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sorvad
July 16, 2025, 07:35:00 GMT permalink Post: 11923490 |
does the ORDER in which the switches were operated give us any clues which seat operated them? I would suspect that most pilots always go left switch then right switch, or the right then left each and every time when switching off. We are creatures of habit.
I haven't seen it mentioned it yet that if the stabiliser cut out switches had been left in the wrong position from the previous maintenance, when would EICAS or some other system alert the pilots to this? Would the alert be in close proximity to when the fuel switches were moved? As others have said I think what this episode has revealed is it's too easy to turn off the engines in flight, and that the fuel cut-off switches should only operate when the relevant throttle is at idle? or should have a 10 second pause when no WOW signal and a definite yes to cockpit video, protected so only accident investigators can access it. I can guarantee the third MCAS event wouldn't have happened if the 2 Lion Air MCAS events had been caught on video. It still shocks me after the first Lion Air near miss where the jump seater saved the day that the plane was released to service "nothing found". And as/when found cockpit video would solve the mystery of MH370. |
HUD Engineer
July 16, 2025, 07:40:00 GMT permalink Post: 11923491 |
Cutoff Action Slip - Room for improvement?
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. We have all role-played in our heads what would have been said in the cockpit in different scenarios. 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
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. ... 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. I'm assuming that isn't an original idea, so how is it already addressed by Boeing, or the airlines, or pilots? |
DutchRoll
July 16, 2025, 07:48:00 GMT permalink Post: 11923494 |
There are still possible factors that would have resulted in the information that has been provided to date that do not involve elephants. It is unreasonable to withhold judgement when there are enough curiosities in the event to keep the investigators busy? The issue of switch locking problems necessitates an in depth understanding of what that may have resulted in. That 2 switches would have the same fault type at the same time is.... unlikely, but stuff happens. Losing a Concorde due to a titanium fillet on a reverser cowl coming adrift on a preceding aircraft is also, stuff happens. Power levers walking back on some types is also a stuff happens event, one that should not occur, it comes up about every second year, and has done for decades. A single point failure remains the likely cause of this disaster, and there are only really 2 that make any sense; a failure of the electrical circuits for the fuel switches, which there is only one remote possible cause, and a cognitive/overt act by the crew.....
I have to totally disagree with that. Publicly released CVR transcripts are edited to remove things like swearing, shouts, screams, etc. Basically stuff which investigators consider not directly relevant to the chain of events in the cockpit and determining actions taken or not taken. Nor do I necessarily trust that brief transcript released is all that was said. If one pilot had said "why did you move the switches to cutoff you *******!!!!!" and if he had shouted it, none of that tone or colourful language would be in the public transcript. You would get exactly what was released in this case. |
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. |
sabenaboy
July 16, 2025, 09:15:00 GMT permalink Post: 11923558 |
Not being a jet pilot. If you have the throttles at full power and the engines are set to cutoff, and they spool down, when you reset to run, will they start and go to full power, or do you have to set the throttles to idle first, then when started go back to full power..? and why don't you have to retard the throttle(s) to idle first, before you can shut the engine down..?
|
AirScotia
July 16, 2025, 09:38:00 GMT permalink Post: 11923580 |
Not being a jet pilot. If you have the throttles at full power and the engines are set to cutoff, and they spool down, when you reset to run, will they start and go to full power, or do you have to set the throttles to idle first, then when started go back to full power..? and why don't you have to retard the throttle(s) to idle first, before you can shut the engine down..?
The. question about enforcing idle throttles before CUTOFF has been discussed voluminously on this thread. |
1stspotter
July 16, 2025, 09:47:00 GMT permalink Post: 11923586 |
It is both fascinating and unsettling to observe how the media in India consistently refuse to acknowledge that suicide may be the most likely scenario. Key voices—such as former pilots and the airline pilots' union—continue to dismiss the possibility that a pilot could have deliberately moved the fuel control switches to the cutoff position. They rely on factually incorrect arguments and emotional reasoning. For instance, some suggest a potential defect in the Boeing 787’s fuel cutoff switches. However, the FAA's Special Airworthiness Information Bulletin (SAIB) they reference was specifically issued for the Boeing 737, not the 787.
An overview of public statements made by pilots in the media can be found here. https://feitoffake.wordpress.com/202...room-in-india/ |
aox
July 16, 2025, 10:13:00 GMT permalink Post: 11923606 |
It is both fascinating and unsettling to observe how the media in India consistently refuse to acknowledge that suicide may be the most likely scenario. Key voices\x97such as former pilots and the airline pilots' union\x97continue to dismiss the possibility that a pilot could have deliberately moved the fuel control switches to the cutoff position. They rely on factually incorrect arguments and emotional reasoning. For instance, some suggest a potential defect in the Boeing 787\x92s fuel cutoff switches.
|
JustusW
July 16, 2025, 10:23:00 GMT permalink Post: 11923614 |
Attention, Wall of Text incoming. Take appropriate precautions and fasten your seatbelts!
I will say that in reading your earlier post, I came away thinking you were arguing for the unlikelihood of suicide in this case, at least in part because it is unlikely in the world of commercial aviation as a historical fact. If that's not the case, I apologize. But I will add I think other commentary here has fallen into this trap, as discussed in my referenced post.
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.
But TL;DR - I'd posit that the rate of truly experienced mental health issues experienced in pilots is higher than whatever rate almost anyone is thinking.
Around 12% of people globally have a mental health issue at any given time - even being incredibly conservative, the rate in pilots is clearly going to be at least in single whole figure percentages (which is far from rare). Obviously the majority of these issues are not going to be those with severe outcomes, but some will. And almost all mental health issues tend to affect cognitive ability to at least some level. Slowness in action and fatigue are diagnostic criteria for many of the most common mental health conditions for example. 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.
As a critical care physician (with AVMED background), these last few years we seeing unprecedented rates of self-reported stress, anxiety, depression, and deliberate self-harm. This is being experienced in most western countries (perhaps globally, but I have less direct knowledge of non-western countries). It is absolutely off the scale. In my 35 year career, I have never seen anything like the last 4 years.
Sadly, I am confident this phenomenon will result in more incidents like Germanwings, MH370 and this. 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. Last edited by JustusW; 16th July 2025 at 10:37 . |
sabenaboy
July 16, 2025, 10:30:00 GMT permalink Post: 11923618 |
It is both fascinating and unsettling to observe how the media in India consistently refuse to acknowledge that suicide may be the most likely scenario. Key voices\x97such as former pilots and the airline pilots' union\x97continue to dismiss the possibility that a pilot could have deliberately moved the fuel control switches to the cutoff position. They rely on factually incorrect arguments and emotional reasoning. For instance, some suggest a potential defect in the Boeing 787\x92s fuel cutoff switches. However, the FAA's Special Airworthiness Information Bulletin (SAIB) they reference was specifically issued for the Boeing 737, not the 787.
An overview of public statements made by pilots in the media can be found here. https://feitoffake.wordpress.com/202...room-in-india/ |
1stspotter
July 16, 2025, 10:33:00 GMT permalink Post: 11923620 |
Fact is both fuel cutoff switches moved to the cutoff position three seconds after the wheels left the runway. While the speed was 180 knots. Nothing indicates a problem with the thrust of the engines. So explain why one of the pilots , a ghost, an iPad set *both* switches to cutoff just after liftoff while the aircraft had a normal speed and no indications of a problem. Mind there is no issue with those switches. The FAA SAIB was for the Boeing 737 https://feitoffake.wordpress.com/202...787-explained/ There is just one explanation: one of the pilots deliberately set both switches to cutoff. |
JustusW
July 16, 2025, 10:43:00 GMT permalink Post: 11923626 |
"There is a reasonable explanation: One of the pilots set both switches to cutoff." There is no known evidence for the claim of intent. There are documented instances of pilots making fatal mistakes out of the blue. Human Error is by far the more likely explanation. |
Dani
July 16, 2025, 11:09:00 GMT permalink Post: 11923641 |
I would love to explain, but my posts get deleted.
While I fully understand that a normal working fuel cut off switch on a Boeing can not move to cut off by itself, I'm completly certain that it can when the locking mechanism is not properly installed. In such a case, the moving part of the lever could even stand on a "needle point position", meaning it's neither in the on or off position. Smallest movement of the aircraft or a hand can move the lever to on or off. I also observed many pilots in my career holding their hand at the backstop of the thrust levers on the pedestal as PM. Comes from a certain mistrust to the other pilot (mostly captains do that). If this hand falls down by a gust or a bump on the runway, his hand falls down on the pedestal. Exact location of the cut-off switches. If the locking mechanism isn't installed, you don't even feel that you moved it. Dani |
1stspotter
July 16, 2025, 11:10:00 GMT permalink Post: 11923642 |
I wonder if the people who are so adamant that mistaken operation of the wrong control is simply impossible have ever had a windscreen wipe in a car while intending to use an indicator light. And if they have, have some of these occasions happened at higher than average stress moments, such as someone else behaving oddly at a junction.
(Of vehicles with two sets of stalk mounted switches adjacent to the steering wheel, some have lights on the left, and some have lights on the right. This may be, but isn't always, related to whether the home market of the car design drives on the left or the right. British drivers and owners of some Japanese cars may have more experience of both than Europeans only ever driving cars from their home country.) When the fuel needs to be cut because of an engine failure there is a strict procedure before the switch is set to CUTOFF. Both pilots need to confirm the location (left or right) of the engine. No pilot will without consent switch off the fuel. However this is what happened. |
Sev68
July 16, 2025, 11:18:00 GMT permalink Post: 11923647 |
The video doesn't answer two questions:
- The report reveals information about some conversation between the pilots confirming they both became at some point aware of the cut off. Was the recovery of the position of the switches as fast as possible in the captain's opinion. - Does the captain interpret the Why question as a guess of the pilot who asked it, instead of asking as a witness of the transition? |
1stspotter
July 16, 2025, 11:19:00 GMT permalink Post: 11923649 |
I would love to explain, but my posts get deleted.
While I fully understand that a normal working fuel cut off switch on a Boeing can not move to cut off by itself, I'm completly certain that it can when the locking mechanism is not properly installed. In such a case, the moving part of the lever could even stand on a "needle point position", meaning it's neither in the on or off position. Smallest movement of the aircraft or a hand can move the lever to on or off. I also observed many pilots in my career holding their hand at the backstop of the thrust levers on the pedestal as PM. Comes from a certain mistrust to the other pilot (mostly captains do that). If this hand falls down by a gust or a bump on the runway, his hand falls down on the pedestal. Exact location of the cut-off switches. If the locking mechanism isn't installed, you don't even feel that you moved it. Dani See https://feitoffake.wordpress.com/202...787-explained/ So your scenario is impossible. |
fgrieu
July 16, 2025, 11:47:00 GMT permalink Post: 11923668 |
Replacement of throttle control module, wiring of fuel control switches
The
preliminary report
states:
The scrutiny of maintenance records revealed that the throttle control module was replaced on VT-ANB in 2019 and 2023. However, the reason for the replacement was not linked to the fuel control switch.
Are there records that on this or similar type, after a replacement of the throttle control module, the fuel control switches became defective, and how ? What type of switches are they: SPST, SPDT with 3 wires used ? For SPST or equivalent, is "cutoff" the "make" or "break" state ? Is there a common connection for the two switches, like a ground return or common live? |
DutchRoll
July 16, 2025, 11:50:00 GMT permalink Post: 11923671 |
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. 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. |
bongo bongo
July 16, 2025, 12:03:00 GMT permalink Post: 11923681 |
I would love to explain, but my posts get deleted.
While I fully understand that a normal working fuel cut off switch on a Boeing can not move to cut off by itself, I'm completly certain that it can when the locking mechanism is not properly installed. In such a case, the moving part of the lever could even stand on a "needle point position", meaning it's neither in the on or off position. Smallest movement of the aircraft or a hand can move the lever to on or off. I also observed many pilots in my career holding their hand at the backstop of the thrust levers on the pedestal as PM. Comes from a certain mistrust to the other pilot (mostly captains do that). If this hand falls down by a gust or a bump on the runway, his hand falls down on the pedestal. Exact location of the cut-off switches. If the locking mechanism isn't installed, you don't even feel that you moved it. Dani |
Lonewolf_50
July 16, 2025, 12:47:00 GMT permalink Post: 11923713 |
I'll offer a guess as to why...later.
I'm completly certain that it can when the locking mechanism is not properly installed.
In such a case, the moving part of the lever could even stand on a "needle point position", meaning it's neither in the on or off position. Smallest movement of the aircraft or a hand can move the lever to on or off.
I also observed many pilots in my career holding their hand at the backstop of the thrust levers on the pedestal as PM. Comes from a certain mistrust to the other pilot (mostly captains do that). If this hand falls down by a gust or a bump on the runway, his hand falls down on the pedestal. Exact location of the cut-off switches. If the locking mechanism isn't installed, you don't even feel that you moved it. Has anyone demonstrated to you something like "watch this, Dani: if I pull the switch up and get it to hang on the little lock/cam, the engine will still start" ... in the sim or in the aircraft. I'd be interested to read of your experiences with that switch and that non-standard positioning of it that you describe. Beyond that, did you bother to look at the position of the fuel control switches that were in the preliminary report? They were found in the RUN position. See page ten of the preliminary report. Neither of them was cocked off, as in the picture of a misaligned switch from a 737 that you referred to.
You mean just because it never has happened, it's impossible? What a strange argument.
If you look closely at the picture in post no 262 Preliminary Air India crash report published I see a perfect example of a wrongly installed locking mechanism.
How on earth do you think this argument is unthinkable, when there are even safety bulletins and mandatory maintenance orders about this very problem?
I'm on neighter side. That's why facts are more important for me than for many others.
You have established no basis for why you believe that the switches on this 787 were incorrectly installed, given that
As to post deletions: as with some of mine being deleted, we both seem to get involved in the running rodent machine despite any intentions to avoid it. For DaveReidUK Your post is, at best, disingenuous. (But thank you for posting an excerpt from the bulletin ![]() The error was found on a 737, and the competent authority issued that alert having recognized that similar switches might have similar problems - they used the word potentia l - not because switches on all of those other models had been found to have that problem. From your subsequent post:
..to be replaced if found defective,
Given that this is the year 2025, (and the maintenance actions mentioned in the preliminary report) 1spotter's point on the "red herring" is a bit stronger than you allow. Please go back and read page 6 of the prelim report, top half. Something else to think upon: how many 737s does Air India operate?
As of June 2025, Air India operates a fleet of 190 aircraft, both narrowbody and widebody aircraft with a fleet composed of
Airbus A319
,
A320
,
A320neo
,
A321
,
A321neo
,
A350
as well as the
Boeing 777
and
Boeing 787
.
For the moment I don't think that it does, however, it might. The investigators have a variety of other rocks to turn over and see what crawls out from under them. They may find evidence of various maintenance issues that have an impact on this accident. As of today, though, such information has not been released (but I will offer you a guess that all of that is in the process of being collected and analyzed, even now, as a part of their investigation). Full disclosure: I don't fly Boeings, I do not work for Boeing, I have no shares in Boeing stock, and I am still slightly pissed at Boeing for the MCAS screw up on the 737-MAX. Last edited by Lonewolf_50; 16th July 2025 at 13:12 . |
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