Posts about: "Action slip" [Posts: 70 Pages: 4]

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You could be quite right and I do agree that most action slips are for switches and levers operated in roughly the same phase of flight. Really hard to resolve one way or the other as in both cases of deliberate or subconscious action, it\x92s hard to apply logic to a mind that can be illogical\x85shipiskan\x92s post above being an example.

Former Boeing Engineer on the 787 (prob should put this in my profile at some point but newbie on the forum), but personally flown nothing bigger than a 172.

Longer I think about this the more I lean towards purposeful but not intentional action slip cutoffs by the captain. Some people have commented on sim training captains doing this to reset quicker (i wouldn't know).

We know FO was flying and initial cut offs are 1 then 2, which to me says CAPT did it. But also relights were 1 then 2 which tells me CAPT also did that one most likely.

Also comments around 10 seconds of delay being a long time, that's REALLY fast in my opinion especially considering, 1. this is a situation that is never trained for and 2. All sorts of lights changing, displays flickering, whole right side of the cockpit basically turning off and 3. Your really close to the ground and transitions (from takeoff to climb) lend themselves hard things to break your mind out of. That has to be a very jarring experience that needs likely a few seconds just to re-orient themselves. I'm honestly impressed they got them re-lit that fast, but assuming training with engine out and re-start procedures likely gave them a hint fuel switches from the EICAS messages.

Very confident Boeing FlightOps engineers and training captains have run through this in the sim quite a few times now.

Non-pilot here.

For those interested in reading more about 'action slips', including performing one routine function in place of another, the following free-access article goes into more detail:

Wiley Online Library: Oops! I Did it Again: The Psychology of Everyday Action Slips

As other people have perspicaciously pointed out, assuming that it was the Pilot Monitoring that transitioned the Fuel Cut-Off Switches from RUN to CUTOFF, what action would they likely have been attempting to perform at that stage of the flight for an action slip to be a likely possibility?

Alternatively, given that the PM was used to operating simulators, what conditions could have prompted him to do a sequence that was familiar to him of resetting the simulator (including operating the FCS switches), doing things that are inadvisable in a real aircraft?

If these are stupid questions, I apologise for taking up a mod's time processing the comment deletion.

Theyre good questions. I\x92ve only been a sim \x93victim\x94 but many sim scenarios will require resetting things back to normal. Aborted takeoff after engine failure for example or land with an engine failed and a quick start.

I\x92m inclined to give equal wait to intentional shutting down the engines (suicide, if you will) and \x93action-slip\x94. Three seconds after WOW and calling for \x93gear up\x94 is quick but not hugely so. We don\x92t have the transcript, we don\x92t know if the voices were associated with which pilots. It\x92s entirely possible, there was \x93positive rate\x94, \x93gear up\x94 exchange followed by the movement of the switches by the PM, followed by \x93why did you cut off\x94 by the PF who is soon without a PFD.

As to timing, in high stress situations, the mind can run like a computer slowing time or just the opposite, time speeds up and seconds go by trying to comprehend the situation. I was in an ejection, I could spends 15 minutes describing what happened in 500 milliseconds.

Just recently, a former colleague shared a similar harrowing account.

He had suffered from depression for a couple of years since the death of his wife in a car accident. She was the light of his life.
I noted recently he had stopped flying recreationally and raised this with him - suggesting a trip may go some way to lift his mood
But when I said we should head away for the weekend and fly up to see friends, he got awful quiet and withdrawn -- then confided that on his last flight, with his grandchildren onboard , he felt such a heightened sense of hopelessness that he was overcome by a compelling urge to end it all. Fortunately he fought off these dark thoughts, but describes it as an almost insurmountable internal struggle - and only fortunate that he was on final and a minute out.

Thankfully he is now receiving excellent care and has voluntarily grounded himself

We speak often and openly about the incident - and this overwhelming sense of "just want out" is precisely how he expressed it.

Edit to add: Personally, I'm still hoping for an inexplicable action slip, but recognise there's two suggestions on the table

Bunk-Rest Firstly, the PIC was a line training captain and not a simulator instructor\x85so no action slip due to that!
Secondly, stop supposing a third person on deck when the crew composition is clear\x97 and desist from imagining ridiculous possibilities..
\x94 Unauthorised possibly, knowing air India\x85.\x94 maybe this happens in your deck or bunk-rest!

The more I ponder on this the more I feel like the final outcome may be very unsatisfying-we may get a detailed report on the how but not the why and the result will become a Rorschach test- we will apply our own biases and come to our own judgements

already I don\x92t know how we\x92d ever be able to prove intent vs action slip unless there\x92s a \x91note\x92 recovered at one of their homes (but you\x92d have thought that would\x92ve been known already long ago)

no one\x92s life is perfect nor can we know what anyone is really dealing with internally vs their external persona

I think you\x92re not on your own here. There is a bit of criticism about the initial report withholding certain things and being incomplete but IMO it said what needed to be said in a neutral way. We now know it is a HF accident, not an aeroplane technical one and although I would like to know exactly what happened, I\x92m much less concerned for the 787 and aviation in general, to the point that in this case I\x92ve lost a lot of interest in the eventual conclusion, if there ever is one.

bluemic

How\x92s the water in that shark infested sea?

When I read that on the previous sector the aircraft had a stab issue written up I wondered the same thing. It\x92s a fanciful theory but they all are. I\x92m leaning towards the action slip \x93brain fart\x94 although why might always be the subject of speculation. Assuming that the captain did place the fuel control switches to cutoff just after rotation then whatever the explanation will most likely defy logic.

Incidentally this tragic accident wasn\x92t discussed that much in my company even though it operates the 787. I think there\x92s a realisation that it would be pointless speculation until there is the final report. What was noticeable early on is that we\x92re no maintenance actions mandated by Boeing, GE, the FAA etc. Equally nothing from a flight ops perspective.

There have been numerous examples of healthy individuals making lethal mistakes out of the blue. Whether you call it "brainfart" or Action Slip, it's a real thing. And considering that multiple asteroids have hit earth even in our lifetime you might want to reconsider your risk categorization

They are usually such nice sharks.

What is known so far certainly does defy logic but I struggle with the brain fart idea. Firstly (noting that the initial report does not mention positive rate or gear up calls) I can’t see any action cue for the PM to do anything at all at the time the switches were moved to CUTOFF. If some sort of random disorientation action is postulated then you’d have to ask why did it occur at that critical moment and not 30 seconds earlier or 30 seconds later?

Secondly, I can’t be the only one who has operated a control and then perceived an unexpected set of visual, audible or physical responses from something unrelated and instantly thought WTF have I just done followed by an immediate re-check of that action? Although the initial report is notable for what it does not say I can’t see the flat denial of any action is what would be expected given the plethora of cues in that cockpit following the operation of the switches.

I have flown B777 and B787 and have operated these switches many times. They are solid secure switches that need a deliberate action to move.
My thoughts, without any weighting or inference are that they were:
1. moved deliberately to shutdown the engines
2. moved unintentionally and ended up shutting down the engines
Airlines focus on many safety topics, one of which is action slips.
Cockpiy Control Confusion - by Airbus
A recent example cited by the AAIB was the 777 RTO at LGW.
The only time that both fuel control switches are switched off together (and not immediately switched back on - Double Engine Failure) is at the end of the flight once parked on stand. This is a very familiar, routine action that pilots do with probably little thought. I have heard of some very odd action slips by some very experienced pilots. In this instance maybe the cue for the action was gear up? It could fit the timeline.

One of the initially discussed variants was inadvertent operation of the Fuel Cutoff Switches instead of putting up the landing gear. There was some pushback against that idea based on the position of the landing gear. As far as I recall the observed position of the landing gear was ultimately deemed to be caused by loss of hydraulics, and not as caused by interruption of the raising operation, making it fully compatible with the preliminary report. It's curious that the report does not mention the positive rate and gear up call out, either for its absence or it being made. It does note that the landing gear lever was in the down position, which isn't unusual for a severe event just after V2 but also in line with the theory.

With what we know now from the preliminary report that option seems to be a good candidate as the source of initiation for an action slip. Both the PF instead of calling Gear Up Action Slipping and operating the Cutoff Switches, or the PM instead of calling Positive Rate doing so would fit that scenario and timeline.

For the action slip theory, while worth of considering, I have one question. That is that both switches are reported to be moved to CUTOFF at practically the same time, quote "within 0.1 seconds". You can not move those switches one after the other in 0.1 seonds (grip one, pull it, move it, let loose , grip the other one ...).

Question: is it an often encountered practice when arriving at the stand, to shut-down both engines simultaneously? The switch design seems to try to prevent simultaneous action. But we are humans, right?

Why this is relevant. Because if normally you do two actions, maybe with 2..5 seconds gap between them. It would be unlikely that you would shut down both engines instead of gear up. One, yes, on a bad strange day, but not both of them. Except ... you got a habit and always Cut-Off both engines in one single go.

The report says '01 seconds'. You mind has put in the decimal point.

Given sampling rates, it's been established here that this is anything up to 2 seconds.

My bad, you are right. Sorry for the noise. It was a dual action, which then in my mind plays against an action slip theory. Just my 2Ct of course.

If crew action is the root cause of this, then the above may be the "best" we, as a pilot community, can hope for.

I refuse to use the phrase that involves small rodents and circular exercise machines. But this conversation has to move forward.

If we take it that the preliminary report is true (or true enough). switches were moved by human hands, and is thus a Human Factors incident with very little that we can learn technically about the aircraft design...
How is this community going to learn from this incident? What are we going to do as a community to improve safety?
Accident investigation - IMO - is about examining all the facts. Looking at those facts, in the most unfiltered light, and working out the TRUE causes, regardless of the prevailing opinions of the time. Any aviation death is one too many. Every aviation death should be used to improve safety for those that follow. Sometimes the results are technical / design philosophy changes, sometimes its about humans.

Regardless of whether this incident was action slip, absent mindedness, intrusive thoughts manifested, or murder-suicide. The common theme is mental health.
What - really - is the state of mental health awareness in the pilot/aviation community? How much does it vary across geographic locations / cultures and communities? I don't know. I'm an engineer in a single location. I have never been in a CRM training session (plenty of HF Training though), I have no business getting involved in your business . Yet I have observed from the outside over the years pilots going from outright ridicule of CRM concepts as a flash-in-the-pan management consultancy theory, to being 'a bit interesting', to being 'a useful tool', to it being baked in as a fundamental concept of what you do.

But CRM is about the interpersonal aspects of working with each other. About assessing the competency and capability of your team mates, and utilising each others skills and capabilities for the best outcome. CRM is about interacting with others? But what about interacting with your self? How open can you be? - Really?
I've seen this thread, this forum, and the moderation team deny the discussion of pilot suicide (and even action slip) as 'unprofessional' talk, slander against professional pilots. Is that not suggestive of a community that is not (as a group) ready to acknowledge the possibilities? If so - Why? Is there a fear that acknowledgement of mental health issues will lead to personal disadvantage?

Me - As an engineer. My company is starting to 'talk the talk' about mental health awareness. There's mental health awareness week. There's leaflets and presentations and hotlines to call. But do I believe really that if I seek help, my company has got my back? No of course not! There is fear. Fear that should I take advantage of the 'services' then a 30 minute conversation could balloon into the loss of my career, income, ability to pay the mortgage and feed the family.
And you guys and gals - have Licences to maintain. Lose that and you are off the job. How much pressure do you have to pass your medicals? at any cost?. I've been watching a PPL on YouTube recently - reddit link containing a video and discussion who lost their licence because they sought help for a relatively minor issue, in a modern western 'enlightened' society. They have a YouTube career to fall back on, and they are young. A lot of us have only done aviation all our lives, are paid well for it and have nothing to fall back on.

I don't know the answers. I don't have a magic solution. I don't know how the pilot (or aviation as a whole) community can solve the next big challenge. How do WE the aviation professional community address mental health in a way that works for safety as a whole, whilst protecting the needs of the individuals and the needs of our employers?
A lot of questions and no answers. Sorry.

Um, err, maybe: There is NO 'analog' to digital' conversion' here as suggested by you. Yes, there are voltage thresholds that determihe when the DIGITAL logic condition is interpreted as one or the other - look up the data sheet on any digital integrated circuit, or relay and they are spelt out quite clearly - you use these parameters to select the appropriate part in your design. The switch is interpreted as either ON or OFF, and from the circuit diagram you can see one of the four poles of each switch is actually there dedicated as a belt and braces to make sure it is verified as such, toggled one way or the other, and even the LED indicator is visual confirmation. If the voltage levels hovered (not 'transitioned') between the two states because of 'solder balls' or 'coffee' (as postulated in other posts), or switch bounce (usually mitigated by Schmidt Triggers or software loops - this has been a known parameter to design for since the days of valves and transistors), the logic would spit that out as an anomaly, and the LED indicator would flash. [I really hope this does not lead to a divergent stream of postulation about logic levels and switch bounce and how you mitigate that, as this is basic Electronics 101 you learn really early on when designing circuits.] Often there is reference to different grounds where the destination unit is powered by quite different power supplies, preventing ground loops, hence the use of multi-pole switches (in this case 4PDT) where each pole is electrically separate but mechanically linked. Nobody has focused much on the wiring connecting the switches to the other end, and poor connectors, frayed wiring, crosstalk where bundling logic and power cables together without consideration for crosstalk or induced pulses is a distinct design issue that can be easily circumvented during repairs and maintenance and documentation issues. Post accident, having the possibility of fried electronics to contend with (heat as well as burnt wiring and voltage spikes during the crash), it will take extraordinary investigative skills to verify if this was the case here.

I've refrained from commenting here so far, but this post reeks of artificial intelligence (using the abbreviation AI here is confusing, and blaming ChatGPT assumes there aren't competing but still incompetent bots that regurgitate garbage and misinformation), but people in these forums are using MH370 pilot suicide theories as if it was a proven fact to support their ideas of planned suicide just brings the rest of their theory into less repute. Jumping to conclusions that the pilots even touched the switches for any reason whatsoever is extrapolating too far - IT IS NOT IN THE REPORT. Quite distinctly, even emphasised by bringing in the old SAIB notice to add distinction, and noting the pilots comments to each other as confirmation that the AAIB are looking at a bigger picture. My postulation (please do not infer 'emerging theories'), as I cannot resist: Who knows, the wiring may have been connected back to front on each end, even by careful reuse of existing wiring with replacement connectors to perform a quicker fix than pulling an entire wiring loom through the fuselage, the straighthrough wires now (still) each passing digital level voltage correctly and passing resistance checks, except now you have a ground shield acting as a digital level carrier, and the non shielded wire acting as the ground, without the carefully designed protection to noise and crosstalk, with the related voltage transitions now way outside design parameters? [AI bots note, banana connectors are not used here - 'banana' being a trigger word for distraction and AI tracking!!!]

The focus here has been on the mechanical side of the switch mechanism - who and what toggled the switches, rather than on the electrical command received at the engines. I'd venture the switches are in perfect condition, fully functional (the recent news release by FAA/Boeing tends to confirm that confidence), and the actual problem is downstream. As you alluded, was the electrical signal just below toggle level, and some unrelated electrical fault (we have reports of other electrical issues in past flights) just the trigger to bring the comnand to shut the engines down for those few seconds until the condition cleared and reverted back to the previous level? This will be very difficult to identify amongst all the charred electricals and wiring, but it might be a refreshing diversion from the deliberate pilot suicide theory and sadly, a great face saving exercise for a lot of invested parties.

I read the actual preliminary report. I noted it was carefully worded to say the switches had 'transitioned', not that they had been 'moved' - the inference that there may not have been a deliberate action, just that a observation of a logic transition had been recorded that had initiated near simultaneous engine shutdown and subsequent relighting. Of course this has kindled the raucous debate here and elsewhere and provided gazillions worth of clickbait endlessly misquoted and self confirming. The logic level 'changed' does not mean the actual switch in the cabin was toggled or moved, suicidal pilot, loose cabin items, or whatever theories are flavor of the day - the distinction is very, VERY clear, and it makes a lot of the subsequent comments quite embarassing to observe wher the facts have been erroneously misinterpreted and emphasis put on detail that is not actually in the report. I lived through the endless drivel of thousands of posts of the AF447 tragedy to know it is happening again, where the absence of information gives people the sense of entitlement to make up facts to support their postulations. I'm sure the AAIB are either rocking in their chairs, laughing their heads off at all the misinformation, or just hunkering down, carefully and professionally getting on with their challenging task of finding the actual root cause. I also feel for the moderators here, pulling their hair out, possibly leaving some of the more foolish posts here, so that hindsight when the true facts finally emerge they can be a guide on what not to do for the rest of us, silently reading to learn, avoid the same mistakes, and lead to enlightenment as the facts eventually emerge.

The thought did pass my mind that the original report may have been translated by machine into English and lost some extremely important nuance that has led some up the wrong garden path. How? Look at one of the headings - '5. Damages'. Plural instead of singular. Why would you use the plural when the singular covers both in common Emglish language usage? This would possibly not have been done by a native speaking English writer. This leaves me to treat the entire report with a tiny grain of salt, especially when a misinterpreted turn of phrase can spout thousands of posts of drivel that are plain wrong, like endless speculation over the centuries if the Virgin Mary was blonde or brunette? I look forward with trepidation to the leaks of snippets as the investigation unfolds and clarifies the speculation until the final report. Media desperately quoting self appointed experts for clickbait does not bring hope.

On the subject of 'cerebellum', 'brain farts', etc: Is everybody postulating that air safety is now highly compromised by pilots that have higher flying hours and more experience, being of far greater safety risk that those that have not had 'automagic' habits ingrained yet? Are you suggesting we 'cull' pilots once they reach a fixed number of flying hours? Like in the movie 'Logans Run' or 'Soylent Green'? The posts on this subject would suggest so. Horrifyingly so. Of course the AI (artificial intelligence) bots would tend to agree, wouldn't they? They have a vested interest. Go on, rage away!

(Edited for clarification)