Posts about: "Preliminary Report" [Posts: 277 Pages: 14]

For Dr Bru and Engineless:
I think that there is a thread about hacking of airliners somewhere on PPRuNe, might want to take that discussion there.
(Here is one, there are others)

A short response to you both:
1. Note that the article was from 2019
2. I am very doubtful that this occurred, beyond estimating the efficacy of any protections Boeing and Honeywell will have come up with since that article was published.
I doubt that either company sat on their hands after that Black Hat conference.
3. Caveat: yes, hackers never sleep .
= So some kind of sabotage is supposedly done, you think? = (I'll put the speculation into the spoiler)



But I think that you are both grasping at straws, for a variety of reasons, among which are:
1. No evidence to date.
2. Nothing in the report (but then, it's a prelim report)
3. If that kind of thing was going on, I don't think that the report would appear to lean so hard toward the human factors piece.
4. Unless that is part of the deception plan!
5. Yeah, right, we are back to the Hollywood thriller that neither of you have gotten a producer to try and get filmed.
6. Fear
7. Surprise
8. A fanatical devotion to Saint Bernoulli.

Please take any further discussion of this line of inquiry to a thread involving hacking.
Thank you all in advance.
T28B

(As an aside: if you took a look at the debris field, and the fact of the post impact fire, finding any evidence of something like what you are alluding to would be tough unless there's a way to parse EAFR information to detect the intrusion into the system of spurious / outside signals).

I believe it is highly unlikely that anything will occur in any of the legal - or investigatory - processes happening now or which will occur, that will meet the "proof beyond a reasonable doubt" standard.

Absolutely. The attempted reading of tea leaves to interpret what the authors may have meant beyond what they said, or what they intended to convey by not saying something else, may be fun for some, but it really contributes nothing to understanding this crash.

We know with reasonable (although not perfect) certainty that the fuel control switches were placed in CUTOFF almost immediately after rotation and were later moved back to RUN. We do not know who did that or why it was done and we don't have nearly enough information to answer those questions with any confidence.

You're making things up, attributing motive where you cannot possibly know motive. You're just guessing, and conveniently making your guesses match your preferred scenario. It is entirely possible, indeed it is the way it is supposed to be done, that the investigators have included what is known with reasonable certainty, and known to be relevant, at this point and not included other things about which they are uncertain.

It's certainly possible that we will someday learn that the Indian investigators have been conducting a manipulative campaign and using the preliminary report as an instrument of that campaign, but there is absolutely no evidence of that currently available to us now.

I think you misunderstand me. I agree with your first paragraph. The point I thought I was making is that the investigators wish to convey that the evidence points to human action. ( and not, for example, the number of poles on a switch).
Why the person in charge of the hand did that is unlikely ever to be known.

He perhaps used the wrong turn of phrase there.

Something like sabotage/hacking would be in the realm of what's addressed in a criminal investigation.

Our topic in this thread is the preliminary report of the accident investigation team.
(That's a reminder for all, not just D Bru).

If you would copy and paste which part of the preliminary report has raised this question in your mind, it will help get you a satisfying response from the other posters here.
The report is linked in the first post of this thread, and is attached to post # 3 in .pdf format .

Quick admin note: you can like a post, and you can remove your like for a post. (Just hit the thumb again, it will remove it).
On this forum (unlike some other internet sites) you cannot unlike a post.

Speculation on Maintenance Actions/Ground Crew Actions:
We must accept that there is very little hard information in the Preliminary Report addressing maintenance actions before this flight. When the final report, or perhaps an interim report, is issued then more detail on the activity by the ground crews between the successful flight from Delhi and the unsuccessful flight to Gatwick will become available.

I ask that we all refrain from spinning the hamster wheel regarding
'What if they removed or repaired that gizmo-thingamajig?'
unless there is something to anchor that to from the report.

Thank you all in advance.

So why did they give so much space to a discussion of SAIB NM-18-33? It's obvious that the switches were not faulty, or they'd have said. If they couldn't tell if the switches were faulty, they'd have said. They do tell us that the throttle control module was swapped out and there's been no problem with the switches. So they don't need to mention it. It doesn't read to me as a logical part of the preliminary report, but as something they were under pressure to include to imply that there may have been a technical problem rather than pilot malfunction.

The fuel control switches are clearly central to the investigation as the cause of the accident, and it is public knowledge that there was a SAIB relating.

Simplest answer is often the best - they included it to show they had considered it?

Imagine this forum if they hadn't included a nod to the SAIB - 90% of posts would be about the SAIB. can't really win on this one in the court of public opinion.

Included or not, they made no recommendations for even proactive reminding of the SAIB to operators. This is more telling for me.

It also is both possible without imagining things, and consistent with - shall we call it "best practices" under Annex 13 - for the person or persons who wrote and approved the preliminary report to have taken into consideration the attention their report would receive from many audiences, not only aviation professionals.

The prevalence of the 787 type. The quite recent travails of Boeing and the pace of its recovery (and some doubters that it can or will recover). The orders of magnitude increase in information, as well as misinformation or even disinformation, about this accident compared to .... well, compared to the UPS accident in Birmingham in 2013 (Flight 1354), cited as it was the first "current" accident occuring as of my stumbling across this forum and its threads. Sure, not a dramatic passenger aircraft accident but still valid for comparing the information environment then, and now.

The persons responsible for this report, I think, did not act improperly if they included information not strictly necessary for the purpose of keeping aviation cognescenti updated about what is known with some (imprecisely defined) level of certainty and clarity. Such other information items could be intended to make some effort at mitigating ("minimizing" would be hoping for too much) the volumes of noise emanating from all over.

Then there's the point about the report source knowing who did what, and when, but not providing specifics. Perhaps forensic analysis of the voice recording is ongoing, perhaps an analysis was completed but with reason to examine more closely. Regardless, I do not find it an affront either to solid, long-established principles of the Chicago Convention and Annex 13, or to the general ideas about advancing aviation safety, for the report sources to not treat the 30-day rule for preliminary reports as some "complete download demand function." Given what is reported about the fuel cutoff switches moving and the summarized cockpit statements, either way the final facts resolve will be tremendously impactful for the airline, the CAA of India, and the country (including but not only in its role as a major aviation Member State).

I wouldn't hold this view if it was a question of deception. I see it instead as a matter of reasonable discretion, about both ..."what to leave in, what to leave out" (with apologies to Bob Seeger, "Against the Wind", 1980).

Literally what the Preliminary Report says happened. Even the Pilots' exchange fits within this context.

In my opinion, not enough attention is being paid to why the Pilot Monitoring might have *had to* execute the memory items for dual-engine failure.

Other than the report stating (by implication of IAS etc) no issue with thrust until the switches were moved, as well as the CVR exchange shared makes basically no sense in that scenario.

The issue received extensive news coverage. I am sure they felt a need to address it.

There would have been multiple similar failures in different locations. The data for the EAFR is completely separated from the wiring and circuitry for the HP fuel valves. - And that on both engines.

That is nonsense. There is no "fuel cut-off module". The fuel cut-off HP valves are operated directly by the cut-off switches through simple latching solenoids. No computer involved, not part of any communication network of the plane. The FADECs (which itself are totally separated from the rest of the aircraft) only get information on the status of the switches; e.g. to faciliate engine restart.

Likely because the FDR readout showed the engines at the appropriate takeoff thrust, then the switches move, takeoff thrust goes away. Switches move back to RUN and the quick restart begins.

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.

For GroundedSpanner:
You seem to have left out the fatigue bit.
From further back in this thread, and as addressed in previous threads, as to what the SAIB that was mentioned in the report covered:
Beyond that, I ask all of you posting in this thread for the first time, or with little aviation experience, to go to post number 1.

Read the entire Preliminary report, and pay particular attention to pages 5 through 9.
Five different buildings were damaged, badly, because this aircraft hit five buildings as it came down with forward momentum.
Parts of the aircraft hit some buildings and not others.
There was a fire. The debris field was spread out over a large area.

There were whole, and broken, and burned parts of this aircraft all over the place at the crash site that the investigators needed to identify and sift through, and then try to use, to come up with the who, what, where, why, when and how of this accident.

The flight deck was found about 650 feet from the initial impact point.
The overall extent of the debris field was roughly 1000 feet by 400 feet. That's about three football pitches/fields long (plus a bit) and one football pitch/field wide (plus a bit).

Cut the investigating team a break, if you please, and exercise a bit of patience.

I have to say I'm really impressed with your work. It's no co-incidence that this image has been used noting that the rat is deployed which means the generators are already offline,
I'm equally impressed by how quickly No1 engine recovered. I think it's safe to say that this situation is not recoverable, but a truly impressive piece of engineering all the same.

Might be that a good place to start would be to identify some real dots, because those links don't point to anything but the same unsubstantiated commentaries which don't give us facts, just conjectures based on nothing but gossip really.

The first link does confirm that the records for the captain were provided to the investigation (as would be expected) and nothing found:

• TATA, the parent company of Air India, pushed back, saying, “He did take bereavement leave in 2022 following his mother’s death, and his medical records were submitted as part of the investigation, and the preliminary report did not find anything noteworthy.”

To connect the dots, you first have to identify them, and to be honest, I'd be totally shocked if the investigation had not got to the question you are posing well before you did, and not found anything credible to go on. What do you think the team missed that you, sitting comfortably here, haven't? Do you know something about a causal link between bereavement leave and suicide, for example?