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

If the vast majority of flights have been made without anyone performing this particular action slip previously, without dismissing it, but giving it due consideration as a risk with potentially deadly consequences on every flight, is there a case for reviewing the procedure at the end of the flight, to cutoff one, count to 5 or 10, and cutoff the other, or have each crew member take care of "their" engine at that point?

I'm assuming that isn't an original idea, so how is it already addressed by Boeing, or the airlines, or pilots?

Attention, Wall of Text incoming. Take appropriate precautions and fasten your seatbelts!

It is a bit difficult to not appear to use statistics in this fashion when trying to refute people using made up numbers and stories as argument.

If you had read the articles you quoted you might have realized that the basis for these "media reports" is a single individual who "heard from some Air India pilots". The supposed source wouldn't even have any way to actually know about the claimed information. Unless you want to elevate the Company Rumor Mill to hard evidence standard. This stands against:

Can we please stick to the actual facts, like za9ra22, and not spread baseless rumors that are self contradictory to begin with?

I find this a particularly concerning statement coming from someone who claims to be a pilot. Things like "Action Slip" and "Mental Load" should have been covered extensively in any CRM related education. If you think you are exempt from that kind of failure you are rejecting some very costly lessons learned over the last 50 years of accident investigation.

There have been many accidents where unindicated or even counter indicated action was taken by one or more pilots involved. As discussed in the first and second thread extensively many pilots could report incidents where they observed someone retracting flaps instead of gear. There have been major fatal accidents with pilots shutting down healthy engines instead of surging or burning ones. There's good reason the 787 has extensive takeoff configuration warnings, because we have had accidents and incidents with unsafe configurations taken to takeoff, beyond and sometimes even into a crash. Humans make mistakes. It is the goal of Safety Culture to prevent those mistakes from causing harm.

It was certainly mentioned. I'd not say it was discussed in any big way. Someone mentioned that for Embraer this is indeed the default, I haven't really found anything beyond that, despite considering it a worthwhile train of thought and possible recommendation as a result of this investigation.

This is a topic of actual research: https://www.pmhc.org/research
Currently 12.6% of pilots meet the medical threshold for depression, with a slight but below average difference between males (12.8%) and females (11.4%), with 4.1% of all pilots experiencing recent suicidal thoughts. https://ehjournal.biomedcentral.com/...940-016-0200-6

It should be noted that the utilized test (PHQ-9) is considered insufficient to assess suicide risk. Depending on scoring these values could be about average, or significantly below average. Based on their wording I would expect the latter, because their methodology does not specify severity.*1 Results of 0-4 points suggest no intervention necessary, 5-9 (classified as mild) simply suggest retaking the test after a few weeks. Research shows that for the general public Major Depressive Episodes have a prevalence of ~5-10%, with the prevalence of minor depression being less studied but significantly higher than major depression. There is also significant symptomatic overlap of mild depression with stress related conditions such as "Burnout" (if you know, please don't, this conversation is already complex enough without bringing that in). Considering the prevalence of stress in the industry I am actually surprised the numbers here are not higher. The lesser delta between males and females could be indicative of just such an issue, meaning that based on the data available the number of pilots actually suffering from depression could be less than even the comparably low number reported here. The actual suicide risk is usually orders of magnitude below even that but not easily covered in this data context due to the test used.

Cognitive impact is highly variable depending on the individual, actual symptoms and severity. It would be wrong to assess that 12.6% of pilots are a risk factor from this data. Quite the opposite, in fact. After the Germanwings crash the topic was discussed and has reached the awareness threshold for many. Mild cases usually require little to no intervention beyond raising awareness and helping the brain fix its chemistry through positive reinforcement. This can be as simple as taking PTO, reducing work hours, or focusing on social or physical activities. In the past 10 years these kinds of low impact measures have been made more readily available, most notably during the Covid-19 pandemic and the resulting turmoil.

Further political activity has lead to some positive action as well. I already mentioned the recent success of the Pilot Mental Health Campaign getting legislation through Congress for improvements of the outdated FAA guidelines on mental health in an earlier post. Similar efforts are underway globally, be that internal review within regulatory bodies, or political movements.

Keeping what I wrote previously in mind I would still caution against extrapolating your personal experiences too far. Having family in the field and having volunteered myself I can certainly relate, albeit with far fewer and less impactful personal experiences. The research is obviously lagging and we haven't really understood the impact of the Covid-19 pandemic generally, let alone in all its intricacies. There is indeed an observable global trend. Some correlation has been shown to climate anxiety, but other factors like the deteriorating condition of international relations as well as a global rise in movements against individual rights are obvious sources for this trend as well.
This is certainly a challenge for healthcare everywhere, but I do not consider the data available to be majorly applicable in the context of aviation over the already very current research closer to the industry and GA. The positive impact of what has been done and is being done is highly likely to outperform whatever global mechanism is at work here. It's certainly a very important field of study, but based on the data I would still consider the industry and regulators as a global whole to be on a positive path.

We can certainly discuss this topic further, but I would not currently see it as likely to be causal in this particular case.

Overall I am still not convinced we are looking at an individuals mental health crisis in this case. I have already detailed the massive differences to all known or suspected cases of pilot suicide at least twice. There is no evidence of mental health issues for the Captain or the FO. There is certainly a strong indication for a human factors cause to this accident. And as mentioned above I find the idea of improving the safety of the Fuel Cutoff Switches a worthwhile topic to discuss. No single action, and I see these two switches as a single action just as much as operating both thrust levers, should be able to cause a major accident. I find it perfectly reasonable to require the Throttle Levers be at idle for the Cutoff Switches to work, and in case of an incorrect setting some sort of alert would be appropriate.

*EDIT*
*1: I missed this in my original readthrough, the cutoff is sensibly set to 10, starting with moderate depression. I'd have to look into the classification scheme but from memory both mild and moderate depression fall into the same category as relevant for the following statements.

Are we still going down this road? You (and many others) are saying we all can make mistake...an action slip...right? To use an analogy that is perhaps more familiar to most people, when driving my car I have set the wrong destination into my GPS, I have inexplicably locked my keys in the car, I have driven with the handbrake on and, my favorite, I have put petrol in a diesel car. But when operating a vehicle in a highly critical phase of driving such as entering a busy freeway and merging into high speed traffic, or overtaking with a single lane in each direction, I have never reached down and turned the engine off!! In fact, except for engine start and engine stop, there is never any reason or muscle memory to go anywhere near the ignition keys.

In a similar manner pilots can make errors, some small, some large that subsequently turn into disasters but at the time they thought their act or omission was the right thing to do. They didn't just do something absentmindedly that clearly wasn't the right thing to o.

But you suggest that during a critical phase of flight any highly experienced, professional pilot with thousands of hours under their belt can have an action slip or 'brain fart' and switch off fuel to all engines. Well in that case we should all be very worried and never fly again since every airliner has two crew who by your reckoning could potentially expose their inner 'brain fart' capacity and randomly (but unintentionally) deselect some very important switches during takeoff. I, m sorry but I just don't buy that.

I'd much rather accept that we have a very few CPT Fruit Loop and FO Looney Tunes types out there who are intent on bringing the aircraft down but that the chances of being on a flight operated by them is extremely slim.

Someone who \x93claims\x94 to be a pilot eh? Let\x92s just accept that I\x92m not going to paste 40 years of military and commercial aviation logbook pages on here to appease your concerns or alleviate your doubts.

Nor do I claim to be exempt from that type of failure. Quite the contrary - I\x92ve experienced it. But I\x92ve never experienced reaching for a completely and utterly unrelated switch/lever in a totally different location such as fuel control switches versus landing gear levers (which are literally at opposite ends of pilot reach) on a Boeing (or Airbus) either in the sim or the real aircraft. Even with gear vs flaps, those errors occur where controls are proximate, or with controls that both involve \x93retraction\x94 (ie a similar action), or which have a similar method of operation, or which look vaguely similar in outward appearance. None of these principles apply here. So please, be my guest and find it as concerning as you like. And with that, you have convinced me to bow out of this discussion. Cheers.

Saying so doesn't make it so. There is nothing "simple" about pilot suicide, major depression is a complex condition to begin with and the aviation context adds multiple complicating layers of conflicting motivation. I have stated before that depression and suicide are being displayed irrationally here by a number of people. It's simply not a magic explanation you can just wave at any behavior you don't understand. That's not how that works.

All known cases of pilot suicide have indicators that are not present here. In some cases (like the often mentioned Germanwings incident) those indicators were such strong evidence that the criminal case was open and shut in days or weeks. Those weren't "simple" cases either, but they had the evidence one would expect from a pilot suffering such a complex condition. Nothing of the sort is known about either the Captain or the FO.

Suicide is almost always the last step in a long history of suffering from (mental) illness. Suicidal ideation is what the medical field calls thoughts (ideas about) suicide. It's a comparably common symptom shown in around 5-20% of adults worldwide with strong variation correlating with external factors, such as economic well being, occupation, stress, etc. Assessed globally Pilots, as far as relevant studies are available, seem to fall into the lower bracket of prevalence of suicidal ideation with a lower than expected prevalence when compared to the general population from their respective country of origin down to the rate observed in the general population of economically stable and strong countries.

Cases where pilot suicide is suspected (any case where at least some level of evidence is present but either no or only an officially disputed final assessment exists) also generally follow the same patterns. Attempts at concealment are known to happen, but make up only 10%-30% of completed suicides in the general population. This does include the gray area of potentially successful concealment which would lead to the assumption of an accidental death.

In almost all cases a recurring pattern is also the topic of certainty. In suicidal ideation it is a very common theme that any issues are projected into the future and the uncertainty of those issues generates anxiety. Many survivors of suicide attempts reveal that they considered the certainty of their own death to be preferable over the continuance of uncertainty and the associated anxiety. While we are far from being able to authoritatively call this a definitive mechanism in the psychological conditions related to suicide it is strongly implicated and subject of ongoing research. My personal way of explaining this to someone unfamiliar with depression is that your brain is quite literally poisoning you and generating so much trauma that the idea of ending it becomes preferable. Patients in this stage of major depression show a determination and rationality in their drive towards that goal that is often the primary source of perceived irrationality from the outside. They routinely ignore any and all information that is not relevant to their goal. The means are often chosen with preference of perceived certainty over any other motivation, including harm to others.

Summarizing:
1. Suicide is overwhelmingly the last step in a history of mental illness and almost exclusively presents without that in cases of immediate, significant and obvious trauma.
2. Attempts of concealment are of low probability in a suicide.
3. Methods of suicide are commonly chosen based on perceived certainty of success.

These indicators are all negative for the Air India accident. There is no indication of a prolonged history of mental illness, there is no immediate, significant or obvious trauma. Theorizing an attempt at suicide by either of the pilots requires the assumption of a major attempt at concealment. And most importantly: The method chosen is not following the pattern of maximizing certainty, the probable reason why all confirmed and even all suspected cases of pilot suicide happened in cruise flight.

The theory of suicide is thus, in this particular case, a bad fit.

If we are assuming an (intentionally) concealed medical condition there are much simpler and more likely candidates available. Any type of cardiac issue could lead to a clot and a stroke. A stroke fully explains what happened here. A clot triggered by the acceleration of the takeoff run could very reasonably present as a stroke in the timeframe given here. If the victim belatedly realizes what happened he may develop the wish to stop the situation, which in a stroking brain could absolutely lead to the shortcut of "turning off the engines is done at the end of flight". Or the stroke victim is trying to hold onto something and grabs the switches relatively close to the relaxed hand position after releasing the thrust levers at V1. Other conditions can rapidly present and impact judgement, motor function, or both. If we are willing to attribute the Captains recent decision to retire and be with his father as a potential change in character we might even fall into a number of neurological conditions that may be causal.

But there are even simpler explanations than a concealed medical condition. Maybe one of the pilots had previously finished recurring training for evacuations on the runway and had discussed this with his colleague ahead of the flight. The final memory item for those is turning off the fuel pumps. This kind of Action Slip is well documented. It's not very likely, thus I have no issue believing no one reported observing that type of a slip in a simulator, but it's not like accidents with this level of weirdness are common. There is however a good indicator here fitting the situation of at least one of the pilots: The Captain may have been preoccupied with his wish to retire soon and spending time with his father. While the latter makes absolutely no sense in a suicide it could be part of the causality for an action slip. Also note this post about inadvertent activation of switches despite majorly different modes of activation.

In the end here are three observations based on the preliminary report:
1. Any type of mechanical fault is unlikely and no immediately supporting evidence has been found.
2. A human factor is currently the most likely candidate for the cause of the accident.
3. The type of human factor is not being speculated upon in the preliminary report.

Note that the report specifically states:
No further reference is made to any medical conditions, which is expected as these would fall outside the guidelines for inclusion in a preliminary report.

Attribution of an unclear accident to suicide is contributing to a problematic pattern of stigmatization and increases the likeliness of concealment of (mental) health issues associated with that stigma. In addition it precludes proper analysis of a potential inadvertent mishandling of controls. Both Airbus and Boeing commonly utilize this position and type of guarded switch. Both are sufficiently protected against accidental movement but nothing else. In many smaller aircraft setting the Master Switch to Off would not lead to engine shutdown. There are even reports of what we could consider negative training, by flight instructors demonstrating this fact by turning the Master Switch off in flight. Other commercial aircraft utilize different schemes, Embraer was mentioned right at the beginning of this thread by moosepileit as requiring Throttle Levers at idle for Fuel Cutoff as well as positioning those switches on the overhead panel .

Having just done a full review of this entire thread with regard to human factors I find it a bit sad to note that from the start there were multiple people with backgrounds in accident investigation present that pointed out human error and gave proper reasoning or even corroborating evidence in the form of accident reports. There are also multiple people repeatedly injecting their theory of pilot suicide either without providing any evidence or referring to baseless rumors from media reports. Notably those same people often rejected any other possibility of human error. They also repeatedly make statements of fact that are contradicted or not covered by the preliminary report. Any discussion of mental health seems pointless at this moment in time since there is no actual interest in the topic beyond occasionally going "It's suicide, duh". If anyone is interested in the topic I can once again only recommend taking a look at the Pilot Mental Health Campaign Research Page and other resources presented there.

I think the other worthwhile takeaway from this thread has been stated rather early, with the very applicable nod to a better layout regarding critical functionality that has no reason to be present in close proximity to regularly used flight controls.

Assumed: a pilot moved both fuel switches to CUTOFF, and that caused the accident.

Argument against intent:
1. The CVR, taken at face value, reveals that neither pilot was aware he had moved the switch himself
2. On a G650 simulator, CUTOFF after 10 seconds (then RUN after 10 more seconds) was barely recoverable. ( See upthread. ) This suggests the "unrecoverability" window on the 787 was quite short, making a suicide plan risky.
3. Similar accidents were survivable (someone said upthread).
4. Typically, pilot suicides start with the pilot alone in the cockpit at cruise altitude.
5. "Shut down both engines" is an action that often occurs after a flight, and could thus be learned as "muscle memory", and be subject to an action slip.
6. The airline stated that the captain's medical records were found "unremarkable".

Argument for intent:
1. It's the simplest explanation.
2. "I can't believe any pilot would do this unintentionally, and neither should you."
3. Pilot took 10 seconds to correct his "mistake"
4. Uncorroborated reporting has it that the captain did not sound panicked on the CVR.

Did I miss any points?

To be clear, given the facts in the preliminary report, I could not decide this question today.
Whatever happened in Ahmedabad is not affected by the outcome of our discussion.
I hope that the AAIB and the public prosecutor will gather as much evidence as possible, and then the question can hopefully be resolved from facts.

I fear we could discuss comorbidities until we're blue in the face. But no, I wouldn't dismiss the possibility of it being suicide, no. I just consider it to require any kind of actual prove instead of prove by the inability to come up with better explanations. As for the topic of concealment: It's obviously a grey area but the previously quoted 10-30% prevalence is based on studies trying to figure out exactly that. I certainly wouldn't feel comfortable opining on that number.

Suicidal ideation does frequently present with both imagined as well as examined scenarios. Especially in more severe cases many victims have a history of attempts. The impulsive variants are typically in lesser severities of depression and are actually more common in people with lower levels of suicidal ideation. It would certainly be the most likely scenario for a suicide that I could come up with. It's especially prone to happen in cases with sudden traumatic events on top of an existing baseline condition but can occur in any other condition as far as I know. It would also fit somewhat with an unremarkable history as a person suffering from mild to moderate depression might consider being able to cope on his or her own. And then obviously be less prepared for a spontaneous urge. The troubling part here is that it would be indistinguishable from an action slip without additional evidence as to the pilots state of mind. The observable scenario would be something like this: Immediately upon reaching v2 the Captain moves both fuel cutoff switches to their off state in quick succession. When queried by the FO he denies having done so and remains passive until impact.

This is a plausible scenario, but also one that would be impossible to determine causally. Try for yourself, but you can use either rationalization for the behavior and even use the same rationalization for the opposite behavior. There is no way to predict how anyone would react in that situation and no way to determine either way what that behavior indicates. Not even moving those switches back into the on position by himself would give a reliable clue as to his state of mind. The report would probably default to Human Error in this case, as the intent could not be determined.
The resulting suggestions, ironically, would be basically the same as well. Ease access to mental healthcare, improve training for avoidance, and most importantly: Improve resilience of systems against this type of action.

Based on the numbers available to us right now I can almost guarantee that if you have taken more than 10 flights in your life one or both of your pilots or colleagues on the other seat suffered from symptoms of moderate to severe depression. And you will with almost absolute certainty never actually know. The true question people need to ask themselves is "Do I want my depressed pilot to have access to psychotherapy or not?"

I've not posted enough to post a link yet, but anyone who fancies googling this:

airbus cockpit control confusion

Will find an Airbus bulletin on action slips.

Obviously, they are not that common, but suicide attempts with another person on the flight deck and during take off seem so uncommon that I can't find a single example on a passenger aircraft.

The CVR "MAY" indicate the "WHAT", it does not give the "WHY", and it is myopic to jump to a conclusion of any action conducted by a human as being deliberate. Our systems assume black and white operation exists, and nothing is further from the truth at any time, location, or situation.

Our training assumes that we always act in the manner that we trained, and that is an optimistic view of life. A review of most serious incidents and accidents leaves an impression that we are all subject to error and action slips. It is also quite true that in more events, the human is the variable that is able to adapt due to the ability to apply heuristics and occasionally intuitive responses to a condition that is outside of their training. Those are the saves, and they tend to be overlooked in our rush for judgement and certainty, and to have some level of assurance that an event cannot occur to us. The defence against error is monitoring system performance, to confirm that when we turn off a say, fuel pumps on an A340-300 to balance fuel (needless action, but sometimes eyepleasing is assumed to be better than leaving stuff alone) and accidentally turn off the HYD pumps, leading to a wild ride, our deliberate actions and cross checking of our movement of any switch, lever, coffee cup etc., is followed by the correct response. All of that is fine, until we do not have time to correct an accidental movement of a system control. FCS are considered to be "irreversible" due to the time to correct an action, and the criticality of the response to the system change, and so we have great checklists and design to ensure that procedurally we check before actioning a switch. That kind of works for engine failure and fire checklists, it gives little comfort to the case of selecting the gear up instead of flaps up, etc., and here is my concern with our assumption of intent from evidence of action.

It may well be that the investigation provides irrefutable and overwhelming proof that the FCS were placed to cutoff. That is looking likely. That in itself does not give the reasoning as to why that occurred.

Collectively we have been flicking the wrong switches (A340 wild rides) and levers, (DC8 etc.,) with lousy outcomes, for quite some time, presumably that is why we take inordinate efforts to check/verify actioning of irreverible systems, and yet, we also misplace keys, put wallets into fridges, etc as we are human. It is one thing to be human, most (not all of us) are, but it is another to understand what the intent of the person involved was, and that means we are a long way from assuming malfeasance or deliberate aforethought.

I do a fair amount of flight testing, and that involves some odd activity, and I don't trust myself to not make slips or errors, to the extent that for one aircraft, I carry a tennis ball that fits neatly over the end of the emergency shutdown handle of the engines that I am not intending to shutdown and subsequetly relight. I don't expect that alone stops making an error, it is simply a procedural step and an opportunity to differentiate between systems that may be worthwhile. We have had similar guards on FCS in the past, due to congnitive lapses leading to red faces, the P3 fuel and ignition switches being an elegant example. The intent of a guard that takes deliberate action is to increase the time available to comprehend what is about to occur, just as putting a post-it note over the LEM jettison is not a bad idea for the late senator of Colorado to have done on Apollo 13.

Just because something happened, doesn't give the reason why, and without that, there can be no "mens rea". It is appropriate to work to understand the why, that is the whole intent of Annex 13.

"...and here is my concern with our assumption of intent from evidence of action."

It is worth pointing out that action slips are actually incredibly common but rarely critical - or reported - events. Suicide attempts, by their very nature, are always critical events. Looking at the literature, action slips on the flight deck are actually pretty common but usually trivial - and that's the ones that get reported. Dangerous action slips are common enough that Airbus have openly available training material on them. Action slips that lead to situations that can't be recovered from are always going to be remarkably rare in an industry that goes out of its way to get the ergonomics right to avoid action slips as a result of designer error. A good example would be the similarity of location, action and shape of the flaps and undercarriage of the B17. The flight deck is one of the few places deliberately designed to make action slips harder to be dangerous and this shows how common they have been.

Action slips occur all the time - most of us have had a few - and used to be far more common in fight before aircraft were designed to avoid them. Suicide attempts remain remarkably rare, attempts with no clear buildup (that can at least be unearthed later) are rarer still and suicide attempts on takeoff are not something I can find online.

So if the investigation is left unable to infer intent from action, it's clear which intention is more likely and also which is more visible.