly when the pilot flying manually makes any selection changes the thinking is when more than a few degrees is selected in reality the decent rate could be in TENS OF THOUSANDS of feet! There was a well known fatal accident in Austria many years ago involving an A320 that flew into the side of the Alps during initial decent from altitude (more than likely in IMC conditions) because the PF inadvertently did this very thing thinking he was in v/s and in actual fact it was in fpa and the rate of decent was off the clock and unrecoverable. This may be the only Airbus non "boxed" callout that only provides the most a soft and subtle indication and is easily missed. I may have omitted some other data but forgive me however I would think other Airbus pilots will surely understand. Don't know if this configuration has been changed as of this day.

This is what I was thinking. I have 7000 hours in the ATR and we never had an auto position for the props. When I saw the video showing an AUTO position I have to think and its been 25 years since I flew the ATR, I didn't recall the AUTO position . But its crazy they didn't catch this and actually did this.

As a sim pilot i also did mistakes like using speedbreaks during long desend and forgeting about them. It's really unpleasent situation on Airbus A320 when you apply full power and still having -1000 vertical speed. I undertood that mistakes pretty fast. But i still think that proper aural warning can be a very good solution. But not like in Cessna citation longutude when you set power to 0 and getting "Landing gear" warning at FL440.

Hi Magnar, thank you for covering this topic, as I for one, wondered about the ergonomics and its possible impact on this accident. You provided a great perspective in human factors. Cheers mate 👍👌👍

Great video. And flap/speed brake mix up HAS actually been happening fairly recently on A320s. There is NOTHING wrong with this cockpit design. I feel that changing it would only increase risk. The emphasis needs to be put on human factors. Whether or not this is 100% the cause, the fact is, these slips have been happening, but are usually caught. Or only result in an overspeed and a maintenance write up. In a cockpit, with vibrations, noise, distraction, multi-tasking, fatigue, it is so important to follow a pattern. We all have flow patterns. My own for this is made up, because nobody really taught it, and they should. Look, do, verify. Look at thing you are moving. NEVER move a handle or switch from muscle memory on an airplane unless it is ON THE YOKE or thrust levers. Do the action. Verify you got the correct result. After flying the e145, e175, A320, and now the 737, any one of those can punish you if you just start throwing levers. On the 737, this is extra important because there are so many flap settings and it is prone to asymmetry. It doesn't have fancy EICAS or ECAM. So looking at the flap lever, moving the flap lever, and looking at the flap indicator to verify that it not only went to the correct location but didn't stop with a split is imperative so you can discover it right away. I will admit, my high horse isn't impervious. I once accidentally turned off the B hydraulics on the 737 instead of the engine anti ice. Same type of switch in a similar position overhead. Boy, was I surprised when my autopilot kicked off. But a relatively minor oops only increased my resolve to do my flow every time I do something. Fly safe.

Outstanding job, Magnar! I'm a pilot too and love the details that you provide. Thank you!

Thanks for your videos magnar, we really appreciate them out here in the real world!! We all discussed this accident at work and a few of us even re-created it in the SIM to see what it would look like. Surprisingly there was little or no warning to the Crew for inadvertently feathering both engines on base or late downwind, in fact the aircraft actually performed quite well with the props feathered momentarily!! The only warning was the AC wild generators dropping off line with a single chime!! yes the design was a contributing factor..........but only a small one. keep up the great work.

Thanks for that worthwhile additional report on cockpit design issues. It looks as if the first officer did not have time to look down at the pedestal when attempting to change the flap setting on final approach and made that fateful mistake with insufficient altitude to recover power and control. Such an ambiguous situation deserves clarification by civav authorities as well.

There are 2 kinds of pilots in the cockpit, those that have moved a wrong lever and those that are going to move a wrong lever. I don't care how much experience you have or how much you say you ALWAYS check. Sooner or later you will do it.

I agree that an attention slip in this case is likely to be the key factor, but cockpit design should as much as possible prevent it from happening. Let’s just imagine the opposite scenario, where identical levers for thrust, condition, flaps and landing gear are all put beside one another, close to each other, with identical shape and color. This indeed would be like one of those “attention test” games, and it would be a call for accidents to happen: clearly no manufacturer would be so crazy to conceive it. So, if such opposite scenario is the wrongest possible, why not differentiating the options even more, besides what it’s already done, that is basically only the “order” of levers from left to right and their shape. In this aircraft, the condition levers and the flap lever are also almost the same size, beside the fact of being literally two inches apart. A big lesson for future aircraft cockpit design standards

The old codition lever design follows CSU prop lever designs, and is intuitive for pilots coming from GA (e.g. for full power it's mixture full rich, prop to max RPM, and then throttle to max). However with PEC and AUTO RPM settings the condition lever is much less frequently used, and maybe a plastic guard cover (like in the Embraer E-Jets) can be added.

I would definitely prefer critical levers to be in the middle of the cockpit. This let’s both pilots to keep an eye on it!

I once pulled the mixture control instead of the carburettor heat control while downwind for landing. Not something I ever repeated. I was inexperienced, but even so, I must have used the carburettor heat control hundreds of times by that point. So why the mistake? I've no idea.

I dont know what is the case in the ATR, but shouldnt there be a big red text on the display saying ”R/L prop feather” and maybe also an oral warning in case you feather the props when there is no weight on wheels? There isn’t many good reasons besides an engine failure to feather the props in flight.

Great explanation of why this cant be called a design error. Multiple errors made by BOTH pilots 1. On master caution did not problem solve the zero torque issue as props feathered. 2. On zero torque on both engines and not problem solving feather should have performed immediate forced landing on old runway which was right there. 3. Both pilots flew the plane into a stall/spin. For both pilots to make these errors together is beyond inexplicable Possible explanations: A. Uncommanded auto feather. Both pilots failed to apply 100% Override. B. Pilot monitoring suffered a stroke or sudden mental impairment but was still capable of speech. Pilot flying deferred decision making to superior who was in no position to think coherently.

Hello Mr. Magnar, as a comment I can share the following: I remember clearly in a flight coming out from Jamaica in an Emb 120 and my self on the jump seat when after take off the captain ask for gear up and the first officer catch the flap lever, immediately I hold his hand and stretch forward to select the gear up, as you said the f/0 could not give any explanation, but look like happen quiet often. Thank you very much for your info and support.

Human error (which is likely in this case) can never be completely removed, no matter how you design the cockpit, as you very clearly point out. Anyone who has ever put their cellphone in the refrigerator or tried to answer the phone by picking up a TV remote knows how easy it is to make the silliest mistakes. Maybe a possible improvement to the ATR might be to add an audible alarm if you feather both propellers while in air? Or maybe a voice recording saying "Feather Feather" or something like that? Considering how quickly it might go wrong if you lose all thrust at such low speed and altitude, I would think that having an extra layer of protection against this wouldn't be a bad idea.

Thank you for a clear explanation of the issues at hand. We're looking forward to the final report!

Hi Magnar, you make many good points about the designs of the cockpit and putting aside my opinion that it is a “dangerous design”, it doesn’t seem to happen all that often nor is it a problem unique to ATR planes. Why do I think it’s a dangerous design? Well, here’s my “ideal”… Ensure what would dramatically increase an aspect of flight (thrust, lift, drag) and there’s no “teeth” that requires you to lift a catch to activate should be in places as far apart as possible (ie. Conditions Levers and Flaps in this case). I think one plane the ATR manufacturers can take inspiration from if they plan to redesign their cockpit is the Diamond DA62 aircraft. Where the flaps controls are on the front panel. Feel free to disagree as I don’t fly the ATR series. But still, I agree with you that it’s all about getting used to the cockpit design and double checking that you’re on the right lever before manipulating it, will do more than any redesign.

En god video, som alltid, og hyggelig å få med litt Fleksnes også.

Great video Magnar. As per EASA Certification Specification CS 25.1153 amendment 27 (latest) Propeller feathering controls: (a) There must be a separate propeller feathering control for each propeller. The control must have means to prevent its inadvertent operation. (b) If feathering is accomplished by movement of the propeller pitch or speed control lever, there must be means to prevent the inadvertent movement of this lever to the feathering position during normal operation. This has not changed since JAR25 change 15 of which the ATR 72-212A certification basis requirements are set. (EASA.A.084 issue 10). The design does confirm to the above regulations set by EASA, however I can't find anywhere in the CS of the requirement for a set gap or distance between the levers.

Thank you Captain!

Maybe they should put a buzzer for when the Props go into Feather if the Landing gear is still up. Then have a Cutoff switch can be activated to silence the buzzer if the Prop has to be Feathered in flight. At least this way it would make the Pilots aware of what’s going on. Or maybe change the shape.

Still watching the video but I'm kind of shocked at all the previous video comments calling this a bad design. "Why did they put two important controls side by side?" The whole pedestal is important controls. Of course they are side by side. Do you want to have the pilots moving all over the flight deck for related controls? That would be a bad design. Honestly I'm not sure how someone could move the wrong levers. Even without looking they are going to feel different.

The speculated accident sequence has more to do with the particular nature of line instruction flights than with cockpit design. There's typically supposed to be a pilot monitoring to focus inside the cockpit while the pilot flying is focused outside during visual maneuvers, but in this scenario the line instructor was expected to split their attention in order to familiarize the captain with the visual cues of the new airport. The better questions are whether two-pilot line instruction on passenger flights is a dangerous practice, whether it violates some of the principles of crew resource management, whether there should always be a third pilot in the cockpit monitoring line training flights with passengers, or even whether simulators can play a greater role in line training.

Yes, I concur with others who commented here that there is nothing wrong with the placement of those controls. The flap lever is a different colour, and shape and it is placed at a lower level than the prop feather levers. This was nothing more than an unforgivable mistake by the captain, I believe.

Thank you for your time! ❤

I know of at least one incident where the FO feathered #2 when Capt asked for Flaps30 , They did a go around and returned...

I surprised no one has mentioned that the co-pilots husband worked for Yeti and also died 16 years prior. The money she got from his death was used to get her license. She was under review to become a captain. many human factors come into play.

This accident may have been avoided by a simple SOP. When flaps are to be moved, the airspeed needs to be double-checked to be within the range of the next flap setting, and the the flap lever needs to be moved (of course). But here's the important part: keep your fingers on the flap lever while looking at the flap indicator and announcing something like "Flaps 30 set and indicating" once the indicator is showing the desired flap position. In this case, the flap indicator would not have moved and prompted a correction.

I completely disagree with this assumption. Firstly, the feel and travel of both these levers are completely different. Secondly, pilots can easily notice the change in sound caused from feathering. Yes, human error can be a factor leading to moving the wrong lever, but after that CVR recording of what have been released so far suggests that the captain seating on the left seat was heard saying there is no power multiple times. Now, if Captain on the right (Instructor) moved the condition lever by mistake they would have noticed it when the captain on the right was shouting there is no power. Also, there is a picture of the center console taken on the accident site which shows the condition lever was at a normal position and not feather.

One QUICK addition should be voice warnings given so that they know props or power was turned off with AI in a box nowadays- it would be easy and not costly to add on.

Great video and great explanation. Thank you Captain.

I was waiting your video about this accident and you explore very well different scenarios of this kind of accident.Thanks

Personally for me there is one big factor. The seating position. The instructor was seated on the right seat, keep in mind that it is not his usual position. Instructors and captains have a tendency to play with power levers to help First Officers and trainee captains. Thee closest levers are the power levers when he is in left seat.. Now that he is seated on the right seat. The closest levers are the condition lever which could have been mistaken for power levers. When you are tired .. looking out on a new runway and slightly high, wanting to reduce power to extend flaps or gear.. they may feel like power levers..you can make mistakes. God knows why he pulled the condition lever but this could be a possibility as its a little strange to mistake condition levers for flap levers. Or while seated on the left seat the flaps are the farthest and it would have been natural for him to think the same and pulled the condition lever as both have detends.

A common factor is the pilot or copilot who makes the mistake, confirms verbally the right one. So, the colleague asumes there are no errors. I think the cockpit should have a synthetic voice confirming out loud every command. Then, in the event of a mistake both pilots can realise.

Yes. 9:40 I've had it happen. A320 and FO retracted flaps when he meant for the speed brakes to stow them. We were high and fast so his workload was high - mercifully it was caught and reversed quickly and all was normal afterwards. Just yesterday we were approaching our destination and had predetermined an hour earlier to land Flaps 3 for LLWAS for the airport (no storms on the field or nearby). On approach I called, by muscle memory, Flaps Full, Landing Checklist. She read back Speed Checked, Flaps Full, Landing Checklist. I heard "FULL" and immediately realized what I had done. I called again, and apologized, and said "lets try that again! Flaps 3, Landing Checklist please" she was confused, and rightfully so. Even though I briefed Flaps 3, it had been an hour since we briefed and we BOTH forgot we are using Flaps 3, and the ECAM Landing Memo had not yet displayed due to our height. Perhaps from now on I will brief the callout to hopefully trigger myself and the FO "It will be 'Flaps 3 - Landing Checklist' instead of the usual Flaps Full." I'll intentionally leave out the "landing checklist" part associated with full in hopes to train the brain for that moment. Let's see if it works! 😂

Flight crews make mistakes from time to time. That's perfectly normal. What's not normal, is why this crew didn't correct the mistake....and they had ample time to correct (i.e. multiple seconds, perhaps tens of seconds even) How could they not detect the change in sound or see that the wrong lever was moved when the speed started to bleed off. How can it be????

What about all the audible and visual warnings displayed on the main panel alerting of the loss of systems when you bring the condition levers to feather, including loss of ACW, etc. Did they not sound? Did the pilots ignore them?

One word comment: Exactly!

Someone pointed out it may have had more to do with the guy being on the opposite side than normal for him. My gear shift and emergency brake handle are close, but it’s not a struggle. If I were trying to drive from the back seat I might grab the wrong one.

A few observations here following the previous videos; 1) the instructor moved the wrong leaver and confirmed the action which didn't even happen. This is muscle reflex without doing a simple confirmational check. 2) the leavers are completely different designs in terms of feel not to mention that the flaps are 1 lever compared to 2 for the pitch. 3) I feel there was total lack of monitoring of the systems during this maneuvering. It's not a design flaw it's a gross pilot failure.

Your focus on “human nature” is important far beyond aviation. We are so accustomed to reducing everything we do down to myriad factors. Important, yes, but all “factors” without context doesn’t add up to the same whole from where they were extracted. Just my gross generalisation, the East Asian cultures (i.e. where Magnar is) have generally more “holistic” views on well, human nature and what we do… Not relevant, but so nice to see a Widerøe -8, and then Fleksnes… 👍

I totally understand the captain making the mistake of moving the wrong lever - these things happen, humans are not infallible. What does worry me more, and makes no sense, is the fact that the error was not spotted and rectified by either of the two experienced pilots. Bearing in mind how the aircraft started to behave, that I'm afraid is unbelievable!

I think .. there should be a direct warning sing or sound when you put the propellers on feather while flying! The only reason to feather would be engine failure I guess. So there should be a direct warning if feathering is selected especially if the speed is below lets say 200knots!

I am a student pilot so forgive my mistakes, but I have seen a video where the pilot called out he did not have any thrust, moments after the instructor wrongly move the condition levers backward. I can not blame him, but the pilot calling NO thrust should have been a BIG Alarm specially in the pattern. Also if speed is king , why the pilot did not followed up sticking his focus on the speed if he did not feel any thrust? And calling or checking all levers w a quick sight on the panel? My instructor always say if you feel or see something wrong say it and solve it immediately specially on approach

It's purely human error. Single flap lever to be pulled up to move down. Where as instructor captain pulled all the way both control levers to feather the propellers. Blaming aircraft design very less to agree. Rest as you said to wait for the final report. Always your opinion is very interesting and very informative.

To be honest... Any pilot rated in a given aircraft should know all levers by muscle memory and be fully capable to differentiate between a middle double lever and a single right hand side single lever

There is a flap setting indicator, wouldn't it be wise to have a pitch setting indicator as well or even an auto announcement saying "Feathered," once the lever is moved.

Thank you very much for this instructive update!

Time to introduce 2-button airplane. One button to fly the plane and the second button is to land it. And trust me, the human mind will continue to make mistakes. There's easly like 1000000 buttons and levers in a cockpit so very easy to press the wrong button..occasionally at least. And iam realy impressed it doesnt happen more often. Hat-off to all pilots out there doing some incredible job. Cudos to you!

There are already so many differences between the levers... colour, shape, functionality when operating, range of operations. Cannot cater for inattention and someone simply using muscle memory. No need to change anything in my opinion. Except get rid of the problematic first officers! 🤣 (But that what the bean counters are starting to look into anyway!) Thanks for the video though.

I stick to my view that the F50 layout is always better, because you'd feather 1 engine and not both. Also, perhaps "reedbacks" could be implemented auto by the cockpit and not the PM ... so you fly, you call gear down, PM puts gear down, cockpit sais "gear selected down" .. then the PM can still report or call "green". you call "flaps 30", PM selects, cockpit calls "flaps 30". This way both PF and PM can HEAR the call for what has been done.

the ultimate answer is, airplane controls are complex & the cockpit is small, so, you do need high density of levers/buttons/etc... & yes, it does increase the chance of mistakes, so a pilot has to be very aware of what he is doing.... does that mean it is an inherently dangerous design?? no! it is the best design that they can do with the conditions they are given. does that mean that we/they should not be thinking of ways to make the GUI of our aircraft safer?? the exact opposite! we definitely should always be trying to improve on safety where practicable and those who're qualified are constantly working at it.

I think this comes down to muscle memory and complainciancy. It's really hard to build a failsafe for these events.

Similar accident happened today in Brazil 8/9/24 same AC type too, wonder if the pilot engaged the feather prop lever.

Early in my driving experience, while cruising at 60 mph, I was bothered by the position of the keys hanging from the ignition, so I went to feel if the bunch of keys was not twisted up - as soon as I put my hand on it, my hand switched the ignition off (un-intentionally of course and only by one notch, so I still had steering). I was completely taken by surprise, why did I do that??? I immediately switched it back to on (not starter position), and the only thing happened was a loss of power for a second or two while the ignition was off (I didn't change my foot on the accelerator during the whole event), and the power came back. I can only think it was "muscle memory", my hand doing a familiar action, but in the wrong situation. I wonder if my event and this accident were the same sort of thing?

NASA has studied human factors and released what they learned. You can do a lot to prevent some errors, but can never have perfect humans.

Not design issue, human error. The condition levers need deliberate additional action to move to feather position

I wonder also whether sunlight into the eyes of both pilots as they turned onto finals for 12 played a part . Weather and time of day indicate that this may have been the case - but the voice recorders will probably not enlighten us on this . As you say , it's never just one factor.

All PF, should confirm their call-outs are being performed correctly, imho. Never had experience as I never had a co-pilot to do things. "Slip ups" will happen as documented even by Magnar

Layout aside, when you are used to do A first, later B, at some point in time you will do B first. The main problem here is that such a mistake at this critical point when a small loss of airspeed will lead to a stall, will be fatal within a few seconds. How could you design the aeroplane (or implement procedures) to prevent that?

This has to be deeply investigated, something isn't right about the pilot monitoring!!!!

Very informative video thanks

I wonder if atr would consider installing a similar gate to the idle gate for the cond. levers to pull them to feather.

Magnar, it may be verry long ago that i knew how to handle an aircraft, Did do lot of simulator instruction. I can't resemble an incident where a pilot (experienced or not) mistakes a lever, or lever movement. I think this might be a case of pilot overload. As you said: "Having the correct intensions but executing them wrong" This can be caused by inexperience, or fatigue (unfortunately for me the main cause of leaving aviation) Being a crew you work together but ypu are both responsable for save flight. When driving around the Chaufeur basicly should keep his/her eyes on the PDF some less on the ND, and if applicable of course on the IAS. Even under high load this realy is not to hard, and should give time enough to peek a bit around the cockpit, at least at the Torque indicators and prop RPM. Still there should be way time enough to enjoy the flight, and have a look outside. This goes even with trivial emergencies like an engine failure, or sudden loss of equipment. If this is not the case, the left seat is just not (yet) the right place for this pilot !!! As a (soon to be) Capt. you should as be relaxed in the cockpit as you are in your excelent video's

One time I almost put my spoon into a trash can instead of the sink.

I'm not a pilot, but would it not be safer if the pilot-flying would check each action by the pilot-not-flying as a mistake can then be easily recognized and corrected?

Speak, point, check is the best policy. Make sure you have the correct switch/device!

I see no reason why the pilot monitoring should not be trained to look at the lever he/she has just moved to confirm it was the correct one and ensure ECAM or lights or other such indicators confirm the position before confirming to the PF that the instructed command has been carried out and confirmed. Flying into and out of an airport is very high load work! Assuming that you have executed the right command should not be made. No you cannot blame the cockpit layout.

So there should be for each action an audio message telling What has be done. « Propeller feathered », flaps 10° etc. Why have we got a message on hower pcs « are you sure …. » before any critical action?

Pilots have raised flaps instead of gear, in A320 parking brake which looks different operates in circular fashion yet it was put on instead of lowering flaps a few time bursting tyres, instead of setting VS -700ft altitude was set and activated ending up in different mode in fatal accident, similar thing was done in B777 at SFO accident. The main reason for this is the selection of these levers and FCU modes are done subconsciously without identifying the switch or lever and not checked afterwards for correctness, while these items, irrespective of the experience pilot has need to be done by select, confirm, activate and recheck. Pilots need to be trained, insisted upon and corrected when observed deviating. Many co pilots have habit of keeping their hand on some lever which is bad and are likely to operate that lever when something else is asked for.

This event and the others you mention highlights why it is important for the flying pilot to monitor the actions of the non-flying pilot. This provides the opportunity to stop an incorrect response on the part of the other pilot. The flight deck is a noisy environment, and at times the workload is very high. Commands can be mis-heard or mis-interpreted. Mistakes can and will happen, and the only way to reduce mistakes is for BOTH pilots to continuously monitor the actions of the other. And now they talk about single pilot operations in large complex airliners? Who would monitor and correct a single pilot?

The two pilots were operating into a very new airport and had departed suddenly from their expected approach - they may have been stressed and their workload was probably greater than they had expected. I speculate - PNF might have chosen not to check his actions visually, thinking his workload did not give him enough time to do so. *If* that is what happened, what would the error be ? There are a number of contributory factors and therefore a number of ways of classifying the error.

Since all changes of the mentioned levers are monitored and recorded by the computer system, would it not be possible to have an audible confirmation off such changes during take off and landing? The humans on the seats can give incorrect confirmation, computers never do.

No, I don't think so...Over 7000 hours in the BE-1900, SAAB-340 and DHC-8...Never heard of this ever being an issue...

Extremelly good content! Thanks

Unless in an emergency situation, it might be opportune for flight crew to adopt what I call the "Japanese Train Driver" Philosophy. This is where they actually point at a signal light, say the action required, then execute the action required. So, hear the command from your fellow pilot, look at the lever / switch, touch it, then only execute the action.

Well, this was a good explanation.. 👍

I don't think there's anything wrong with the ATR design. The flap lever is completely different from the condition levers. It's a differently shaped single lever that also operates differently to the two condition levers which are not as simple to pull back. Any professional pilot could easily distinguish between the two.

I’ve always thought about tat when I used to fly the ATR. Why is it so close to the throttle and flaps. It should be way more away from in between the flap lever and throttle.

Thank you Captain.😊

IMO, the pilot who's last flight it was, did this deliberately. There is previous incidents whereby a pilot committed suicide by crashing a plane. He was experienced enough to trouble shoot an incident like this.

When operating with 2 crew, surely both of them (and especially PNF) have time to look at the controls as they operate them. What are they trained to do ?

Great discussion.Thanks.