Introduction
Inadvertently using the wrong cockpit control is a subtle but significant risk in daily flight operations. It is a situation that can affect pilots of any experience level and aircraft type. Despite modern flight decks being highly ergonomic and system-resilient, errors such as selecting flaps instead of landing gear, or engaging the parking brake instead of starting an engine, can and do occur.
This article explores the phenomenon of cockpit control confusion, using a real-world case study to highlight key lessons. It also analyses the human factors involved, outlines contributing causes, and provides actionable prevention strategies to help mitigate such incidents.
Case Study: Parking Brake vs. Engine Start
Event Description:
During pushback of an Airbus A319, the First Officer (acting as Pilot Flying) informed the ground crew they were ready for pushback and engine start. Once cleared, the parking brake was released, and the "Before Start" checklist was completed. As the aircraft began to move, the First Officer announced, “Starting engine one.” The Captain acknowledged the call.
However, the First Officer inadvertently turned the parking brake handle ON, thinking they were activating the engine mode selector to IGN/START. The aircraft halted abruptly, causing the nose landing gear to jump off the towbar-less tug and become lodged on top of its platform, with the nosewheel turned more than 90 degrees. Two cabin crew members sustained minor injuries during the abrupt stop, while passengers and crew safely deplaned from the rear stairs.
Root Cause:
Both the PARKING BRK handle and the ENG MODE selector:
· Are located on the centre pedestal.
· Require a clockwise action to operate.
· Are part of the pushback/start sequence.
Due to routine behaviour, the First Officer manipulated the familiar control—the parking brake—instead of performing a visual confirmation and correctly using the engine mode selector.
Why Does Cockpit Control Confusion Occur?
1. The Nature of Skill-Based Errors
According to human factors expert James Reason (1990), there are two types of skill-based errors:
· Lapses: Actions that are omitted.
· Slips: Actions that are performed incorrectly.
Cockpit control confusion falls into the category of slips, where the intended action is correct, but the wrong control is actuated due to a lack of active attention. These errors occur even during normal operations and are not a reflection of inadequate knowledge or capability.
2. The Human Brain and Routines
Our brains are wired to create routines to save cognitive effort. Once a task is mastered and frequently repeated, it becomes automatic. This is why experienced pilots, who have developed strong muscle memory, are ironically more prone to cockpit control confusion, especially under normal, low-stress conditions.
This automation can help manage workload, but dangerous when attentional control lapses during seemingly routine actions.
3. Factors Contributing to Control Confusion
·
Familiarity & Proximity of Controls
Confusion is more likely when controls are:
o Frequently used (e.g., flaps, brakes, gear).
o Located close to one another.
o Similar in shape and feel (e.g., EXPED vs. APPR pushbuttons).
· Anticipatory Action
When pilots rest their hands on a control in anticipation, it can lock their focus into a subconscious action path, causing inadvertent activation of the wrong control.
· Distractions and Interruptions
Unexpected interruptions during normal flows can disengage active thinking, leading to slips.
· Fatigue and Overconfidence
These lower a pilot’s attentional vigilance, making errors more likely even in familiar sequences.
Other Real-World Examples
· Flaps vs. Landing Gear Selection
Though these levers are shaped differently and located separately (gear on main panel, flaps on pedestal), there have been documented incidents where pilots selected flaps instead of gear, or vice versa, due to ingrained routine behaviours.
· EXPED vs. APPR Pushbutton Confusion
Located adjacent on the FCU, these two pushbuttons have similar tactile feedback, leading to occasional selection errors, especially when one is closer to the PF's hand position.
Challenges in Prevention
· Cockpit Design Limits
Changing the design of well-established control layouts used across global fleets is difficult and can have unintended consequences.
· Training Limitations
Because slips occur due to automaticity, conventional training or technical skill enhancement does little to mitigate them.
· Underreporting
Many such incidents go unreported, as they often result in no operational consequence. This hampers the ability to study patterns and introduce mitigations.
The Importance of Reporting and Awareness
Even if no harm occurred, reporting cockpit control confusion is essential to:
· Understand root causes and context.
· Identify patterns and trends.
· Develop meaningful mitigations.
Fostering a just culture and a speak-up environment encourages crews to share incidents, strengthening organizational safety intelligence.
Prevention: What Pilots and Operators Can Do
Flight Crew Best Practices
As highlighted in Airbus Flight Crew Techniques Manuals (FCTMs) across all models (A300-600, A310, A320, A330/A340, A380, A350, A220), the following practices are recommended:
· Avoid resting hands on controls
This prevents unintentional activation.
· Do not anticipate actions
Always complete the current step before preparing for the next.
· Perform a visual check before using a control
Even in routine flows, verify the correct switch/lever before actuation.
· Verify action outcomes
Always confirm the intended result—gear status, flap configuration, brake release, etc.
· Break the automation loop
Maintain active thinking and vigilance, especially during procedural transitions.
Use of Additional Callouts
Several operators have reduced cockpit control confusion events by integrating specific callouts before critical control actions:
· Engine Start Sequence:
PF points and calls: “ENG MODE SELECTOR” before rotating it.
· Flap Selection:
PM places a hand on the flap lever, calls: “Flaps,” then moves it while announcing the intended flap setting.
· Landing Gear Operation:
PM places hand on the gear lever, calls: “Gear,” followed by “Up” or “Down” as appropriate.
These simple verbal confirmations elevate attention levels and reduce slips. However, crews must remain mindful that over time, even such safety aids can become automated and lose effectiveness.
Conclusion
Cockpit control confusion is a subtle, often overlooked hazard in flight operations—born not from ignorance, but from expertise. The same routines that make pilots efficient can also make them vulnerable.
Operators can significantly reduce the risk of such incidents by understanding the cognitive basis of slips, fostering a reporting culture, and embedding mindful techniques such as visual checks and callouts. While aircraft systems are robust and often compensate for such slips, preventive actions remain the first and best line of defence.
Key Takeaway:
Control your controls—with your mind, not just your muscle memory.
For more information, view the video from Airbus World Instructor News ( WIN ).
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