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MaybeItIs
July 13, 2025, 05:51:00 GMT permalink Post: 11921038 |
@Maybeitis,
how about we leave the total redesign of the fuel switch locations and operation (which have been moved billions of times in thousands of aircraft without a hitch) until the final report is out.
These were deliberately moved. It wasn't a brain-fart. Unless the interim report omits crew calls which turn the scenario on it's head. Happy to oblige. TBH, I'm no longer so concerned with what really happened inside the cockpit of AI171. What the final report says won't make any difference. I can see some flaws in the Boeing design (don't know Airbus so can't compare), and propose a few ideas to deal with that, and with the fact that we humans are highly flawed. Sometimes, the brain doesn't know what the right hand is doing. That's a wee problem. My theory FWIW, says this won't have been called at all. And that "it" was done entirely without intention. The intention was to do something else. So, in that case, was it deliberate? I say No. It was an accident. It was IMO, done with the best of intentions, but resulted in a serious blunder, with the wrong switches getting turned off. By what has been termed here "a slip". I agree with that. As I've mentioned, I now believe that when you know someone (including yourself) is doing something wrong, you seem to be more likely to make a mistake yourself. It's as if you automatically become partners in crime. (Even you and yourself!) Did you read this article? Some of the comments are also well worth reading. https://avherald.com/h?article=48d1e3ae&opt=0 This [i.e 171] accident (I think the correct term) has absolutely fascinated me, and caused me to think a great deal. My recent posts are not really about 171. Only a result of it. For the benefit of all. You know how people who have lost loved ones want their death to somehow benefit others? I didn't lose anyone in this crash, but that's a beautiful thing about we flawed humans. I'll shut up now. Thanks for allowing me to participate. |
za9ra22
July 13, 2025, 22:02:00 GMT permalink Post: 11921714 |
Here is something I have not seen on this thread. In the UK, as I understand it, an accident investigation is lead by the AAIB, however if evidence is discovered that suggests a criminal act has taken place then the police lead the investigation with the AAIB in a supporting role. Here is the
memorandum of understanding [pdf]
describing this, sections 3.5 and 3.6 describe the difference.
I assume something of the same happens in India. However, I can not find any evidence online that a criminal investigation has been launched there and it seems AAIB (India) continues to lead the investigation. This suggests that, with all the evidence gathered by the investigators so far (which is substantial), there are no grounds to conclude that a criminal act had been committed. In other words, this is an accident and not deliberate. If there's one factor which strikes me as pertinent to the AI171 prelim report, it's that it may have been written in the form we see, to help hold the question of criminality sufficiently distant that the investigators don't loose control of the investigation. |
Lead Balloon
July 14, 2025, 07:45:00 GMT permalink Post: 11921923 |
And that is what will drive it.
We have all had to accept CCTV if we want to pump gas, scan groceries, walk into a bank, get on a bus, walk thru an airport, or catch an Uber. We have the situation where pilot malfeasance is now the number 1 cause of RPT fatalities. Guess where this is headed. |
slats11
July 14, 2025, 11:23:00 GMT permalink Post: 11922102 |
@ The Brigadier
Looked at objectively, having Cockpit Video and Voice Recorder (CVVR) can only improve accident investigation accuracy by clarifying ambiguous events, providing visual confirmation of actions taken (or not taken) by flight crew and gives investigators insights on crew coordination, error chains, and situational awareness. Of course pilot Unions have their objections. I wonder if pilots all refuse to fit dashcams in their cars?
​​​​​​​
Despite my understanding and
agreeing with the
merits of the arguments made by commercial pilots about the potentially deleterious effects of cockpit videos and the publication of raw recorder information, I think it would be prudent for commercial pilots to brace for a mugging by political reality. If the truth is that the course of events in the cockpit of AI171 is 'pretty clear' from the recorded voice and data recorders, the political pressure to reveal, 'soon', what is 'pretty clear' is likely to become overwhelming in the context of previous tragedies. And any impediment to that happening in future tragedies, because of pilot resistance, will be steamrolled. If pilots want to argue that they will be 'less safe', I wish them luck in getting popular support.
I believe the industry should embrace change. If not, the industry risks finding itself embraced by change. Better to be out in front of this issue and negotiating appropriate safeguards on CCTV monitoring, rather than being dragged along reluctantly and with less influence. Last edited by T28B; 14th July 2025 at 12:06 . Reason: fixed brackets |
D Bru
July 14, 2025, 17:26:00 GMT permalink Post: 11922380 |
Good analysis; AvH MN4 thing is an absolute ruse
The preliminary report narrows things down a lot but not as much as it could have done. The report will have been approved by several people. What we see is their consensus. Why did they choose this version?
The report is written to point the finger directly at: (i) the fuel cutoff switches and (ii) either pilot error or pilot mal-intent using them. The report is not written to point the finger at an electrical or mechanical malfunction. ...... The investigating team already knows. They could have disclosed more of the cockpit conversation, which would be a lot of help to us PPRuNers, but didn't need to. They have let Boeing and the type off the hook and put the blame on the pilots. They have fulfilled the primary purpose of an investigation -- to find out what happened. Interestingly, they did not disclose whether it was error and mal-intent. Perhaps that is because they couldn't answer the grisly question: which is least worst, from the point-of-view of the airline, the victims' families and future customers? Two posters above have quoted AvHerald's report that "... India's media reports that the investigation is NOT focusing on a human action causing the fuel switches to appear in the CUTOFF position, but on a system failure." One interpretation of this is that the investigation knows all about the human action and that the system they refer to is the industry's approach to pilot mental heath and well-being. YYZJim |
Pip_Pip
July 14, 2025, 19:48:00 GMT permalink Post: 11922457 |
I have been hesitating to ask, but I'd like to check whether something I spotted is significant. (I think it is probably
NOT
significant, but it does no harm to confirm this whilst there is little in the way of new information to discuss).
I believe all three sources are reliable and verified. 1. Aviation Daily, June 25: "the DGCA carried out surveillance... at major airports, including those in Delhi and Mumbai. The surveillance order was issued on June 19, and the DGCA summarized its findings in a June 24 statement. \x93The assessment covered a wide range of areas such as flight operations, airworthiness, ramp safety, air traffic control, pre-flight medical evaluations and communication, navigation and surveillance systems." The order was issued on June 19, a week after AI171, and could feasibly have been informed by initial findings from the investigation (though not from anything on the EAFRs, which were not downloaded until much later). However, the timeframe is so tight that I'm inclined to think the assessment was either (a) a complete coincidence, or (b) a reassurance exercise. Question : is it standard to include a review of pre-flight medical evaluations in such an exercise? (I don't see why it wouldn't be). 2. PIB press release from the Ministry of Civil Aviation on 26 JUN 2025 1:17PM: "The [investigation] team, constituted as per international protocol, is led by DG AAIB, and includes an aviation medicine specialist , an ATC officer, and representatives from NTSB." The very first team member mentioned is an aviation medicine specialist. This could be coincidence or due to any number of trivial reasons, e.g. alphabetical order by surname. Still, I remember raising an eyebrow at the time (several weeks ago, to be clear). The Preliminary Report ( PR ) includes a much longer list of team members on page 5, whereas the aforementioned press release singles out three in particular. Relevant? 3. The PR implies that the Aviation Medicine Specialist and an Aviation Psychologist were both drafted in as supplementary Subject Matter Experts (alongside several others I should add) at some point after the original team had been established. I expect this is a common occurrence, but is it universal ? Question: At what stage of an investigation would one typically pick up the phone to these particular SMEs (automatically on day one or as deemed necessary)? Individually, the above observations seem mostly routine to me. Together, they strike me as little more than a coincidence, but still... Do those with experience of such investigations have a view on the drafting-in, and the disclosure, of these two SMEs within the first two weeks of an investigation? Disclaimer: By setting out my sources and thought process in some detail, it may create the impression that I am pushing an agenda. I assure you I am not. I am merely trying to be unambiguous about the facts I am asking you to opine on. |
sabenaboy
July 16, 2025, 08:56:00 GMT permalink Post: 11923539 |
What action should be taken after this crash?
After 9/11, many countries and airlines changed their jumpseat policies, restricting access to the flight deck to active crew members only. That was a knee-jerk reaction. Imagine there had been jumpseaters on the doomed 9/11 flights — wouldn’t they have tried to stop the cockpit intruders? With jumpseaters present, the pilots would at least have stood a better chance of defending themselves and avoiding being overpowered so quickly.
After 9/11, reinforced cockpit door locks were also introduced. But did that really make aviation safer? Consider Germanwings 9525, or MH370. On narrowbody aircraft, these locks don’t even prevent a group of terrorists seated in one of the front rows from storming the cockpit when the door is opened for a meal or a bathroom break. And yet, after GW9525, no one suggested removing the locks — despite the fact that they contributed to that tragedy. Instead, many airlines — including mine — introduced a policy requiring that no pilot ever be left alone in the cockpit. But to what end? Would a flight attendant really be able to stop a determined pilot from committing suicide? It takes only seconds to shut off fuel control switches, pull engine master switches, and activate fire handles. A flight attendant could just as easily do those things, or take the cockpit fire axe and attack the remaining pilot, then lock the door. How rigorous are the background checks for flight attendants compared to pilots? And now, in the US, some pilots are even allowed to carry guns in the cockpit. How long before that leads to catastrophe? I fear it’s only a matter of time. I suspect there will again be knee-jerk reactions to AI171. Perhaps making it harder to operate critical switches? Would that really improve safety? Or installing CCTV in the cockpit? Would that prevent pilot suicide, or simply make it harder to hide? And would the cost and complexity really be worth it? In my view, the biggest opportunity for improvement lies not in aircraft design, but in human resources. How can we better support pilots who are feeling down, stressed, or depressed? I don’t believe every crash necessarily calls for a technical or procedural fix. In this case, I see no compelling reason to change the aircraft itself. Of course, the one sure way to eliminate pilot suicide would be to remove pilots altogether and fully automate flight. But I believe it will take a long time before such a system is truly safer than what we have today. The best course of action for now is the same as in many situations in the cockpit: sit on your hands, resist the urge to act impulsively, and thoroughly investigate what would truly be the most effective response. In my country, the ministry of transport has adopted the goal of “zero” road traffic fatalities. That’s unrealistic — even absurd — unless you ban all forms of transport altogether. Perhaps we should acknowledge that not every incident or accident needs to be followed by a remedial action. In the case of AI171, any action we take should focus squarely on human factors. |
MissChief
July 16, 2025, 14:12:00 GMT permalink Post: 11923751 |
I really don't get it why you oppose to the thought it could happen on any Boeing aircraft. Since they are all very similar switches. Maybe it's even possible to interchange some of them. There are so many errors a maintenance organization can make. Fake parts?
What really frightens me is that you and others resolutely block even to think about the possibility. Because, let's be honest, the probability is not zero (and I would say nearer to 1 than to 0). I have never moved such a switch, since I fly Airbus. Let me ask you your question differently: How many times have you moved a faulty switch? I know, that you and many others would immediatly identify such a bad switch and would render the aircraft as not airworthy. This is not the question. The question is: Has the Air India crew on that day identified the fault. And if yes, have they continued the flight preparation. You don't need a suicide theory to explain such a simple course of action. Dani A suicide is inherently a complex issue, which may be impulsive or may be pre-meditated. The may be a medical history behind the actions of a person taking their life, and in many cases there may be no past indicators. In any event, shocking though it is, a pilot's deliberate actions with the fuel controls is a possible or probable cause of the crash of AI171. |
Michael Dowding
July 17, 2025, 14:35:00 GMT permalink Post: 11924443 |
Oldrightie
I am not aware of a part of the prelim report, second paragraph being discussed anywhere. Something I find, if I'm correct, not discussed yet for me surely very significant.
"The EGT was observed to be rising for both engines indicating relight. Engine 1\x92s core deceleration stopped, reversed and started to progress to recovery. Engine 2 was able to relight but could not arrest core speed deceleration and re-introduced fuel repeatedly to increase core speed acceleration and recovery . The EAFR recording stopped at 08:09:11" Forgive my now 20 years into retirement as an F/O on the B737 400 and A320/21 but I still retain my lifelong avid interest in all things aviation. So am I correct in thinking this paragraph indicates significantly that eng2, right hand, core compressor had failed, albeit not explosively? It relit and fuel was being "re-introduced repeatedly "but could not arrest core speed deceleration". From day one I believed that no 2 failed after V1 and that the automatic correction for this on the 787 hid all but a possibly apparent small nose right on its climb out. Additionally I surmised that with all the warnings this produced, the low altitude and few seconds to address such a failure, the first recycle was offered up to the no 1 engine switch, in haste. The immediate result then RAT extension, a check on the engine parameters and an action on the no 2 switch, again in haste on realisation that was down on N2, then, sadly too late, No 1 recycled successfully. Unlike No 2. Heaven knows, a similar mistake was made on the Kegworth B737, when all he time in the world was available compared to AI171. To me the long debate here about suicide is very unprofessional and surely this factual part of the report, has masses more credence, regardless of the consequences facing the AI crew. If this bit about No 2 engine report is as I interpret, I would at least hope, if not already, someone else has picked it up, or at least it will get more attention ere long. God bless all the people so badly affected and I pray the cause will be one day revealed and not be buried to protect the money men. Has been known. ![]() |
1stspotter
July 17, 2025, 16:17:00 GMT permalink Post: 11924501 |
She told utter nonsense. This is the person who said the stuff quoted below. I hope you agree with me the ANA B787 uncommanded dual engine shutdown in 2019 *** after landing *** had nothing to do with a ' similar fuel cut-off malfunction during final approach". There is also no Boeing software issue in the case of AI171. The ANA B787 ASN wrote: A Boeing 787-8 of All Nippon Airways operating ANA/NH985 from Tokyo/Haneda to Osaka/Itami stuck on runway 32L while landing at Itami due to sudden shut-down of both engines after Thrust Reverser actuation. Ms Schiavo said: "As fresh scrutiny surrounds Boeing after the Air India AI 171 crash, aviation expert Mary Schiavo reveals that a similar fuel cut-off malfunction plagued a Japanese Boeing 787 in 2019 \x97 with pilots never touching the controls. Investigators now face mounting questions on why warnings were missed and why Boeing\x92s software may still pose a global threat." and Mary Schiavo revealed that a near-identical incident occurred in 2019 on a Boeing 787 operated by ANA during its final approach to Osaka. \x93The investigation revealed the plane software made the 787 think it was on the ground, and the Thrust Control Malfunction Accommodation (TCMA) system cut the fuel to the engines,\x94 she said. On that occasion, both engines shut down simultaneously, but the crew landed safely. The Japanese aviation authority and Boeing traced the incident to a software fault, not human error. ANA\x92s Dreamliner, carrying 118 people, had to be towed off the runway. |
Andy_S
July 17, 2025, 19:26:00 GMT permalink Post: 11924596 |
AI171 took off in a broadly South Westerly direction and came down about 500m from the Civil Hospital (Red Marker in the image below) ![]() I really don't see any good options. And the river is still 2km distant (and in any case at right angles to the direction of flight). |
Musician
July 17, 2025, 21:02:00 GMT permalink Post: 11924663 |
That's what I wondered.
AI171 took off in a broadly South Westerly direction and came down about 500m from the Civil Hospital (Red Marker in the image below) ![]() I really don't see any good options. And the river is still 2km distant (and in any case at right angles to the direction of flight). |
galaxy flyer
July 17, 2025, 23:23:00 GMT permalink Post: 11924758 |
That's what I wondered.
AI171 took off in a broadly South Westerly direction and came down about 500m from the Civil Hospital (Red Marker in the image below) ![]() I really don't see any good options. And the river is still 2km distant (and in any case at right angles to the direction of flight). |