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fdr
July 13, 2025, 02:44:00 GMT permalink Post: 11920995 |
There is one known inadvertent shutdown with this type of switch, on a B744, many years ago, when the Rosen visor fell from the upper sun visor rail when being relocated. That managed to turn off 1 fuel switch. The report is quite comprehensive for an interim report, and it does not draw any conclusions as yet as to how or why the fuel control discrete is recorded as OFF, however, it is troubling. I would reserve opinion until there is a clear spectral analysis that shows the selection of the fuel switches off, and then back on. As to the time to react, the crew in this case if unaware of the causation will have a fair recognition time to assimilate the information that is presented, and then to determine that the cause is the switches being off is going to take some time to process, discover the system status and respond, if that is what happened. I remain concerned with liquid ingress to the control system, giving a change in the sensed switch position rather than the selected position. That is looking like a long shot, but then this event is way outside of the normal box. |
MaybeItIs
July 13, 2025, 04:15:00 GMT permalink Post: 11921010 |
You want these switches within reach of both pilots, in a position where hands are not constantly passing over them, able to be actioned quickly, to be internally guarded (= require 2 distinct actions to move) as well as externally protected (side guards). It also seems logical to have them near the thrust levers.
Boeing have achieved all this. It feels like it would be an error to try and redesign these switches in light of this incident. The switches operated as they were commanded. ![]() The switches must be accessible - Yes They are where hands regularly pass over them - a No. As I see it, a certain expression regarding the back end of a male dog comes to mind! ![]() Able to be actioned quickly - arguably, currently, it's much too quickly, IMHO. Guarded - when it comes to Cerebellum (Yes, please search that word in this thread)-generated actions, that makes zero difference. When the Cerebellum has been trained and learned, it will repeat the most complex sequences you can think of - without you having to think of them. That's the REAL problem that needs to be solved. Logical - Yes, but really No! Putting them close together can more easily result in the wrong action at times of high stress, confusion, fear, danger, urgency, whatever. I say they need a major, i.e. Total redesign. But one of the big problems is that these two switches are used at least a couple of times on every flight. So, they are true Cerebellum Fodder. However, here's one suggestion. The modern plane is full of sensors, interlocks and logic devices. Use them a bit smarter, I say! When the plane is on the ground, allow the Fuel Switches to be turned On and Off without debate. But using Air/Ground and /(or?) WoW, when the plane is in the air, the process must be made markedly different. At the very LEAST, make them properly guarded, so a flap must be lifted to action them. And as soon as the flap gets lifted in flight, a very loud alarm and maybe a light is triggered. Then, everybody knows, no need for guessing. Until you or your fellow pilot presses the Confirm button somewhere nearby, the switches can't be moved - or are disabled, or something. If you don't regularly use this procedure, the Cerebellum won't be so likely to Run It Automatically in a panicked rush. The different process from what you did just at the start of the flight will trip up the cerebellum somewhat, and trigger the Higher Brain to start thinking...: "What? Is this correct?" How about this? Subsequent thoughts: The Confirm button would only remain live for a short period, say 3 seconds, during which time, you can operate the switch. Then it resets. Another idea: Leave the Fuel Cutoff switches right where they are, as they are. But, when in Flight, totally disable them. Alarm if moved. Put the In-Flight Shutoff switches in the overhead panel, with the same kind of aural/visual Confirmation-required warning system permanently operative. P.P.S. That may not be enough, maybe there needs to be a Takeoff speed transition added - i.e. Before Rotate. Maybe just after V1? Last edited by MaybeItIs; 13th July 2025 at 04:48 . Reason: add the subs. |
AfricanSkies
July 13, 2025, 05:12:00 GMT permalink Post: 11921023 |
Just a thought \x97 the fire extinguisher handles perform the same function as the fuel cut-off.
Could there have been a strap /booklet or something else that accidentally got under the fire handles and activated them when one of the pilots pulled on the item? The fire handles are not particularly well protected against something getting underneath them Is there any information on whether the fuel cutoff switches and fire handles register as separate events on the flight data recorder, or if both are logged under a common indication, such as 'fuel switch cut off'? ![]() |
Captain Biggles 101
July 13, 2025, 11:24:00 GMT permalink Post: 11921244 |
It actually doesn\x92t matter who said it for the purposes of diagnosing deliberate action, if it\x92s someone trying to cover their tracks and deflect blame onto the other person it still represents cognition that the movement of the switches was a deliberate act and will have been recorded as such.
The only known fact is that engines for some reason were shut down. The other known fact is that there is a recorded indication that the start lever command was recorded as both cutoff in short succession then followed by idle detent causing a restart attempt. I think the key unknowns here are important. 1. Was the start lever position recorded, or only the electrical signal? My money is on an electrical signal not position, therefore the manual positioning of the start levers is not conclusively proven. 2. The bulletin for locking mechanism for the start levers has been mentioned in the preliminary report. This is a huge unknown. Did that mean that in a failure that the levers could both move into cutoff at the same time? This occurred exactly as the aircraft was rotating and increasing pitch. 3. The information from the CVR if taken at face value must not be discounted. No pilot actually confirmed conclusively seeing the other move the switch. This could have been an assumption noticing an engine failure, seeing the start levers positions in cutoff or indeed seeing the start levers moved deliberately. This is a huge critical unknown. 4. One pilot asked 'why did you cutoff' and the other responded 'I didn't'. This is not a confirmation of anything for sure. In fact it is equally a suggestion no pilot moved the switches, equally as it is saying they did. This is not conclusive. This raises an important question, was this genuine, did either pilot have any reason in their life to attempt to do this and then cover their actions? There is zero suggestion here either way, but hopefully investigators will already be looking at their backgrounds and state of affairs. 5. There is no indication who or what commanded the engines back to idle detent again. There is proof of both engines attempting to restart. I would take this as confirmation of teamwork existing on the flight deck, and this would suggest a lack of deliberate interference by either pilot. Should that have been deliberately done, so much more could have happened. It just hasn't been alluded to in the preliminary report. My own impression is that it did not appear to be a situation of a deliberate act to crash. I say this as they appear to have both tried to save the aircraft and immediately restart the engines and recover taking some critical timely actions demonstrating competent reaction. The timing of the commanding fuel to cutoff is critical imo. The aircraft was pitching. If an accidental command to cutoff occurred then I feel this however unlikely would have been made instead of another action. The only likely thing happening at that exact time or due 2-3 seconds after lift off was gear up. The CVR and recorded timing of engine failure in relation to that challenge and response in SOP will be key imo. Did the challenge for gear up occur before the idle detent electrical signals? Also, the focus should be on that bulletin for the locking mechanism for the start levers. I just cannot imagine an experienced crew doing this by accident and the information just doesn't suggest a deliberate act. My post is just to highlight huge lists of unknowns. The media appears to have made their mind up that the flight crew did this. I just highlight that is definitely not confirmed yet. We have a whole list of unknowns and conflicting communication that raises more questions than they solve. I would urge zero conclusions be made, and RIP the crew and passengers. There are zero conclusions to what happened yet in my opinion, and I think the suggestion to relatives of the flight crew and families tragically killed that this is a known pilot deliberate action simply cannot be made at this point. We must not blame the flight crew prematurely or pretend we know what happened. I think the media should take note and back off from all the assumptions. Last edited by Captain Biggles 101; 14th July 2025 at 09:29 . |
Natterjak
July 13, 2025, 11:29:00 GMT permalink Post: 11921250 |
THE LANDING GEAR
There are many missing jigsaw pieces here that are highly relevant to building an understanding of what these guys were going through. One being that the gear was not raised. The report ( very oddly in my opinion ) is NOT declaring any voice data on the prompts/commands to raise it once they achieved a positive ROC after lift-off. At lift off, it's pretty safe to assume ( yes, I know ) that everything was going according to plan....so why, oh why wasn't the gear raised.....? This is quite extraordinary because:-
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adfad
July 13, 2025, 13:01:00 GMT permalink Post: 11921309 |
The fact is the moment the report was released all other previous theories were all but invalidated and deliberate action became 2nd or 1st most probable.
I do agree that at this point deliberate action is the most likely cause, followed by extreme psychological episode. Casual accidental movement if it was remotely probable would surely have been detected in decades of operation and mitigated with a redesign. |
SRMman
July 13, 2025, 13:04:00 GMT permalink Post: 11921311 |
I still think that one of the most puzzling things from the Preliminary Report is the 4 second gap between Engine 1 fuel cutoff switch being returned to RUN, and that of Engine 2. It seems generally agreed one second is a reasonable time to operate both switches, so why did it take so long to move the 2nd switch?
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Abbas Ibn Firnas
July 13, 2025, 13:25:00 GMT permalink Post: 11921321 |
I still think that one of the most puzzling things from the Preliminary Report is the 4 second gap between Engine 1 fuel cutoff switch being returned to RUN, and that of Engine 2. It seems generally agreed one second is a reasonable time to operate both switches, so why did it take so long to move the 2nd switch?
I'm not implicating either pilot, without more evidence. |
Phil Stunell
July 13, 2025, 13:29:00 GMT permalink Post: 11921325 |
This is excellent, thank you. It has helped me to crystallise a thought about the length of time the switches were at cut off.
10 seconds is a long time in a life threatening situation (like most clich\xe9s, the cinematic trope of time slowing down only reflects people's real experiences, mine included). Reaction times to completely unexpected events can be in the order of 3-5 seconds, but I find it hard to think that it would have taken any pilot as much as 5-7 seconds to set the first switch back to run. It's not something that anyone trying to save the aircraft is going to take time to consider. Possible explanations for the length of time are a physical altercation - but if that was so, then why did the switches then stay at run? We will be none the wiser on that, at least until the next report. Another, perhaps more likely possibility is that the switch movement itself was unnoticed by at least one of the pilots, and was not noticed until its effects took hold a couple of seconds later (my phrasing here is intended to leave open the question of how the switch moved, or was moved). Combined with the startle reaction time, this would start to explain a 10 second delay. So I expect the CVR comments are towards the later end of the possible range indicated in the excellent diagram. If powered by the RAT or APU would that introduce a time delay before you an can effectively put them back to Run? |
RetiredF4
July 13, 2025, 13:29:00 GMT permalink Post: 11921326 |
I still think that one of the most puzzling things from the Preliminary Report is the 4 second gap between Engine 1 fuel cutoff switch being returned to RUN, and that of Engine 2. It seems generally agreed one second is a reasonable time to operate both switches, so why did it take so long to move the 2nd switch?
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nomess
July 13, 2025, 13:34:00 GMT permalink Post: 11921328 |
I still think that one of the most puzzling things from the Preliminary Report is the 4 second gap between Engine 1 fuel cutoff switch being returned to RUN, and that of Engine 2. It seems generally agreed one second is a reasonable time to operate both switches, so why did it take so long to move the 2nd switch?
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Easy Street
July 13, 2025, 14:11:00 GMT permalink Post: 11921348 |
I still think that one of the most puzzling things from the Preliminary Report is the 4 second gap between Engine 1 fuel cutoff switch being returned to RUN, and that of Engine 2. It seems generally agreed one second is a reasonable time to operate both switches, so why did it take so long to move the 2nd switch?
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double-oscar
July 13, 2025, 14:45:00 GMT permalink Post: 11921364 |
It would have been useful if more of the CVR data had been released so as to see the crew interaction. Also the language used on what was released seems to refer to a third person.
However, from an operator perspective. Captain PM, FO PF. PF selects TOGA and follows the thrust levers, Captain confirms Thrust Set and replaces FO hands on the Thrust Levers. 80Kt call by PM, acknowledged by PF. Aircraft calls V1, Captain should withdraw hands from Thrust Levers and calls Rotate at Vr. PM is looking for confirmation the aircraft is climbing and calls Positive Rate. PF confirms and calls Gear Up. At this point the PF will be looking through the HUD looking to follow the flight director, the PM would be checking LNAV had engaged and at 400\x92 checking THR REF and VNAV SPD. However, at this point a loss of thrust occurred. So how was this apparent to the PF who would have been looking out with both hands on the control wheel. Reduction in pitch? GPWS call-out? Decreasing N1 on the engine instruments? EICAS ENG SHUTDOWN? What did the PM see? Who called out the situation? Were any actions called for? At some point as the generators went off line all the FO instruments would have blanked. Did the Captain assume control? I don\x92t think I would have been thinking about the Fuel Cut-Off switches at that point, yet they were specifically mentioned which does mean the switches were moved and it wasn\x92t some internal fault. Hopefully, as the CVR is further analysed some more information will come to light. |
skippybangkok
July 13, 2025, 15:02:00 GMT permalink Post: 11921377 |
With the greatest respect, I don't think any deliberate act has been proven. Allocating blame on assumptions should be avoided. People should work on facts, and then unconfirmed assumptions.
The only known fact is that engines for some reason were shut down. The other known fact is that there is a recorded indication that the start lever command was recorded as both cutoff in short succession then followed by idle detent causing a restart attempt. I think the key unknowns here are important. 1. Was the start lever position recorded, or only the electrical signal? My money is on an electrical signal not position, therefore the manual positioning of the start levers is not conclusively proven. 2. The bulletin for locking mechanism for the start levers has been mentioned in the preliminary report. This is a huge unknown. Did that mean that in a failure that the levers could both move into cutoff at the same time? This occurred exactly as the aircraft was rotating and increasing pitch. 3. The information from the CVR if taken at face value must not be discounted. No pilot actually confirmed conclusively seeing the other move the switch. This could have been an assumption noticing an engine failure, seeing the start levers positions in cutoff or indeed seeing the start levers moved deliberately. This is a huge critical unknown. 4. One pilot asked 'why did you cutoff' and the other responded 'I didn't'. This is not a confirmation of anything for sure. In fact it is equally a suggestion nobody pilot moved the switches as it is saying they did. This is not conclusive. This raises an important question, was this genuine, did either pilot have any reason in their life to attempt to do this and then cover their actions? There is zero suggestion here either way, but hopefully investigators will already be looking at their backgrounds and state of affairs. 5. There is no indication who or what commanded the engines back to idle detent again. There is proof of both engines attempting to restart. I would take this as confirmation of teamwork existing on the flight deck, and this would suggest a lack of deliberate interference by either pilot. Should that have been deliberately done, so much more could have happened. It just hasn't been alluded to in the preliminary report. My own impression is that it did not appear to be a situation of a deliberate act to crash. I say this as they appear to have both tried to save the aircraft and immediately restart the engines and recover taking some critical timely actions demonstrating competent reaction. The timing of the commanding fuel to cutoff os critical imo. The aircraft was pitching. If an accidental command to cutoff occurred then I feel this however unlikely would have been made instead of another action. The only likely thing happening at that exact time or due 2-3 seconds after lift off was gear up. The CVR and recorded timing of engine failure in relation to that challenge and response in SOP will be key imo. Did the challenge for gear up occur before the idle detent electrical signals? Also, the focus should be on that bulletin for the locking mechanism for the start levers. I just cannot imagine an experienced crew doing this by accident and the information just doesn't suggest a deliberate act. My post is just to highlight huge lists of unknowns. The media appears to have made their mind up that the flight crew did this. I just highlight that is definitely not confirmed yet. We have a whole list of unknowns and conflicting communication that raises more questions than they solve. I would urge zero conclusions be made, and RIP the crew and passengers. There are zero conclusions to what happened yet in my opinion, and I think the suggestion to relatives of the flight crew and families tragically killed that this is a known pilot deliberate action simply cannot be made at this point. We must not blame the flight crew prematurely or pretend we know what happened. I think the media should take note and back off from all the assumptions. Kudos to the crew for trying to re-light the engines so quickly. My 10 cents is on the switches and there is not a aireworthiness directive out there for nothing. |
oceancrosser
July 13, 2025, 15:35:00 GMT permalink Post: 11921397 |
Since some posters seem focused on the theory that the fuel control switches didn't move - just the electric output did (and as I posted earlier, the FDR only knows electrical states, there is literally no other way for the FDR to monitor the switch position).
So I did a little thought experiment. Uncommanded engine shutdowns (for all causes) are already rare - a 10-6 event. Now, during my 40 year career, I can't remember ever encountering a case where the fuel shutoff was commanded without a corresponding movement of the fuel switch. However in this industry it's a good idea to 'never say never', so let's assume it's happened. It would take something like a hot short to cause it to happen (moving the voltage from RUN to CUTOFF) since an open circuit will simply leave the valves where they were. That would put its probability way out there - something like 10-8/hr. The left and right engine wiring is physically isolated from the other engine - nothing gets routed in common bundles between the engines. Hence there is simply no way a localized issue could affect both engine's wire bundles. So we're talking two independent events that cause the switch output to electrical change state between RUN and CUTOFF without associated switch movement. So now were out in a 10-16/hr. territory. Now, these independent events both occur a second apart - 3,600 seconds/hr., so we've just added ~8 orders of magnitude to the dual failure probability number (10-24/hr.). Now, they both somehow return to normal withing a few seconds of each other - another ~8 orders of magnitude so we're talking 10-32. That means the probability of this happening at any time since the Big Bang is way less than one.... Space aliens look reasonable in comparison. So can we discuss things that might actually have happened? Now my operator had an incident on a 757 in cruise about 10 years ago where the spar valve closed without command. The SPAR VALVE light will probably have lit up (can\x92t remember) but the engine died. From crz thrust to no thrust in seconds. So such things are not unknown. |
Contact Approach
July 13, 2025, 18:03:00 GMT permalink Post: 11921494 |
It would have been useful if more of the CVR data had been released so as to see the crew interaction. Also the language used on what was released seems to refer to a third person.
However, from an operator perspective. Captain PM, FO PF. PF selects TOGA and follows the thrust levers, Captain confirms Thrust Set and replaces FO hands on the Thrust Levers. 80Kt call by PM, acknowledged by PF. Aircraft calls V1, Captain should withdraw hands from Thrust Levers and calls Rotate at Vr. PM is looking for confirmation the aircraft is climbing and calls Positive Rate. PF confirms and calls Gear Up. At this point the PF will be looking through the HUD looking to follow the flight director, the PM would be checking LNAV had engaged and at 400\x92 checking THR REF and VNAV SPD. However, at this point a loss of thrust occurred. So how was this apparent to the PF who would have been looking out with both hands on the control wheel. Reduction in pitch? GPWS call-out? Decreasing N1 on the engine instruments? EICAS ENG SHUTDOWN? What did the PM see? Who called out the situation? Were any actions called for? At some point as the generators went off line all the FO instruments would have blanked. Did the Captain assume control? I don\x92t think I would have been thinking about the Fuel Cut-Off switches at that point, yet they were specifically mentioned which does mean the switches were moved and it wasn\x92t some internal fault. Hopefully, as the CVR is further analysed some more information will come to light. Interestingly ENG 1 was cut off first\x85 |
Semreh
July 13, 2025, 20:42:00 GMT permalink Post: 11921631 |
Action slips - further information
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
Type of slip: Habit intrusion/'double capture slip'
Analysis: Incorrect motor schema is activated during a task due to failure of sustained focal attention to the task in working memory Example: Going to the kitchen sink to wash a dish but finding yourself washing one's hands instead 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. |
galaxy flyer
July 13, 2025, 20:53:00 GMT permalink Post: 11921645 |
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. 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. |
sabenaboy
July 13, 2025, 21:11:00 GMT permalink Post: 11921663 |
That totally clears up any doubt then, because a media interview where claims are made without any substantive evidence at all are clearly to be taken as gospel.
What I found interesting when viewing the Captain's background, was that he was a long-time carer for his aging father, and had called home before the flight to confirm that he would be in contact again once arrived in London. Also that he was highly respected with no history of difficult personal interactions, and had passed all medical clearances. I'm sure we're all open to actual evidence though.
Without any substantive evidence at all...
![]() The two fuel cutoff switches were put in the OFF position. If you have ever used those switches yourself, you will know that it can not be accidental. A deliberate action from one of the pilots is BY FAR the most plausible (or only) explanation. I feel very sorry for the innocent pilot in the cockpit and the hundreds of other victims. Having passed many medical examinations, I can assure you that psychological testing is not part of the periodic medicals.
I'm sure we're all open to actual evidence though.
Please enlighten me about how much time you have spent in an airline cockpit... Judging by what you contribute I suspect it will not be much. |
za9ra22
July 13, 2025, 21:18:00 GMT permalink Post: 11921672 |
![]() The two fuel cutoff switches were put in the OFF position. If you have ever used those switches yourself, you will know that it can not be accidental. A deliberate action from one of the pilots is BY FAR the most plausible (or only) explanation. I feel very sorry for the innocent pilot in the cockpit and the hundreds of other victims. Having passed many medical examinations, I can assure you that psychological testing is not part of the periodic medicals. It does appear to me that you're NOT open to evidence if you continue to deny that a deliberate pilot action is not plausible. Please enlighten me about how much time you have spent in an airline cockpit... Judging by what you contribute I suspect it will not be much. Having added your newer arguments too, you appear to have ignored what I've said since. But to respond to your direct question, my time in an airline cockpit is that which related to participating (as a human factors SME) in an aircraft accident investigation. Not much, but not actually relevant to the point I made relating to your post, or this subsequently - unless you contend that investigators have no place in investigating an accident. |
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