Air India 787 Crashes in Western India

The report said “there are no recommended actions” to the aircraft and engine manufacturers, Boeing and General Electric.

Not the outcome I was expecting.

I can almost hear the cautious sigh of relief at Boeing.
 
I wasn't going to post this before, but now it seems more relevant. One evening after work, someone I know pretty well who had a long day, not much sleep the night before, and just tired, tried to swipe the access turnstile going out. They don't swipe out, they only swipe in, since they were put in years ago. Not only did this person not realize they did it, but when someone else pointed out they didn't have to swipe out the response was "yeah I know" and another attempt to swipe out. It took a full 5 seconds before they figured it out.

So if the switches were flipped off by a person, not sure if it's startle response as I think Tools suggested it could be, or intentional, or just tired and their brain followed the wrong flow.
 
Albany Tom said:
I wasn't going to post this before, but now it seems more relevant. One evening after work, someone I know pretty well who had a long day, not much sleep the night before, and just tired, tried to swipe the access turnstile going out. They don't swipe out, they only swipe in, since they were put in years ago. Not only did this person not realize they did it, but when someone else pointed out they didn't have to swipe out the response was "yeah I know" and another attempt to swipe out. It took a full 5 seconds before they figured it out.

So if the switches were flipped off by a person, not sure if it's startle response as I think Tools suggested it could be, or intentional, or just tired and their brain followed the wrong flow.
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Tired brains are responsible for a huge percentage of problems.
 
JimLAFB said:
If that happened right after the gear up command my wild speculation becomes less wild. I would ask any of you active 787 flyers to check if you can shutdown without pulling the switches up next time you block in. I'm guessing there is some ergonomic investigating happening in some sims also. They should publish CVR transcript with timeline.
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From the thrust levers to the gear lever is the opposite direction of the switches.
 
So there I was, a young lad experiencing a simulated engine failure, all pull check feathered clean select and locked, did my ABC’s… I’m all lined up on a beautiful field… T-34C.

Three down and locked, flaps half…

Say again… from the back seat…

Three down and locked, flaps half…

You sure?

Three down and locked, flaps half… Starting to add a little attitude…

Read what you see in the gear indicator to me.

UP UP UP…. as opposed to little pictures of wheels, I literally read UP UP UP and finished with:

Three down and locked, flaps half, SIR!

NO WAIT!

We’ve all been there. And we prolly weren’t facing certain death.

To be fair, I haven’t seen a mistake like that made since, um, well, just guessing here… 2pm TODAY.
 
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Lindberg said:
From the thrust levers to the gear lever is the opposite direction of the switches.
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"At V1, the Captain removes his hand from the thrust levers and there are no hands there through rotation." Where did he put his hand after that? Is it possible he dropped it to quadrant behind levers? But if he did brush the switches when going for the gear lever we have to assume a perfect angle, worn switches, or switches without detents which the FAA put out a notice about. And we have to assume the gear lever was positioned up as some say the bogie angle indicates.
 
A few weeks ago, I was flying my 182 back home. I always leave a little power in until I’m in ground effect, then I pull to idle. I land and roll down the runway, and notice suddenly my engine stops. I look over and my mixture is full idle. I have zero literally zero memory of pulling the mixture. I was on the runway saying how did that happen I pulled the throttle. I still don’t believe I pulled the mixture, but the engine says otherwise.

With that said, this seems hard to do like that since it has to be done one by one
 
Question: The gear was selected down, which pretty much makes all the LG comments about "up selected and then stopped in transit," suspect? Accident sequence is just after rotation. Thinking maintenance still can't be unruled.
 
I know nothing about the big iron so apologies if this is a dumb question, but -- if you put the fuel cutoff switches almost all the way to "run" but not *quite* far enough that they fall into the detent, can you still get them to function as running in that case? (So, obviously, functionally on but vulnerable to being bumped.)

One would hope not and that they can't register "on" unless fully in the detent, but I don't know.
 
deyoung said:
I know nothing about the big iron so apologies if this is a dumb question, but -- if you put the fuel cutoff switches almost all the way to "run" but not *quite* far enough that they fall into the detent, can you still get them to function as running in that case? (So, obviously, functionally on but vulnerable to being bumped.)

One would hope not and that they can't register "on" unless fully in the detent, but I don't know.
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Page 10, Fig 13 of report. Is there a detent on the left switch in the mishap AC photo as compared to the generic photo.
 
It’s a pretty deliberate action. Super easy, but just not prone to bumps and not quite on or off situations.

While anything is possible, if they were moved, it was a deliberate action. Maybe not intentional, but the switch was way most likely grabbed, pulled and moved… IF blah blah blah.

I couldn’t begin to imagine how many times I’ve thrown one of those switches and NEVER even came close to an accidental wrong position. Grabbed ‘em and moved them wrongly… but not accidentally.
 
ElPaso Pilot said:
The report said “there are no recommended actions” to the aircraft and engine manufacturers, Boeing and General Electric.

Not the outcome I was expecting.

I can almost hear the cautious sigh of relief at Boeing.
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If software always filters the pilots' input in this plane, and manuals recommend never to decrease power below 400' why did the software, in takeoff configuration, allow for two engines to be shut off on purpose or inadvertently, below this altitude?

I don't think Boeing is off the hook as you believe. On a $300M plane I would expect a FADEC software instruction such as:

-If on takeoff configuration and altitude below 400', then disallow input from cockpit to shut engines down.
-Display failure on EICAS along WITH message for automatic override.

In other words, they recommend actions but don't implement these in their FADEC software? We're talking 5 lines of code that could have saved hundreds of lives if this in fact was the cause of the accident.
 
Wow. How can even one, let alone both fuel cut off switches unintentionally go to cut off? Both at almost the same time? At the most critical point in the flight? Both after V2 - they could have still climbed on just one engine. I believe you have to pull the knob up, rotate, and then activate.

It’s something almost no airline pilot has ever done, so probably not mindless habit/muscle memory.
 
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deyoung said:
I know nothing about the big iron so apologies if this is a dumb question, but -- if you put the fuel cutoff switches almost all the way to "run" but not *quite* far enough that they fall into the detent
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Not on those switches. It's either one or the other.

They don't move unintentionally. When starting the engine, I hang my hand off of the switch while the engine is starting. No chance of it moving without pulling it outward first. When you pull it outward, there's a respectable amount of spring tension holding it in. It's a very positive movement.
 
Larry in TN said:
Not on those switches. It's either one or the other.

They don't move unintentionally. When starting the engine, I hang my hand off of the switch while the engine is starting. No chance of it moving without pulling it outward first. When you pull it outward, there's a respectable amount of spring tension holding it in. It's a very positive movement.
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But Boeing purchased/installed some that you didn't need to pull. I doubt that whatever over-under mechanism that was internal in those switches could let it swing back but the report Page 10, Fig 13 might have one of those switches.
 
WDD said:
Wow. How can even one, let alone both fuel cut off switches unintentionally go to cut off? Both at almost the same time? At the most critical point in the flight? Both after V2 - they could have still climbed on just one engine. I believe you have to pull the knob up, rotate, and then activate.

It’s something almost no airline pilot has ever done, so probably not mindless habit/muscle memory.
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Actually they do it every time they get to the gate and need to shut down the plane ….but yeah, in flight I would assume only in the simulator.
 
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Himayeti said:
If software always filters the pilots' input in this plane, and manuals recommend never to decrease power below 400' why did the software, in takeoff configuration, allow for two engines to be shut off on purpose or inadvertently, below this altitude?

I don't think Boeing is off the hook as you believe. On a $300M plane I would expect a FADEC software instruction such as:

-If on takeoff configuration and altitude below 400', then disallow input from cockpit to shut engines down.
-Display failure on EICAS along WITH message for automatic override.

In other words, they recommend actions but don't implement these in their FADEC software? We're talking 5 lines of code that could have saved hundreds of lives if this in fact was the cause of the accident.
Click to expand...

Do you want software to fly or pilots to fly? Seems like software this time.
 
Some number's to consider:

Average 2 landings and shutdowns per day
365 days a year
11 year old plane.
Equals 8030 operations on each of those switches

They could be getting worn, and easier than originally designed to operate.

But that does not equate to both being improperly operated at the same time.
The verbal "Why" followed by reset indicates intentional act that was a mistake.

The real, un answerable question, what was that man doing last night?


Like Nikhiln said above, I have pulled the mixture to cutoff mistakenly. Mine was in the pattern, and I called "Carb heat on". The engine went silent, I undid what I had just done, power came back, and I then figured out just what I had done.
























;
 
geezer said:
The real, un answerable question, what was that man doing last night?
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Report does mention that they conducted breathalyzer tests upon reporting for duty that morning. Obviously that doesn't cover everything, nor would it address fatigue induced by any number of things.
 
Himayeti said:
If software always filters the pilots' input in this plane, and manuals recommend never to decrease power below 400' why did the software, in takeoff configuration, allow for two engines to be shut off on purpose or inadvertently, below this altitude?

I don't think Boeing is off the hook as you believe. On a $300M plane I would expect a FADEC software instruction such as:

-If on takeoff configuration and altitude below 400', then disallow input from cockpit to shut engines down.
-Display failure on EICAS along WITH message for automatic override.

In other words, they recommend actions but don't implement these in their FADEC software? We're talking 5 lines of code that could have saved hundreds of lives if this in fact was the cause of the accident.
Click to expand...
The “ it is only 5 lines of code “ ignores the fact that non-AI software does not have any notion of context beyond what you can put into these 5 lines of code so cascading failures related to faulty sensors of some kind are very real possibility and usually present the pilot with very confusing and sudden reality where familiar action magically stops working and the only way to debug it is to understand the limited “reality context” software is operating at.
In other words, a pilot can figure out he/ she is currently flying based on many inputs/context ( including basic ones like looking out of the window ) while simple software state machine will be absolutely convinced it is on the ground as soon as , say , pitot tube stops working …

Albeit, in this particular case, disabling fuel switches based on simple criteria you outlined would have been relatively safe thing to do with minimal potential penalty related to cascading sensor failures so perhaps it should have been done.
 
flyingron said:
Yeah, the market didn't think LionAir 610 was a Boeing problem either. Just another third world airline. Even after the Ethernopian air crash the next March and the FAA grounding the max8 did the markets move, but not by much.
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the market was right
 
Himayeti said:
If software always filters the pilots' input in this plane, and manuals recommend never to decrease power below 400' why did the software, in takeoff configuration, allow for two engines to be shut off on purpose or inadvertently, below this altitude?

I don't think Boeing is off the hook as you believe. On a $300M plane I would expect a FADEC software instruction such as:

-If on takeoff configuration and altitude below 400', then disallow input from cockpit to shut engines down.
-Display failure on EICAS along WITH message for automatic override.

In other words, they recommend actions but don't implement these in their FADEC software? We're talking 5 lines of code that could have saved hundreds of lives if this in fact was the cause of the accident.
Click to expand...
Hazard transfer. Typical safety case stuff. So instead of taking care of a hazard systemically you transfer the responsibility to the owner/operator. It’s pretty standard and accepted part of safety systems. It’s not done randomly or on a whim. It has to be backed by analysis of outcomes, probability, and level of risk.

I have seen plenty of stuff done that way for railways. And railway engineering firms would argue we are as safe and often safer than airplanes. In cars it’s more Wild West. Nothing is actually fully on the system, everything is back stopped by the driver being responsible.
 
No, don’t trust the OEM, Boeing, Airbus, or otherwise. Maybe there is a TCAS-type avionics issue regarding fuel or power plant control airborne-mode logic that is yet to be revealed. Maybe the avionics was hacked and in both or other scenarios the FDR recorded switch movement from Run to Cutoff within 1 second of each other and back in 10 seconds without physical movement of the switches while the engines were rolled back.

But the CVR is key when 1 pilot says to another why did the switches get moved to cutoff. And either pilot could be the culprit since either the first pilot (probably the captain who was probably not PIC) did it and yet asked the other pilot why knowing this is recorded on the CVR in order to deflect blame (my first guess) or the first pilot actually observed the second pilot performing these actions and asked why. In either scenario the CVR tells us that there was a pilot action and not an unintended avionics action.

Captain/Dr. Steve’s YouTube was most informative on this as well.
 
Himayeti said:
If software always filters the pilots' input in this plane, and manuals recommend never to decrease power below 400' why did the software, in takeoff configuration, allow for two engines to be shut off on purpose or inadvertently, below this altitude?

I don't think Boeing is off the hook as you believe. On a $300M plane I would expect a FADEC software instruction such as:

-If on takeoff configuration and altitude below 400', then disallow input from cockpit to shut engines down.
-Display failure on EICAS along WITH message for automatic override.

In other words, they recommend actions but don't implement these in their FADEC software? We're talking 5 lines of code that could have saved hundreds of lives if this in fact was the cause of the accident.
Click to expand...

what's the failure hazard analysis supporting your assertions? What about failure of the RA? What about about sensor failures? What about engine fire?

I hope your "5 lines of code" was intended to be hyperbole.
 
JimLAFB said:
I believe some airlines have a procedure to guard the thrust levers. Yes, I've seen the guards. Somehow, someway could a hand guarding the thrust levers slide back and catch both worn switches when going to put the gear up? Tomorrow we may know if the fuel switches being turned off corresponded to a point where gear up was commanded. Or not.
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I have ridden a lot of jumpseats on many different airlines. Never once saw the pilot monitoring guarding the throttles. The PM has things to do like get the gear and flaps up, select nav modes and manage comms.
 
n1g1a said:
No, don’t trust the OEM, Boeing, Airbus, or otherwise. Maybe there is a TCAS-type avionics issue regarding fuel or power plant control airborne-mode logic that is yet to be revealed. Maybe the avionics was hacked and in both or other scenarios the FDR recorded switch movement from Run to Cutoff within 1 second of each other and back in 10 seconds without physical movement of the switches while the engines were rolled back.

But the CVR is key when 1 pilot says to another why did the switches get moved to cutoff. And either pilot could be the culprit since either the first pilot (probably the captain who was probably not PIC) did it and yet asked the other pilot why knowing this is recorded on the CVR in order to deflect blame (my first guess) or the first pilot actually observed the second pilot performing these actions and asked why. In either scenario the CVR tells us that there was a pilot action and not an unintended avionics action.

Captain/Dr. Steve’s YouTube was most informative on this as well.
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I have it on good authority that descendants of the witches of Salem cast a spell on that airframe causing the accident. They will confess soon when they start dunking them!
 
JimLAFB said:
"At V1, the Captain removes his hand from the thrust levers and there are no hands there through rotation." Where did he put his hand after that? Is it possible he dropped it to quadrant behind levers? But if he did brush the switches when going for the gear lever we have to assume a perfect angle, worn switches, or switches without detents which the FAA put out a notice about. And we have to assume the gear lever was positioned up as some say the bogie angle indicates.
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Everyone I ever observed brings there hand up to the yoke. No one drops it on the console. Your scenario would require both switches to have the same failure mode. It also fails to explain the timing. The Captain moves his hand of the thrust levers at V1. The engines were shutdown sequentially not simultaneously 3 to 4 seconds after weight off wheels. The aircraft would have never left the ground if the engines were shutdown at V1.
 
Doesn't appear likely we will ever know who- or why- the cutoff switches were operated; just that they were.

Now someone can explain to me why in the current day (not 50 years ago) a few simple video feeds- especially the cockpit, but also the cabin- have not been incorporated into the realm of mishap data that needs to be retained? Why are we just listening to audio, rather than actually being able to see a video record of events??
 
Gonna need some more bandwidth than available for that one…
 
Tools said:
Gonna need some more bandwidth than available for that one…
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Well, as they said at the beginning of "The Six Million Dollar Man", "We have the technology"...
Incredible innovation in fly-by-wire technology, and these systems are dinosaurs IMO.
 
tobnpr said:
Doesn't appear likely we will ever know who- or why- the cutoff switches were operated; just that they were.

Now someone can explain to me why in the current day (not 50 years ago) a few simple video feeds- especially the cockpit, but also the cabin- have not been incorporated into the realm of mishap data that needs to be retained? Why are we just listening to audio, rather than actually being able to see a video record of events??
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Who gets to pay for it?
 
We need the answer to who said what, which I’m sure voice analysis will reveal.

But what I am thinking about a lot. If it was accidental, the other pilot who said “why did you do that” .. that wouldn’t have been his immediate one second later thought. It would have been “wtf is going on fuel flow is dropping, thrust is dropping etc “. He immediately jumped to “why did you do that”.. which to me says he saw from the corner of his eyes it happening. He was aware that is what happened.. there was no startled WTF is happening response and then realization fuel switches are on cut off
 
Nikhiln25 said:
We need the answer to who said what, which I’m sure voice analysis will reveal.

But what I am thinking about a lot. If it was accidental, the other pilot who said “why did you do that” .. that wouldn’t have been his immediate one second later thought. It would have been “wtf is going on fuel flow is dropping, thrust is dropping etc “. He immediately jumped to “why did you do that”.. which to me says he saw from the corner of his eyes it happening. He was aware that is what happened.. there was no startled WTF is happening response and then realization fuel switches are on cut off
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Yeah, or he saw the effect, and assumed that the other pilot was the cause; if so, that's very quick thinking.
I sort of like Juan Browne's inadvertent shutoff theory, just to remove much of the onus from the pilots. Well, sort of; it would still require moving the cutoffs, and not simultaneously.
 
Unless the pilot who said “why did you do that” was the one who shut off the fuel, knowing the CVR would pick that up and put blame on the other guy.


In this video you get the timeline as well as a nice view of the cut off levers. Odd, at 5:10 the phrase used was “why did he …”, not “why did you ..”.

It would be more natural to say “why did you” if you’re speaking to the other pilot. You might be lead to say “why did he” instead if you had a mind set of speaking to the CVR.
 
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