337 Yeti Airlines flight 691 crash – Human Factors for General Aviation Pilots

Max discusses the critical role of human factors in aviation safety, prompted by the tragic crash of Yeti Airlines flight 691 in Nepal in 2023. He emphasizes that pilot error is a significant contributor to aviation accidents, accounting for about 80% of them, underscoring the importance of understanding and mitigating human factors to enhance flight safety. He highlights the significance of human factors, which can affect any general aviation aircraft.

The episode centers on the crash of Yeti Airlines flight 691, an ATR 72, which crashed during a visual approach to Runway 12 at Pokhara International Airport. The flight crew had already completed two legs between Kathmandu and Pokhara earlier in the day. The accident occurred in VMC, with the flight crew initially cleared to land on Runway 30, but later requesting a change to Runway 12 without providing a reason.

During the approach, the Pilot Flying (PF) disengaged the autopilot and called for flaps to be set to 30 degrees. However, the Flight Data Recorder (FDR) did not record any flap movement. Instead, both propellers entered a feathered condition, resulting in a loss of thrust. The cockpit voice recorder (CVR) captured the crew performing the before-landing checklist without noticing the incorrect flap position. Despite increasing the power lever angle, both engines remained at flight idle, contributing to the loss of thrust.

As the aircraft descended, the crew struggled to manage the situation. The PF handed control to the Pilot Monitoring (PM), who also noticed the lack of engine power. The aircraft entered a left bank, and the stick shaker activated, warning of an impending stall. Despite attempts to regain control, the aircraft crashed, killing all 68 passengers and four crew members.

The investigation into the crash revealed several human factors contributing to the accident. The use of noise-canceling headsets by the PF may have reduced his ability to detect auditory cues indicating engine issues. Additionally, the high workload and distractions from operating into a new airport contributed to ineffective Crew Resource Management (CRM) and checklist adherence. The new Pokhara airport’s challenging approach, with a tight circuit and no published instrument procedures, further increased the crew’s workload.

Trescott delves into the SHELL model used to analyze human factors in the accident. The SHELL model examines the interaction between Software, Hardware, Environment, and Liveware (people). The analysis highlighted that the crew’s high workload and distractions, coupled with the challenging visual approach, led to critical errors. The proximity of the propeller condition levers and flap handle on the ATR 72’s center pedestal also contributed to the inadvertent feathering of both propellers.

In discussing workload, Max emphasizes its impact on pilot performance. High workload can lead to increased errors, task degradation, and poor performance. He explains that workload is influenced by task difficulty, the number of tasks in parallel or series, and the time available to complete tasks. Pilots can mitigate high workload by starting descent and approach planning earlier, slowing down the aircraft, and increasing flight path length. These strategies provide more time to complete tasks methodically, reducing the risk of errors.

Trescott also highlights the effects of high workload, such as attentional narrowing and task shedding. Under high workload, pilots may focus excessively on one task, neglecting others, leading to errors and decreased situational awareness. He shares an anecdote about a glider pilot who, under high workload and anxiety, fixated on the landing area and neglected airspeed monitoring, resulting in a stall and crash. This story parallels the Yeti Airlines crash, where high workload and distractions led to the crew’s inability to manage the aircraft properly.

The episode continues by discussing how high workloads can affect decision-making processes. High workload can lead to rapid decisions made without considering all factors, options, or complexities. When pilots are under high workload, they might simplify decision criteria to reduce their workload quickly. This can increase the chance of errors as tasks might be performed hastily and without thorough consideration. High workloads can also lead to autonomous routines or checks being underprioritized, which may cause critical steps to be overlooked.

Task engagement and concentration on a single task are benefits of high workload, but they also pose risks. The captain on the Yeti flight, despite his experience, may have allowed some tasks to become too routine, not giving them the attention they required. Processes that require executive control—such as concentrating, calculating, or performing unfamiliar tasks—can add significantly to workload. When these tasks are combined with existing ones, especially under time constraints, the risk of excessive workload increases.

Trescott explains that task difficulty is often the most challenging workload driver to reduce. However, pilots can manage time limitations by allowing more time for tasks, which helps to avoid workload buildup. Effective CRM practices, such as delegating tasks to colleagues, can also help manage workload. Emergency situations are particularly challenging, but creating time and managing tasks between crew members can help.

Recognizing high workload is critical, but individuals might not always realize it in the moment. Changes in time perception and task absorption can make high workloads less obvious. Therefore, relying on individuals to recognize and manage their workload is unreliable unless they have specific training. Recognizing changes in situations before workload increases and noticing high workload in others are more effective triggers for managing workload.

High workloads can lead to decreased situational awareness, reduced attention span, slower reaction times, increased errors, auditory exclusion, tunnel vision, physical stress responses, impaired decision-making, communication breakdown, and task shedding. Understanding these responses is crucial for developing strategies to mitigate risks associated with high workload.

The episode concludes with a reflection on the experience of the pilots on Yeti Airlines flight 691. The crew was experienced, but the new airport’s challenges and distractions contributed to errors. The check captain’s familiarity with the controls and potential overconfidence might have led to complacency. Trescott warns that overconfidence and complacency are key factors that can erode safety benefits from experience.

Trescott emphasizes the importance of strategies to catch and correct mistakes, highlighting that all pilots are human and fallible, and proactive measures are essential for safety.

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328 Buying a Plane and Crashing on Way Home – N8924Y Piper Twin Comanche

Few tragedies are more poignant than the loss of a pilot on what should have been a routine flight. Many pilots dream of buying their own airplane. But for some pilots, this dream turns into a nightmare all too soon. They never make it home. Instead, they crash along the way, their hopes and aspirations shattered in an instant. This scenario, sadly, is not uncommon. A quick search of the NTSB database reveals numerous accidents involving recently purchased aircraft, many of which occurred shortly after the new owners took possession.

One such tragedy involved the crash of N8924Y, a Piper Twin Comanche, and serves as a sobering reminder of the risks inherent in aviation. The pilot, Rob Prestininzi, had recently acquired the aircraft and was flying it home when disaster struck. The circumstances surrounding the crash share eerie similarities with other accidents of its kind: a long day of flying, fatigue, the pressure to reach a destination, limited experience in the aircraft make and model, and challenging nighttime conditions.

In the case of N8924Y, the pilot’s journey began at Savannah Hardin County Airport in Tennessee, where he picked up the aircraft after a friend had flown him there earlier in the day. Despite encountering various issues, including a landing gear problem and deteriorating weather, the pilot pressed on with the flight. As darkness fell, he found himself struggling to troubleshoot the landing gear issue while simultaneously hand-flying the aircraft and communicating via cell phone.

Tragically, the aircraft ultimately stalled and crashed, claiming the life of the pilot. The NTSB investigation revealed a series of factors that contributed to the accident, including the pilot’s failure to monitor airspeed, the presence of a burned-out landing gear indicator bulb, and the challenges of troubleshooting the issue in low-light conditions.

One of the most haunting aspects of the accident is the realization that it could have been prevented. Had the pilot been more experienced in the aircraft or taken steps to address the landing gear problem earlier in the flight, the outcome might have been different. Additionally, the pressure to complete the journey and the reluctance to deviate from the original plan likely clouded the pilot’s judgment and contributed to his decision to press on despite the challenges he faced.

As aviators, we must recognize the importance of maintaining situational awareness and making sound decisions, especially when faced with adversity. It’s essential to prioritize safety above all else and be willing to reassess our plans in the face of changing circumstances.

The tragic loss of Rob Prestininzi serves as a somber reminder of the need for constant vigilance and adherence to best practices. It highlights the dangers of get-home-it-is, which under the right circumstances can affect any of us. His memory lives on as a cautionary tale for pilots everywhere, urging us to learn from his mistakes and strive to be better, safer aviators.

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327 N84R Beech A36 Crash in KY – Pilot Breaks multiple FAA Rules + GA News

Max discusses a tragic accident that involved a 55-year-old physician who crashed his Beech A36 aircraft, N84R, at Tucker Guthrie Memorial Airport in Harlan, Kentucky, on November 3, 2022. The pilot departed from Knoxville at around 9:32 a.m. with the purpose of attending scheduled appointments at a medical office near the destination airport.

Despite low instrument flight conditions at the time of arrival, the pilot did not file a flight plan, communicate with ATC, or receive a weather briefing before departure. Upon arrival in the airport area, he announced over the CTAF his intention to circle for landing. However, subsequent flight track data revealed that the airplane completed a total of three approaches to the runway, none of which were consistent with the published instrument approach procedure, and all were conducted in low instrument flight conditions.

Witness accounts and flight track data suggested that the pilot routinely landed at the airport under similar weather conditions in the past, displaying a pattern of circling approaches not consistent with published procedures. Additionally, the investigation revealed that the pilot was not instrument current and had a history of conducting circling maneuvers in instrument meteorological conditions (IMC) without clearance.

The NTSB’s final report identified the pilot’s hazardous anti-authority attitude as a contributing factor to the accident, along with his decision to fly into IMC without proper clearance or adherence to established procedures. Furthermore, toxicology testing revealed the presence of methamphetamine and phentermine in the pilot’s system, both of which are substances prohibited by the FAA for pilots due to their potential to impair judgment and performance.

The NTSB emphasized the importance of recognizing and countering hazardous attitudes, such as anti-authority, through adherence to regulations and good decision-making practices. It also highlighted the necessity of effective risk management and honest self-assessment, particularly regarding medical fitness and proficiency in flying. Psychological factors such as risk-taking tendencies, normalization of deviance, and overconfidence were also discussed as potential influences on the pilot’s decision-making process.

Ultimately, the probable cause of the accident was determined to be the pilot’s decision to continue visual flight into IMC during an approach to land, resulting in controlled flight into terrain. The NTSB’s findings underscored the critical importance of adherence to regulations, proper training, and vigilant risk management to ensure aviation safety and prevent avoidable accidents.

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325 N51FM SR22 Crash at Paso Robles – When to fly the Hold at an IF/IAF

Max talks about the accident of N51FM, a Cirrus SR22T at Paso Robles, CA, and emphasizes the importance of understanding approach procedures, particularly when starting an approach from an IF/IAF fix with a racetrack. The accident involved a pilot who failed to follow correct procedures, leading to a crash, though fortunately, all occupants survived. Max breaks down the mistakes made by the pilot and discusses the implications for instrument pilots.

The flight began in Scottsdale, AZ, with the aircraft flying towards Paso Robles after a stop at Big Bear, CA. The host highlights deviations from standard procedures during the approach to Big Bear and the subsequent flight to Paso Robles. The pilot’s missteps include flying the traffic pattern in the wrong direction and excessive speeds that deviated from Cirrus standard operating procedures.

The crucial part of the flight occurs when the aircraft receives clearance for an RNAV (GPS) approach to Paso Robles, specifically to the combined IF/IAF waypoint HOVLI. The host emphasizes the importance of understanding approach segments and when to fly holds at IF/IAFs. In this case, the pilot was required to fly a holding pattern at HOVLI due to the direction of approach. However, the pilot failed to adhere to this requirement, leading to subsequent errors.

After receiving clearance for the approach, the pilot failed to fly the hold at HOVLI, resulting in being significantly above the required altitudes for subsequent fixes. The aircraft’s approach becomes unstable, with including reaching the Vne speed of 208 knots on the approach, and a descent rate that reached 2300 feet per minute. Fortunately, the pilot decided to circle back to runway 19, but instead lined up for runway 13, and then crashing between the two runways.

Max analyzes the human factors that may have influenced the pilot’s decision-making, including pressure to complete the flight, risk perception, and overconfidence. The importance of recognizing and mitigating these human factors is emphasized, highlighting the need for robust training and a safety-oriented mindset.

The accident serves as a cautionary tale, highlighting the consequences of deviating from standard procedures and the importance of maintaining situational awareness and decision-making abilities, especially in challenging situations. The host encourages pilots to prioritize safety, utilize resources effectively, and be willing to execute a go-around when necessary.

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322 N960LP TBM 960 Truckee crash; Robinson helicopter factory tour + GA News

Max talks about the details of the crash of a TBM 960, N960LP, at Truckee, California last weekend. He also talks in detail about his factory tour last week of Robinson Helicopter.

The pilot, by all accounts well trained and experienced in the aircraft. The flight originated from the Centennial Airport, south of Denver, and lasted about 3 hours and 15 minutes. Weather at the time the pilot flew the approach was ½ mile visibility and snow with clouds scattered at 300 feet and overcast at 700 feet. However the approach minimums were 1 mile visibility and the MDA is 582 feet AGL. So the clouds were approximately 120 feet above minimums, and the visibility was ½  mile….less than the minimums.

Max talks about how the pilot flew the instrument approach more or less successfully, though he descended more than 200 feet below the minimums, and he started his turn for the missed approach 1.3 miles beyond the missed approach point. While he flew the approach with the autopilot, he flew the missed approach by hand, and lost control.

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Robinson Helicopter Company Factory Tour video
#227 My Near-Fatal Icing Incident
#233 What You Need to Know about Advisory Glide Slopes
Truckee Airport Procedures and Noise Abatement

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319 Hot Springs Jet Crash, United FL 2477 Houston Overrun, Fuel Related Accidents + GA News

In this episode, Max discusses the crash of N1125A, a 1991 ASTRA/GULFSTREAM 1125 SP business jet at Ingalls Field Airport in Hot Springs, Virgina. It was the third fatal business jet crash in the U.S. in just five weeks. Five people on board were killed. The aircraft had been purchased just 3 ½ months early. ADS-B data shows it had a normal approach on the ILS down to about 1000 feet AGL, where the data stopped. Strong winds prevailed, and it’s likely that there were strong downdrafts on short final, which may have brought the jet down.

Several airline pilots send feedback about the United flight 2477 taxiway overrun at Houston. They also talked about the FOQA programs which would have provided automatic reporting, if this approach to landing met the airline’s criteria for an automatic go around. Max also reads listener emails related to the ten fuel-related accidents discussed last week.

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Astra Jet N1125A accident ADS-B Data
Fear of Landing Blog
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317 Naples Challenger Jet Update & 1994 Challenger Dual Flameout + GA News

In this episode, Max discusses two Challenger jet crashes involving dual engine failures: one in Naples, FL, in February 2024 and another in Nebraska in 1994. The incidents share some similarities.

In the Naples crash, both engines experienced oil pressure warnings within seconds of each other before failing simultaneously. The preliminary report indicates the left landing gear touched down first, followed by the right, before the plane skidded into a concrete barrier. The cabin attendant facilitated passengers’ safe evacuation through the tail compartment. The pilots, highly experienced, had a combined flight time of over 35,000 hours. The aircraft, with GE CF34 Series turbofan engines, underwent recent airworthiness inspections and was fuel-soaked post-crash, ruling out fuel exhaustion.

Further examination revealed thermal damage to engine components but no clear cause for the simultaneous engine failures. Discussion with an Challenger jet pilot who listens to the show recalled a similar incident involving a Challenger aircraft that also had a dual engine flameout in 1994.

That crash occurred during a positioning flight after passenger drop-off, after experiencing a dual engine flameout between FL370 and FL410. The aircraft sustained substantial damage during a forced landing at night in an alfalfa field.

Analysis revealed water contamination in the fuel, leading to the engines’ failure. Both engines were sent for examination, showing consistent findings with fuel samples. The NTSB attributed the crash to inadequate planning, decision-making, and preflight inspections following fuel contamination.

Comparing the two crashes, both had simultaneous dual engine failures occurring around two hours into flight, and both had a yellow liquid in the fuel. At this point, the cause of the Naples crash is still unknown, though Cockpit Voice Recorder and Flight Data Recorder analysis should provide new clues.

The episode underscores the importance of fuel contamination awareness, and the necessity for thorough preflight inspections and proper response to warning signs.

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NTSB Preliminary Report: Colorado Hawker Crash

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309 VFR into IMC and other Recent Loss of Control Accidents + GA News

Max talks about some recent VFR into IMC accidents and other weather-related loss of control accidents. VFR into IMC accidents continue to be a problem for us as GA pilots. Not only are there too many of them, but they also have the highest lethality rate of any accident type, as 90% of these accidents are fatal. They are unique to general aviation, as they are almost non-existent in airline flying. He also talks about how to calculate the bank angle required to get a standard rate turn.

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307 Texas Pilatus PC-12 N188PC Crash and Vectors to Final

Max talks about the FAA Controller Handbook rules for vectoring aircraft and how it relates to the crash of N188PC, a Pilatus PC-12 that crashed in Texas last week. He also talks about helpful tools in the Garmin G1000, G3000, Perspective and GTN 650 and 750 that you can use to tell if you might be getting a late turn from a controller that may take you through the final approach course. He also talks about how to use Garmin’s Runway Extensions and Track Vector when flying a traffic pattern, so that you never overshoot the base to final turn and always roll out on the extended centerline of the runway.

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Mentioned on the Show
N188PC Accident – Wikibase
7110.65AA Controller Handbook
FAA Instrument Procedures Handbook
FAA Instrument Flying Handbook

Max’s Books – Order online or call 800-247-6553 to order.
Max Trescott’s G3000 and G5000 Glass Cockpit Handbook
Max Trescott’s G1000 & Perspective Glass Cockpit Handbook

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302 San Diego Cessna P210 Crash – Poorly flown ILS and low fuel

Max talks about the crash this week of a Cessna P210 in San Diego, and why it crashed. The flight originated in Concord, CA and flew for just over 4 hours to Montgomery Field in San Diego. The aircraft first tried to land at French Valley airport, was high on the approach and went missed. It diverted to Montgomery field to fly the ILS 28R, however the pilot flew about a third of a mile south of the airport, missing the runway. Five minutes after the approach, while climbing for another approach, he ran out of fuel. ATC audio provided by LiveATC.net

Support the Show by buying a Lightspeed ANR Headsets
Max has been using only Lightspeed headsets for nearly 25 years! I love their tradeup program that let’s you trade in an older Lightspeed headset for a newer model. Start with one of the links below, and Lightspeed will pay a referral fee to support Aviation News Talk.
Lightspeed Delta Zulu Headset $1199
Lightspeed Zulu 3 Headset $899
Lightspeed Sierra Headset $699
My Review on the Lightspeed Delta Zulu

Send us your feedback or comments via email

If you have a question you’d like answered on the show, let listeners hear you ask the question, by recording your listener question using your phone.

Mentioned on the Show
ASN Wikibase – N1400 P210 Accident

Max’s Books – Order online or call 800-247-6553 to order.
Max Trescott’s G3000 and G5000 Glass Cockpit Handbook
Max Trescott’s G1000 & Perspective Glass Cockpit Handbook

If you love the show and want more, visit my Patreon page to see fun videos, breaking news, and other posts in the Posts section. And if you decide to make a small donation each month,  you can get some goodies!

Free Index to the first 282 episodes of Aviation New Talk

So You Want To Learn to Fly or Buy a Cirrus seminars
Online Version of the Seminar Coming Soon – Register for Notification

Check out our recommended ADS-B receivers, and order one for yourselfYes, we’ll make a couple of dollars if you do.

Get the Free Aviation News Talk app for iOS or Android.

Check out Max’s Online Courses: G1000 VFR, G1000 IFR, and Flying WAAS & GPS Approaches. Find them all at: https://www.pilotlearning.com/

Social Media
Like Aviation News Talk podcast on Facebook
Follow Max on Instagram
Follow Max on Twitter
Listen to all Aviation News Talk podcasts on YouTube or YouTube Premium

“Go Around” song used by permission of Ken Dravis; you can buy his music at kendravis.com

If you purchase a product through a link on our site, we may receive compensation.