ATSB report • Cessna 441 forced landing, Broome, March '26

[Garfly]

 

In-flight engine shutdown and forced landing involving Cessna 441, VH-LBZ, 3.6 km from Broome Airport, Western Australia, on 19 March 2026 | ATSB

WWW.ATSB.GOV.AU

 

 

 

 

 

 

 

 

And according to the Google bigbot, this ain't the first time such a thing has happened (poor ergonomics strikes again):

 

AI Overview

The primary problem with the Cessna 441’s engine Stop and Start buttons is their vulnerable ergonomic layout in the cockpit. Because these buttons are closely grouped together and lack sufficient physical barriers, pilots have inadvertently triggered engine shutdowns during critical phases of flight.

 

 

 

[facthunter]

Understand your Plane before you start Playing engine failures. Always "confirm" correct switch Before Moving it and it's Purpose/ action.  You should also know the Quick restart procedure. Turbo Props not feathered can create a lot of drag. That's why they Have Auto-feather. Nev

[flying dog]

I agree with Facthunter.

 

I watched the clip and was shocked that the FUEL BOOST and ENGINE OFF buttons were so close to each other and were the same kind of button.

[Thruster88]

That would be a very good reason to Visually identify and only press one  button at a time to avoid the risk of double engine failure. 

[onetrack]

To reach out and hit control buttons by memory, whilst your eyes are elsewhere, as this co-pilot did, would rate as a dangerous cockpit practice - as proven by the result here.

[facthunter]

With Auto feather, it's locked out once one engine has been feathered.  This type of aircraft should easily fly on ONE engine if operated at the required Weights. Doing things at rapid speed invites wrong actions. Nev

[Garfly]

On 03/06/2026 at 8:35 AM, Thruster88 said:

That would be a very good reason to Visually identify and only press one  button at a time to avoid the risk of double engine failure. 

 

Another case in point:

 

 

[BurnieM]

How about we start slapping the CEOs of aircraft manufacturers around for not bothering to hire staff to think about ergonomics ?

This ain't a $150 bicycle.

 

[facthunter]

You will never make a fool proof Plane . Fools use such ingenuity.   Panel Space is at a premium  on such Planes. IF you are endorsed on it you should know it thoroughly or be very careful  before pushing buttons.  In fact double check when involved with any critical control of anything, but PARTICULARLY an aircraft  where there is NO room for error. . Nev 

[johnm]

............ be interesting to know when the pilot 'confessed' to the instructor about when the fuel was turned off ?

* before / after landing

* before / after data

[facthunter]

There's no CVR.  Nev

[kgwilson]

The ergonomic layout of panels of many factory built light aircraft is terrible which is why I designed my own. As aircraft get larger with more functions and engines this becomes more difficult though this is an example of something that should have been thought out better. Yes you should know where everything is and double check what you do but humans make mistakes and better thought in the design of the management systems would reduce the risk of errors considerably 

Edited June 29 by kgwilson

[facthunter]

True but a lot of stuff has to be accessible from both seats. Nev

[sfGnome]

User interface design (i.e. ergonomics in the computer world) seems easy until you do it. I have many stories, but one will do. I was using a tourist website yesterday for entry to a museum. You enter your details, select the payment method, and then tick the “i agree to your rules” box. Nothing happened. I went around in circles for a while before i realised that, having ticked the aforementioned box, you *then* go back *up* to select the payment method. Somehow, that got through all the reviews and user tests and was released on a waiting world.  
 

Often, everyone who checks the layout of an instrument panel has likely been involved in the design, and are blind to the problems that “ingenious fools” will come up with. For user interface (or ergonomic) design, it is super important to let uninvolved, un-knowledgeable, un-instructed people loose on it in a safe, observed environment. 

[facthunter]

While good ergonomics are very desirable your digital comparisons are not that Valid to an aircraft Panel control situation where a lot of things are ON/OFF or Up/Down. Not keyed in. Thankfully.  Nev

[sfGnome]

Sorry, Nev. i should have explained myself better. Anything that is it’s between a person (user) and a machine is a user interface. A brake pedal on a car (an analogue control) is part of the car’s user interface, as is the indicator stalk (a digital - on/off control). I was merely using the website example as I had hit it the day before and it was fresh in my mind. The point I was trying to make was that all user interfaces, including the control panels of planes, need to be test operated by ingenious fools before being put into normal use. I’ve spent my life designing user interfaces - mechanical, electrical and computer - and it took some embarrassing mistakes before I learned that lesson.