July 12, 2025, 01:28:00 GMT
permalink Post: 11920070
Can someone with the engineering knowledge build a timeline/timeframe for fuel cutoff switch RUN to CUTOFF -> fuel stops -> engine flameout -> N2 drops to ? -> VFSGs quit -> RAT deployment starts -> RAT full power -> APU deployment start?
Does the RAT really start providing power in 4 seconds from the E2 fuel cutoff switch RUN -> CUTOFF?
Timeline from AAIB and the public CCTV video:
08:08:33 v1 153 kts
.
08:08:35 vr 155 kts
.
.
.
08:08:39 Liftoff, A/G Air Mode, rotation at 00:18 in public CCTV video
.
.
08:08:42 E1 Fuel Cutoff Switch RUN -> CUTOFF, 180 kts
08:08:43 E2 Fuel Cutoff Switch RUN -> CUTOFF
.............? N1 N2 begin to decrease
.............? "Why did you cutoff", "I didn't"
.............? Airport CCTV shows RAT
.............? N2 < idle speed
08:08:47 RAT hydraulic power
.
08:08:49 Public CCTV video: visible loss of thrust, Alt < 200ft using wingspan
.
.
08:08:52 E1 Fuel Cutoff Switch CUTOFF -> RUN, CCTV video: visible descent
.
08:08:54 APU inlet door begins opening
.
08:08:56 E2 Fuel Cutoff Switch CUTOFF -> RUN
08:09:05 MAYDAY
08:09:11 EAFR Recording stops
08:14:44 Crash Fire Tender leaves airport
Does the RAT really start providing power in 4 seconds from the E2 fuel cutoff switch RUN -> CUTOFF?
Timeline from AAIB and the public CCTV video:
08:08:33 v1 153 kts
.
08:08:35 vr 155 kts
.
.
.
08:08:39 Liftoff, A/G Air Mode, rotation at 00:18 in public CCTV video
.
.
08:08:42 E1 Fuel Cutoff Switch RUN -> CUTOFF, 180 kts
08:08:43 E2 Fuel Cutoff Switch RUN -> CUTOFF
.............? N1 N2 begin to decrease
.............? "Why did you cutoff", "I didn't"
.............? Airport CCTV shows RAT
.............? N2 < idle speed
08:08:47 RAT hydraulic power
.
08:08:49 Public CCTV video: visible loss of thrust, Alt < 200ft using wingspan
.
.
08:08:52 E1 Fuel Cutoff Switch CUTOFF -> RUN, CCTV video: visible descent
.
08:08:54 APU inlet door begins opening
.
08:08:56 E2 Fuel Cutoff Switch CUTOFF -> RUN
08:09:05 MAYDAY
08:09:11 EAFR Recording stops
08:14:44 Crash Fire Tender leaves airport
Last edited by appruser; 12th July 2025 at 01:29 . Reason: readability
July 12, 2025, 03:47:00 GMT
permalink Post: 11920152
Such a fault in a multi pole switch would be odd. And in two switches at roughly the same time?
Typically you'd have a fault in one set of poles, giving you conflicting data.
Such as the EAFR registers a fuel switch in cutoff, but the fuel did not actually cut off.
Don't forget that the RAT deployed instantly, shortly after liftoff, agreeing that both switches were in CUTOFF.
Typically you'd have a fault in one set of poles, giving you conflicting data.
Such as the EAFR registers a fuel switch in cutoff, but the fuel did not actually cut off.
Don't forget that the RAT deployed instantly, shortly after liftoff, agreeing that both switches were in CUTOFF.
Literally covering all the bases with a video would not only show what the switch status was but also how it got there, if it has an immediate effect, which a second line would not do.
July 12, 2025, 07:42:00 GMT
permalink Post: 11920296
Timeline of known events with source attribution from the preliminary report:
08:07:33 ATC: Takeoff clearance
08:07:37 A-SMGCS: Aircraft starts rolling
08:08:33 EAFR: V1 153kts
08:08:35 EAFR: Vr 155kts
08:08:39 EAFR: Gnd-Air mode transition
08:08:42 EAFR: Max IAS 180kts, Eng 1/2 Cutoff switches activate within 1 second of each other
08:08:42 CVR: "Why did you cut off", "I did not" (exact time not specified)
08:08:42 A-SMGCS: RAT deployed (exact time not specified)
08:08:47 EAFR: Both engine N2 below min idle. RAT hyd pwr commences
08:08:52 EAFR: Eng 1 cutoff to RUN
08:08:54 EAFR: APU inlet door opens (auto start logic)
08:08:56 EAFR: Eng 2 cutoff to RUN
08:09:05 ATC: Mayday call
08:09:11 EAFR recording stops
Fuel cutoff switches operated within 1 second of each other suggests to me that the locking mechanism wasn't working as per (SAIB) No. NM-18-33. Any loose item could have accidentally (or not) operated the switches (including hands).
08:07:33 ATC: Takeoff clearance
08:07:37 A-SMGCS: Aircraft starts rolling
08:08:33 EAFR: V1 153kts
08:08:35 EAFR: Vr 155kts
08:08:39 EAFR: Gnd-Air mode transition
08:08:42 EAFR: Max IAS 180kts, Eng 1/2 Cutoff switches activate within 1 second of each other
08:08:42 CVR: "Why did you cut off", "I did not" (exact time not specified)
08:08:42 A-SMGCS: RAT deployed (exact time not specified)
08:08:47 EAFR: Both engine N2 below min idle. RAT hyd pwr commences
08:08:52 EAFR: Eng 1 cutoff to RUN
08:08:54 EAFR: APU inlet door opens (auto start logic)
08:08:56 EAFR: Eng 2 cutoff to RUN
08:09:05 ATC: Mayday call
08:09:11 EAFR recording stops
Fuel cutoff switches operated within 1 second of each other suggests to me that the locking mechanism wasn't working as per (SAIB) No. NM-18-33. Any loose item could have accidentally (or not) operated the switches (including hands).
Last edited by sorvad; 12th July 2025 at 08:03 . Reason: Clarification
July 12, 2025, 08:17:00 GMT
permalink Post: 11920331
Timing of Query Re Cut Off Switches
From the report, there is no indicated time stamp identifying the point when one pilot asked the other "why did you cut off"
This could explain the the assumption that it took ten seconds to reverse the switch positions.
Cut off could have been noticed at any point later than 08:08:42 but before 08:08:52.
This could explain the the assumption that it took ten seconds to reverse the switch positions.
Cut off could have been noticed at any point later than 08:08:42 but before 08:08:52.
July 12, 2025, 08:56:00 GMT
permalink Post: 11920377
Was the RAT deployed manually?
The report says,
It suggests to me that the RAT deployment was initiated while the engines were still above idle and generating electrical power. Obviously one of the pilots could have done it via depressing the switch, as it's a "dual engine failure/stall" memory item (see Air India Ahmedabad accident 12th June 2025 Part 2 ) that won't hurt anything.
Is there a way for the RAT to deploy while the engines are still above idle?
The report says,
As per the EAFR data both engines N2 values passed below minimum idle speed, and the
RAT hydraulic pump began supplying hydraulic power at about 08:08:47 UTC.
This was 5 seconds after the fuel was cut off.
It suggests to me that the RAT deployment was initiated while the engines were still above idle and generating electrical power. Obviously one of the pilots could have done it via depressing the switch, as it's a "dual engine failure/stall" memory item (see Air India Ahmedabad accident 12th June 2025 Part 2 ) that won't hurt anything.
Is there a way for the RAT to deploy while the engines are still above idle?
July 12, 2025, 09:56:00 GMT
permalink Post: 11920444
Believe I have read through all messages in this thread and the interim report twice.
Few points I have not seen mentioned / discussed:
Few points I have not seen mentioned / discussed:
- At no point was gear up commanded (and obviously initiated) ? Did we have a PRC call out ? Assuming they would have commanded gear up does the RAT (plus APU that was also powering up) produce enough hydraulics to perform it ? Assuming so, one might thing it would have given them those few extra seconds they needed for the engine to actually start pushing for real.
- From the satellite pictures and impact points it would seem they could have, by deviating slightly left or right, ended up into a forest / vegetation vs a building. Obviously a very easy call in hindsight but I guess worth mentioning.
July 12, 2025, 10:04:00 GMT
permalink Post: 11920450
Believe I have read through all messages in this thread and the interim report twice.
Few points I have not seen mentioned / discussed:
Few points I have not seen mentioned / discussed:
- At no point was gear up commanded (and obviously initiated) ? Did we have a PRC call out ? Assuming they would have commanded gear up does the RAT (plus APU that was also powering up) produce enough hydraulics to perform it ? Assuming so, one might thing it would have given them those few extra seconds they needed for the engine to actually start pushing for real.
- From the satellite pictures and impact points it would seem they could have, by deviating slightly left or right, ended up into a forest / vegetation vs a building. Obviously a very easy call in hindsight but I guess worth mentioning.
July 12, 2025, 10:43:00 GMT
permalink Post: 11920474
SLF: I have a small observation but I'm not sure what it means or if it has any relevance to the accident.
Previously I had assumed that the ADS-B data cut out at the same time as power was lost, so I imagined that whatever caused the fairly clear loss of thrust would have happened not too long before. But this report throws a bit of a wrench in my understanding of that.
According to the report, the fuel cutoff switches transition from RUN to CUTOFF at or very shortly after 08:08:42 UTC. Both engines' N2 values pass below minimum idle speed and the RAT begins supplying hydraulic power at about 08:08:47. Does this not imply that the generators have already been lost? With the APU also being off (the APU inlet door is noted to start opening at 08:08:54), I would have expected ADS-B data to cut out at or before 08:08:47. But curiously FlightRadar24 at least claims to have received data frames from the aircraft until 08:08:51.640970, almost five seconds later and almost ten seconds after the transition to CUTOFF (though the last frame containing coordinates comes at 08:08:50.871005).
Could anyone with relevant experience confirm how long it would take for AC power to be lost in this situation? Also, is it usual/unusual for a preliminary report like this to mention if/when the flight recorder switched to its independent power supply? I imagine it would definitely be in the final report, but I'd hoped it would be easily observable enough to be in this one.
Beyond idle curiosity I'm asking because the report also says the no. 1 engine's cutoff switch transitioned from CUTOFF to RUN at "about 08:08:52", which oddly coincides with the last ADS-B data frame at 08:08:51.640970, and that seems important somehow. Or more likely I'm just ignorant of some quirk of the 787's electrical system.
For reference FR24's CSV containing all ADS-B frames supposedly received from the aircraft can be found in their post here: https://www.flightradar24.com/blog/f...rom-ahmedabad/
Previously I had assumed that the ADS-B data cut out at the same time as power was lost, so I imagined that whatever caused the fairly clear loss of thrust would have happened not too long before. But this report throws a bit of a wrench in my understanding of that.
According to the report, the fuel cutoff switches transition from RUN to CUTOFF at or very shortly after 08:08:42 UTC. Both engines' N2 values pass below minimum idle speed and the RAT begins supplying hydraulic power at about 08:08:47. Does this not imply that the generators have already been lost? With the APU also being off (the APU inlet door is noted to start opening at 08:08:54), I would have expected ADS-B data to cut out at or before 08:08:47. But curiously FlightRadar24 at least claims to have received data frames from the aircraft until 08:08:51.640970, almost five seconds later and almost ten seconds after the transition to CUTOFF (though the last frame containing coordinates comes at 08:08:50.871005).
Could anyone with relevant experience confirm how long it would take for AC power to be lost in this situation? Also, is it usual/unusual for a preliminary report like this to mention if/when the flight recorder switched to its independent power supply? I imagine it would definitely be in the final report, but I'd hoped it would be easily observable enough to be in this one.
Beyond idle curiosity I'm asking because the report also says the no. 1 engine's cutoff switch transitioned from CUTOFF to RUN at "about 08:08:52", which oddly coincides with the last ADS-B data frame at 08:08:51.640970, and that seems important somehow. Or more likely I'm just ignorant of some quirk of the 787's electrical system.
For reference FR24's CSV containing all ADS-B frames supposedly received from the aircraft can be found in their post here: https://www.flightradar24.com/blog/f...rom-ahmedabad/
July 12, 2025, 11:00:00 GMT
permalink Post: 11920493
nachtmusak
the RAT can be deployed manually, and I believe a pilot did that here before power was lost.
July 12, 2025, 11:02:00 GMT
permalink Post: 11920495
The accident aircraft was written up for a status message of ”STAB POS XDCR” on the previous flight, which is a message relating to implausible data from the stab trim switches. It was released from maintenance (according to the preliminary report) at 06:40UTC ahead of an 07:40UTC departure (the crash flight) with ”no fault found”.
On the 787-8, as all modern planes, switches are not cabled as dry closing contacts all the way from the switch poles to the affected end devices (FADECs in the case of fuel cutoff switches), but rather connect locally to an analogue/digital converter to encode the switch position data onto the digital comms bus ARINC629 which allows all aircraft systems to talk to one another.
Are the fuel cutoff switches, which are positioned adjacent to the stab trim switches, connected to the same ADC module which produced the error message on the previous flight, which maintenance was unable to resolve before the accident flight took off? I do not know, but it must be worthy of being looked into.
On the 787-8, as all modern planes, switches are not cabled as dry closing contacts all the way from the switch poles to the affected end devices (FADECs in the case of fuel cutoff switches), but rather connect locally to an analogue/digital converter to encode the switch position data onto the digital comms bus ARINC629 which allows all aircraft systems to talk to one another.
Are the fuel cutoff switches, which are positioned adjacent to the stab trim switches, connected to the same ADC module which produced the error message on the previous flight, which maintenance was unable to resolve before the accident flight took off? I do not know, but it must be worthy of being looked into.
I think they're called remote data concentrators - in many cases it is a conversion from a direct digital input to a bus signal; electronics would not call it an 'analog' input unless it was actually measuring a quantitative value.
Was the RAT deployed manually?
The report says,
As per the EAFR data both engines N2 values passed below minimum idle speed, and the RAT hydraulic pump began supplying hydraulic power at about 08:08:47 UTC.
This was 5 seconds after the fuel was cut off.
It suggests to me that the RAT deployment was initiated while the engines were still above idle and generating electrical power. Obviously one of the pilots could have done it via depressing the switch, as it's a "dual engine failure/stall" memory item (see Air India Ahmedabad accident 12th June 2025 Part 2 ) that won't hurt anything.
Is there a way for the RAT to deploy while the engines are still above idle?
The report says,
As per the EAFR data both engines N2 values passed below minimum idle speed, and the RAT hydraulic pump began supplying hydraulic power at about 08:08:47 UTC.
This was 5 seconds after the fuel was cut off.
It suggests to me that the RAT deployment was initiated while the engines were still above idle and generating electrical power. Obviously one of the pilots could have done it via depressing the switch, as it's a "dual engine failure/stall" memory item (see Air India Ahmedabad accident 12th June 2025 Part 2 ) that won't hurt anything.
Is there a way for the RAT to deploy while the engines are still above idle?
That is a very good question IMHO.
July 12, 2025, 11:39:00 GMT
permalink Post: 11920545
nachtmusak
the RAT can be deployed manually, and I believe a pilot did that here before power was lost.
The timing of data loss seemingly lining up with the first cutoff switch being flipped back to RUN seems a little too coincidental to me, but again hopefully someone with relevant knowledge has a mundane explanation for this.
On top of that I feel like people are overestimating how long ten seconds actually is, especially considering some of those seconds are reported to have been taken up by confused dialogue (that isn't even reported in its entirety). I thought it was common wisdom that accidents are never down to one thing; it would be light-years from being the first time that suboptimal crew response turned a maybe-recoverable error into a definite disaster without an ounce of malice in the mix.
July 12, 2025, 11:42:00 GMT
permalink Post: 11920553
The fuel control switches were moved to the off position approximately 3 seconds after weight off wheels.
July 12, 2025, 11:46:00 GMT
permalink Post: 11920554
Was the RAT deployed manually?
The report says,
It suggests to me that the RAT deployment was initiated while the engines were still above idle and generating electrical power. Obviously one of the pilots could have done it via depressing the switch, as it's a "dual engine failure/stall" memory item (see Air India Ahmedabad accident 12th June 2025 Part 2 ) that won't hurt anything.
Is there a way for the RAT to deploy while the engines are still above idle?
The report says,
As per the EAFR data both engines N2 values passed below minimum idle speed, and the
RAT hydraulic pump began supplying hydraulic power at about 08:08:47 UTC.
This was 5 seconds after the fuel was cut off.
It suggests to me that the RAT deployment was initiated while the engines were still above idle and generating electrical power. Obviously one of the pilots could have done it via depressing the switch, as it's a "dual engine failure/stall" memory item (see Air India Ahmedabad accident 12th June 2025 Part 2 ) that won't hurt anything.
Is there a way for the RAT to deploy while the engines are still above idle?
July 12, 2025, 19:32:00 GMT
permalink Post: 11920776
Couple of things.
If the red stab trim guards are closed, the switches are in the correct position.
After a 78 dual eng failure the RHS instruments return after the APU comes on line and even then it\x92s slowish as all the previous load-shedding gets reversed.
There would have been no time anyway.
If the red stab trim guards are closed, the switches are in the correct position.
After a 78 dual eng failure the RHS instruments return after the APU comes on line and even then it\x92s slowish as all the previous load-shedding gets reversed.
There would have been no time anyway.
of course when both engines spool down they\x92ll be left in the Boeing equivalent of EMER ELEC, I can\x92t say I know but I would assume this episode take out everything in front of the FO who was PF at the time, the RAT would\x92ve taken time to come online
it would\x92ve been a truly startling event, I wonder if that is when the FO went \x91heads inside\x92 and saw the position of the cut offs or cycled them?
July 13, 2025, 07:18:00 GMT
permalink Post: 11921078
The Action Slip scenario
What is an action slip?
There's a possible scenario we're discussing here that fits all of the available evidence. It proposes that one of the pilots operated the switches in an unconscious action called an "action slip". This is a rote action that we do without conscious thought when we're distracted: we mean to do something, and then we get our signals crossed and do something else. To learn more, search for "action slip" or "cerebellum" on this thread; I hope paulross adds the keyword to the next build of his excellent index at https://paulross.github.io/pprune-th...171/index.html .
How would this scenario play out?
We don't have enough evidence to pin down the exact sequence, so there are some assumptions here that I hope you find plausible. (And obviously it's not the only scenario that fits the evidence.) We especially do not know who did what and why, so that is all guesswork on my part. The times are taken from the preliminary report. The report places the verbal exchange among the pilots where I put it.
———
8:08:39 The 787 becomes airborne. The F/O is pilot flying (PF), with both hands on the yoke. The Captain is PNF (not flying).
8:08:42 The PNF unconsciously flips both fuel switches to CUT OFF, one after the other. This is a rote action performed after each flight, or as training captain in the simulator.
The action cuts power to the engines; they stop delivering thrust almost immediately, and the turbines start slowing down.
The 787 systems disconnect the electrical generators in advance of them failing. The right side
(Captain's side)
of the cockpit l oses power to most instruments. With all 4 generators offline, the RAT deploys to provide emergency power.
The PF feels the cessation of thrust. He looks at the display to see an ENGINES SHUT OFF message. He assumes the PNF shut them off, and asks him why he shut them off. This is the lowest "probe" level on the PACE assertiveness scale; see e.g. https://psychsafety.com/pace-graded-assertiveness/ or search for "probe alert" on pprune if you wish to know more. The highest level of assertiveness, E for "emergency", would have the F/O put the switches back himself immediately, but that would have required a high degree of confidence in the face of the older Captain that may have been difficult to achieve.
Since the action was unconscious, the PNF replies that he did not do that.
8:08:47 The RAT starts delivering hydraulic power, the engines decelerate past idle.
The PNF realizes that engine power is in fact cut. Eventually he checks the switches he thinks he did not touch, sees the engine 1 switch first and flips it back to RUN at 8:08:52. He then thinks to check the second switch and flips it up at 8:08:56.
The accident sequence ensues.
There's really not much the PNF can do at this point. At 8:09:05, he transmits a MAYDAY.
———
Obviously there are variations to this, for example it could have been the PF who put the fuel switches back. (In the above scenario, the PF is focused on flying—aviate!—and never turns his head to see the switches.) My goal was simply to set out a possible sequence, to see whether it feels plausible. Remember, as you see other scenarios put forth, that any issues a person could wrestle with would also be distracting. While both pilots would be very focused during the takeoff run, the moment the aircraft lifted off, the PNF could well have mentally relaxed a little, opening an opportunity for the action slip.
Thoughts?
Edit: I got the roles mixed up; in a fixed scenario, either the Captain was the PF (and may have set the switches to cutoff), or flight control changed over at the power failure.
There's a possible scenario we're discussing here that fits all of the available evidence. It proposes that one of the pilots operated the switches in an unconscious action called an "action slip". This is a rote action that we do without conscious thought when we're distracted: we mean to do something, and then we get our signals crossed and do something else. To learn more, search for "action slip" or "cerebellum" on this thread; I hope paulross adds the keyword to the next build of his excellent index at https://paulross.github.io/pprune-th...171/index.html .
How would this scenario play out?
We don't have enough evidence to pin down the exact sequence, so there are some assumptions here that I hope you find plausible. (And obviously it's not the only scenario that fits the evidence.) We especially do not know who did what and why, so that is all guesswork on my part. The times are taken from the preliminary report. The report places the verbal exchange among the pilots where I put it.
———
8:08:39 The 787 becomes airborne. The F/O is pilot flying (PF), with both hands on the yoke. The Captain is PNF (not flying).
8:08:42 The PNF unconsciously flips both fuel switches to CUT OFF, one after the other. This is a rote action performed after each flight, or as training captain in the simulator.
The action cuts power to the engines; they stop delivering thrust almost immediately, and the turbines start slowing down.
The 787 systems disconnect the electrical generators in advance of them failing. The right side
The PF feels the cessation of thrust. He looks at the display to see an ENGINES SHUT OFF message. He assumes the PNF shut them off, and asks him why he shut them off. This is the lowest "probe" level on the PACE assertiveness scale; see e.g. https://psychsafety.com/pace-graded-assertiveness/ or search for "probe alert" on pprune if you wish to know more. The highest level of assertiveness, E for "emergency", would have the F/O put the switches back himself immediately, but that would have required a high degree of confidence in the face of the older Captain that may have been difficult to achieve.
Since the action was unconscious, the PNF replies that he did not do that.
8:08:47 The RAT starts delivering hydraulic power, the engines decelerate past idle.
The PNF realizes that engine power is in fact cut. Eventually he checks the switches he thinks he did not touch, sees the engine 1 switch first and flips it back to RUN at 8:08:52. He then thinks to check the second switch and flips it up at 8:08:56.
The accident sequence ensues.
There's really not much the PNF can do at this point. At 8:09:05, he transmits a MAYDAY.
———
Obviously there are variations to this, for example it could have been the PF who put the fuel switches back. (In the above scenario, the PF is focused on flying—aviate!—and never turns his head to see the switches.) My goal was simply to set out a possible sequence, to see whether it feels plausible. Remember, as you see other scenarios put forth, that any issues a person could wrestle with would also be distracting. While both pilots would be very focused during the takeoff run, the moment the aircraft lifted off, the PNF could well have mentally relaxed a little, opening an opportunity for the action slip.
Thoughts?
Edit: I got the roles mixed up; in a fixed scenario, either the Captain was the PF (and may have set the switches to cutoff), or flight control changed over at the power failure.
Last edited by Musician; 13th July 2025 at 08:03 .
July 13, 2025, 07:36:00 GMT
permalink Post: 11921087
What is an action slip?
There's a possible scenario we're discussing here that fits all of the available evidence. It proposes that one of the pilots operated the switches in an unconscious action called an "action slip". This is a rote action that we do without conscious thought when we're distracted: we mean to do something, and then we get our signals crossed and do something else. To learn more, search for "action slip" or "cerebellum" on this thread; I hope paulross adds the keyword to the next build of his excellent index at https://paulross.github.io/pprune-th...171/index.html .
How would this scenario play out?
We don't have enough evidence to pin down the exact sequence, so there are some assumptions here that I hope you find plausible. (And obviously it's not the only scenario that fits the evidence.) We especially do not know who did what and why, so that is all guesswork on my part. The times are taken from the preliminary report. The report places the verbal exchange among the pilots where I put it.
\x97\x97\x97
8:08:39 The 787 becomes airborne. The F/O is pilot flying (PF), with both hands on the yoke. The Captain is PNF (not flying).
8:08:42 The PNF unconsciously flicks both fuel switches to CUT OFF, one after the other. This is a rote action performed after each flight, or as training captain in the simulator.
The action cuts power to the engines; they stop delivering thrust almost immediately, and the turbines start slowing down.
The 787 systems disconnect the electrical generators in advance of them failing. The right side (Captain's side) of the cockpit loses power to most instruments. With all 4 generators offline, the RAT deploys to provide emergency power.
The PF feels the cessation of thrust. He looks at the display to see an ENGINES SHUT OFF message. He assumes the PNF shut them off, and asks him why he shut them off. This is the lowest "probe" level on the PACE assertiveness scale; see e.g. https://psychsafety.com/pace-graded-assertiveness/ or search for "probe alert" on pprune if you wish to know more. The highest level of assertiveness, E for "emergency", would have the F/O put the switches back himself immediately, but that would have required a high degree of confidence in the face of the older Captain that may have been difficult to achieve.
Since the action was unconscious, the PNF replies that he did not do that.
8:08:47 The RAT starts delivering hydraulic power, the engines decelerate past idle.
The PNF realizes that engine power is in fact cut. Eventually he checks the switches he thinks he did not touch, sees the engine 1 switch first and flips it back to RUN at 8:08:52. He then thinks to check the second switch and flips it up at 8:08:56.
The accident sequence ensues.
There's really not much the PNF can do at this point. At 8:09:05, he transmits a MAYDAY.
\x97\x97\x97
Obviously there are variations to this, for example it could have been the PF who put the fuel switches back. (In the above scenario, the PF is focused on flying\x97aviate!\x97and never turns his head to see the switches.) My goal was simply to set out a possible sequence, to see whether it feels plausible. Remember, as you see other scenarios put forth, that any issues a person could wrestle with would also be distracting. While both pilots would be very focused during the takeoff run, the moment the aircraft lifted off, the PNF could well have mentally relaxed a little, opening an opportunity for the action slip.
Thoughts?
There's a possible scenario we're discussing here that fits all of the available evidence. It proposes that one of the pilots operated the switches in an unconscious action called an "action slip". This is a rote action that we do without conscious thought when we're distracted: we mean to do something, and then we get our signals crossed and do something else. To learn more, search for "action slip" or "cerebellum" on this thread; I hope paulross adds the keyword to the next build of his excellent index at https://paulross.github.io/pprune-th...171/index.html .
How would this scenario play out?
We don't have enough evidence to pin down the exact sequence, so there are some assumptions here that I hope you find plausible. (And obviously it's not the only scenario that fits the evidence.) We especially do not know who did what and why, so that is all guesswork on my part. The times are taken from the preliminary report. The report places the verbal exchange among the pilots where I put it.
\x97\x97\x97
8:08:39 The 787 becomes airborne. The F/O is pilot flying (PF), with both hands on the yoke. The Captain is PNF (not flying).
8:08:42 The PNF unconsciously flicks both fuel switches to CUT OFF, one after the other. This is a rote action performed after each flight, or as training captain in the simulator.
The action cuts power to the engines; they stop delivering thrust almost immediately, and the turbines start slowing down.
The 787 systems disconnect the electrical generators in advance of them failing. The right side (Captain's side) of the cockpit loses power to most instruments. With all 4 generators offline, the RAT deploys to provide emergency power.
The PF feels the cessation of thrust. He looks at the display to see an ENGINES SHUT OFF message. He assumes the PNF shut them off, and asks him why he shut them off. This is the lowest "probe" level on the PACE assertiveness scale; see e.g. https://psychsafety.com/pace-graded-assertiveness/ or search for "probe alert" on pprune if you wish to know more. The highest level of assertiveness, E for "emergency", would have the F/O put the switches back himself immediately, but that would have required a high degree of confidence in the face of the older Captain that may have been difficult to achieve.
Since the action was unconscious, the PNF replies that he did not do that.
8:08:47 The RAT starts delivering hydraulic power, the engines decelerate past idle.
The PNF realizes that engine power is in fact cut. Eventually he checks the switches he thinks he did not touch, sees the engine 1 switch first and flips it back to RUN at 8:08:52. He then thinks to check the second switch and flips it up at 8:08:56.
The accident sequence ensues.
There's really not much the PNF can do at this point. At 8:09:05, he transmits a MAYDAY.
\x97\x97\x97
Obviously there are variations to this, for example it could have been the PF who put the fuel switches back. (In the above scenario, the PF is focused on flying\x97aviate!\x97and never turns his head to see the switches.) My goal was simply to set out a possible sequence, to see whether it feels plausible. Remember, as you see other scenarios put forth, that any issues a person could wrestle with would also be distracting. While both pilots would be very focused during the takeoff run, the moment the aircraft lifted off, the PNF could well have mentally relaxed a little, opening an opportunity for the action slip.
Thoughts?
July 13, 2025, 07:41:00 GMT
permalink Post: 11921093
What is an action slip?
There's a possible scenario we're discussing here that fits all of the available evidence. It proposes that one of the pilots operated the switches in an unconscious action called an "action slip". This is a rote action that we do without conscious thought when we're distracted: we mean to do something, and then we get our signals crossed and do something else. To learn more, search for "action slip" or "cerebellum" on this thread; I hope paulross adds the keyword to the next build of his excellent index at https://paulross.github.io/pprune-th...171/index.html .
How would this scenario play out?
We don't have enough evidence to pin down the exact sequence, so there are some assumptions here that I hope you find plausible. (And obviously it's not the only scenario that fits the evidence.) We especially do not know who did what and why, so that is all guesswork on my part. The times are taken from the preliminary report. The report places the verbal exchange among the pilots where I put it.
———
8:08:39 The 787 becomes airborne. The F/O is pilot flying (PF), with both hands on the yoke. The Captain is PNF (not flying).
8:08:42 The PNF unconsciously flicks both fuel switches to CUT OFF, one after the other. This is a rote action performed after each flight, or as training captain in the simulator.
The action cuts power to the engines; they stop delivering thrust almost immediately, and the turbines start slowing down.
The 787 systems disconnect the electrical generators in advance of them failing. The right side (Captain's side) of the cockpit loses power to most instruments. With all 4 generators offline, the RAT deploys to provide emergency power.
The PF feels the cessation of thrust. He looks at the display to see an ENGINES SHUT OFF message. He assumes the PNF shut them off, and asks him why he shut them off. This is the lowest "probe" level on the PACE assertiveness scale; see e.g. https://psychsafety.com/pace-graded-assertiveness/ or search for "probe alert" on pprune if you wish to know more. The highest level of assertiveness, E for "emergency", would have the F/O put the switches back himself immediately, but that would have required a high degree of confidence in the face of the older Captain that may have been difficult to achieve.
Since the action was unconscious, the PNF replies that he did not do that.
8:08:47 The RAT starts delivering hydraulic power, the engines decelerate past idle.
The PNF realizes that engine power is in fact cut. Eventually he checks the switches he thinks he did not touch, sees the engine 1 switch first and flips it back to RUN at 8:08:52. He then thinks to check the second switch and flips it up at 8:08:56.
The accident sequence ensues.
There's really not much the PNF can do at this point. At 8:09:05, he transmits a MAYDAY.
———
Obviously there are variations to this, for example it could have been the PF who put the fuel switches back. (In the above scenario, the PF is focused on flying—aviate!—and never turns his head to see the switches.) My goal was simply to set out a possible sequence, to see whether it feels plausible. Remember, as you see other scenarios put forth, that any issues a person could wrestle with would also be distracting. While both pilots would be very focused during the takeoff run, the moment the aircraft lifted off, the PNF could well have mentally relaxed a little, opening an opportunity for the action slip.
Thoughts?
There's a possible scenario we're discussing here that fits all of the available evidence. It proposes that one of the pilots operated the switches in an unconscious action called an "action slip". This is a rote action that we do without conscious thought when we're distracted: we mean to do something, and then we get our signals crossed and do something else. To learn more, search for "action slip" or "cerebellum" on this thread; I hope paulross adds the keyword to the next build of his excellent index at https://paulross.github.io/pprune-th...171/index.html .
How would this scenario play out?
We don't have enough evidence to pin down the exact sequence, so there are some assumptions here that I hope you find plausible. (And obviously it's not the only scenario that fits the evidence.) We especially do not know who did what and why, so that is all guesswork on my part. The times are taken from the preliminary report. The report places the verbal exchange among the pilots where I put it.
———
8:08:39 The 787 becomes airborne. The F/O is pilot flying (PF), with both hands on the yoke. The Captain is PNF (not flying).
8:08:42 The PNF unconsciously flicks both fuel switches to CUT OFF, one after the other. This is a rote action performed after each flight, or as training captain in the simulator.
The action cuts power to the engines; they stop delivering thrust almost immediately, and the turbines start slowing down.
The 787 systems disconnect the electrical generators in advance of them failing. The right side (Captain's side) of the cockpit loses power to most instruments. With all 4 generators offline, the RAT deploys to provide emergency power.
The PF feels the cessation of thrust. He looks at the display to see an ENGINES SHUT OFF message. He assumes the PNF shut them off, and asks him why he shut them off. This is the lowest "probe" level on the PACE assertiveness scale; see e.g. https://psychsafety.com/pace-graded-assertiveness/ or search for "probe alert" on pprune if you wish to know more. The highest level of assertiveness, E for "emergency", would have the F/O put the switches back himself immediately, but that would have required a high degree of confidence in the face of the older Captain that may have been difficult to achieve.
Since the action was unconscious, the PNF replies that he did not do that.
8:08:47 The RAT starts delivering hydraulic power, the engines decelerate past idle.
The PNF realizes that engine power is in fact cut. Eventually he checks the switches he thinks he did not touch, sees the engine 1 switch first and flips it back to RUN at 8:08:52. He then thinks to check the second switch and flips it up at 8:08:56.
The accident sequence ensues.
There's really not much the PNF can do at this point. At 8:09:05, he transmits a MAYDAY.
———
Obviously there are variations to this, for example it could have been the PF who put the fuel switches back. (In the above scenario, the PF is focused on flying—aviate!—and never turns his head to see the switches.) My goal was simply to set out a possible sequence, to see whether it feels plausible. Remember, as you see other scenarios put forth, that any issues a person could wrestle with would also be distracting. While both pilots would be very focused during the takeoff run, the moment the aircraft lifted off, the PNF could well have mentally relaxed a little, opening an opportunity for the action slip.
Thoughts?
Seeing that the gear remained down after liftoff, there was CVR confusion after the event, and there was an attempt to rectify the situation…. I’m now thinking aviation is witnessing its most bizarre action-slip it’s ever seen and we’ll learn that the human automatic system is capable of making the most inappropriate and illogical responses to a given situation. I suspect fatigue and the captains sim experience of flicking switches plays a part.
As a result of this, I think we’ll see a renewed interest in slowing down actions at all times…touch a control, look at it, pause, consciously think about what you are touching before you execute it. This needs to be habitual, especially on LH fleets where fatigue inevitably plays into the operation.
We’ll also be discouraging the “insta-pilot” trend of showing how slick you are (usually on A320) where your hands flick round the flight deck at lightning speed. Even in more benign scenarios like shutdown flows etc, this isn’t a good habit.
July 13, 2025, 10:13:00 GMT
permalink Post: 11921202
Not sure if this is helpful for anyone or not but I thought a visual view of the timeline of events might be useful, in seconds since V1.
I've assumed 1Hz for the switch sampling rate and >1Hz for everything else (could be wrong) to give windows for the switch state changes.
I've also added in the ADS-B relevant data, although made no attempt to work out whether these timestamps are synchronised or not, so take them as you will.
I have assumed the cutoff is in chronological order from the report, albeit I have ignored the RAT supply timestamp in terms of chronology from the CVR recording, as that statement in the report at that time may just be due to contextual nature of the statement, rather than it happening prior to the RAT power supply. This gives a window for potentially when that statement was made (assuming also that it was made prior to reversing cutoff).
Don't think it neccessarily adds anything for me, other than:
- Would we expect ADS-B data to stop on engine transition to run? Note that ADS-B data was received between 08:08:43 and 08:08:51, so apparently only received in the time window that the switches were in "cutoff"
- The window between the switches being shut off and moved to run could be as short as 8 seconds, and the window between engine 1 and engine 2 being moved to run could be as short as 2 seconds
- The statement on the CVR could be a wide range of timepoints.
The ADS-B data is in my view odd, albeit this might be my lack of understanding. Yes, not synchronised, but unless the timestamps are way out (like 10 seconds out, and given the timestamp of max altitude, this feels incredibly unlikely), ADS-B data was transmitted without issue during phase 2 (both engines off, no RAT), and phase 3 (both engines off, RAT)...but NOT phase 4 (both engines firing back up, presumably still with RAT?). Bear in mind that phase 4 is almost half of the short flight. Also it would appear no data during phase 1 (both engines on), including during takeoff, despite receiving data during taxi?
*EDIT* - having looked into some other historical ADS-B data for this airport, albeit a bit cursory, it definitely appears that the lack of data in "phase 1" that I've outlined above is solely a coverage issue, with no other flights I can see having coverage in that area either. It's harder to determine the "phase 4" element as obviously no airplanes in a normal mode are in that geographical region at the altitude in question, but it does appear to be a reasonably safe bet that the missing datapoints are coverage related.
Last edited by Mrshed; 13th July 2025 at 11:47 .
July 13, 2025, 10:23:00 GMT
permalink Post: 11921207
Not sure if this is helpful for anyone or not but I thought a visual view of the timeline of events might be useful, in seconds since V1.
I've assumed 1Hz for the switch sampling rate and >1Hz for everything else (could be wrong) to give windows for the switch state changes.
I've also added in the ADS-B relevant data, although made no attempt to work out whether these timestamps are synchronised or not, so take them as you will.
I have assumed the cutoff is in chronological order from the report, albeit I have ignored the RAT supply timestamp in terms of chronology from the CVR recording, as that statement in the report at that time may just be due to contextual nature of the statement, rather than it happening prior to the RAT power supply. This gives a window for potentially when that statement was made (assuming also that it was made prior to reversing cutoff).
Really highlights how knowing precisely when the why did you cutoff" question was asked might have provided more clarity and less speculation as to how those fateful seconds played out
And it would have helped to know if Positive rate / Gear Up was called ... and when
Last edited by unworry; 13th July 2025 at 12:19 .
July 13, 2025, 10:32:00 GMT
permalink Post: 11921213
Don't think it neccessarily adds anything for me, other than:
- Would we expect ADS-B data to stop on engine transition to run? Note that ADS-B data was received between 08:08:43 and 08:08:51, so apparently only received in the time window that the switches were in "cutoff"
- The window between the switches being shut off and moved to run could be as short as 8 seconds, and the window between engine 1 and engine 2 being moved to run could be as short as 2 seconds
- The statement on the CVR could be a wide range of timepoints.
The ADS-B data is in my view odd, albeit this might be my lack of understanding. Yes, not synchronised, but unless the timestamps are way out (like 10 seconds out, and given the timestamp of max altitude, this feels incredibly unlikely), ADS-B data was transmitted without issue during phase 2 (both engines off, no RAT), and phase 3 (both engines off, RAT)...but NOT phase 4 (both engines firing back up, presumably still with RAT?). Bear in mind that phase 4 is almost half of the short flight. Also it would appear no data during phase 1 (both engines on), including during takeoff, despite receiving data during taxi?
- Would we expect ADS-B data to stop on engine transition to run? Note that ADS-B data was received between 08:08:43 and 08:08:51, so apparently only received in the time window that the switches were in "cutoff"
- The window between the switches being shut off and moved to run could be as short as 8 seconds, and the window between engine 1 and engine 2 being moved to run could be as short as 2 seconds
- The statement on the CVR could be a wide range of timepoints.
The ADS-B data is in my view odd, albeit this might be my lack of understanding. Yes, not synchronised, but unless the timestamps are way out (like 10 seconds out, and given the timestamp of max altitude, this feels incredibly unlikely), ADS-B data was transmitted without issue during phase 2 (both engines off, no RAT), and phase 3 (both engines off, RAT)...but NOT phase 4 (both engines firing back up, presumably still with RAT?). Bear in mind that phase 4 is almost half of the short flight. Also it would appear no data during phase 1 (both engines on), including during takeoff, despite receiving data during taxi?
Assuming the 787 is similar, perhaps the aircraft was broadcasting ADS-B for the full flight (with the transponder running off main battery/RAT power) but the reception was marginal, resulting in no reception until just after liftoff and no reception once they start to sink again.