The preliminary report into the crash of Air India Flight 171 in Ahmedabad last month says the plane came down after fuel was cut to both engines seconds after takeoff. As we reported earlier, leaked reports said the investigation was focused on the fuel cutoff switches. India’s Air Accidents Investigations Branch said in the report that the switch controlling fuel flow to the left engine was moved to the “cutoff” position four seconds after the wheels left the runway, and the switch for the right engine followed one second later. Almost immediately, one pilot asked the other why he had moved the switches, but the second pilot said he did not move them. The switches are immediately below the thrust levers and are designed so they must be lifted before they will move to the cutoff position.
About eight seconds later, someone restored both switches to their correct position but by then the plane was descending and while the engines appear to have automatically relit, they did not produce significant thrust. The ram air turbine deployed about five seconds after the fuel was cut off. A pilot issued a Mayday, mentioning a lack of thrust, and the recording ended six seconds later. The plane crashed into the campus of a medical school a few seconds later, killing 19 people on the ground. All except one of the 242 people onboard was killed. A British passenger walked away from the wreckage with serious injuries. The lack of any kind of repair or defect advisory from Boeing or engine maker GE suggested mechanical faults were not part of the investigation.
In 2018, Boeing issued a Safety Information Bulletin telling owners of most Boeing jets that switches in which that safety feature was disabled had been found on some 737s. It recommended the switches be checked to ensure they could not be inadvertently flipped. Air India said it did not check the switches on its aircraft because the bulletin was voluntary and not mandatory. On Sunday, Boeing and the FAA confirmed they had notified airlines that the switches are airworthy and the engines and aircraft are safe to fly. The report said the switches were found in the “on” position but it did not say if the safety feature was working. The switch module had been replaced twice since the plane was built in 2014. In 2021, airlines were told to replace a component on the engine control computer after a loss of thrust control incident in which a solder ball fractured from repeated heat cycles and vibration. Air India has said it’s up to date on all service bulletins.
From previous comments here, its safe to assume that someone who has flown a 787, will be able to explain how two secured fuel cutoff switches could have been turned to off without CA/FO intervention.
My thoughts, as well, Jason. I saw pics of the switches; they’re of the type that have to be pulled up and past definite lockout tabs to be put in the opposite position. I have some of those in my hangar stash and looked at 'em just today. I wonder if this isn’t another suicide situation? Bumping those wouldn’t work to move them. And even if were the cause, how the heck would two of 'em be moved? The airplane couldn’t have taxied all the way to the runway with those switches ‘off,’ so human intervention HAD to occur. There’s more to this story …
Beyond that, I’d question why they were placed so close to the power levers? There ought to be a panel with all emergency control function switches in one place where a glance could confirm positions and allow rapid access to them. Were I designing the airplane’s functions, that’s what I’d do AND I’d have a warning light if ANY switch was in the wrong position for normal ops.
Ultimately, I presume that the smart people at Boeing have been building aircraft for more than 3 days and have a grasp of monitoring systems which determine the aircraft configuration, power lever position, flap settings, wheel rotation/ gear-load, speed, AoA … prior to allowing/ permitting a fuel cutoff on both engines?
I am not aware of the extent to which electronics/ sensors would be capable to override/ prevent the deliberate fuel cut off in certain critical configurations.
IOW, in my mind, attempting to cut fuel in a T/O- / Landing - Config would be answered with a master caution and require another step/ acknowledgement prior to execution. If any system failure/ error was capable to cut the fuel to both engines in such configs, a big can of worms is wide open.
We are not thinking Cessna 172 or light twin where the “accidental” closing of a fuel selector switch is a simply mechanical function, well known cause for fatal accidents and obviously not possible to idiot-proof.
The 787 fuel switches turn the fuel off - period. There is no system to disable them if the airplane doesn’t think you should be doing that. Boeing assumed the pilots would not turn the fuel off at random times just to see what happened next.
Well this was certainly unexpected, considering that all of the aviation world was trying to find a rational explanation. When is the next article due here that promotes mental health pilots keep flying?
Low level engine relights are a muscle memory item. If you’ve ever done them for real or more likely in simulators during recurrent training you know from experience that you don’t want to be fishing around some “all emergency controls panel” for the applicable switches. All jets I have flown have fuel cutoff on the throttle quadrant or even piggybacking on the throttle levers themselves for a reason.
Arthur, your reference to mental health assumes it to be the only factor motivating human behavior associated with placing fuel switches from run to cutoff immediately after liftoff. Whereas mental health may more likely motivate such behavior in western industrialized societies, one needs to accord just as much or even more weight to political and cultural motivations in other societies as well. That said, with the increasing breakdown in disciplined political rhetoric in western industrialized society, we might soon also be needing to factor that into our human behavior motivations.
Can both fuel switches be operated within 0.1 seconds of each other (maybe with one hand?) - and - regardless of aircraft config?
Sounds highly interesting from a litigatory standpoint, even if a extended suicide scenario was in progress.
Considering that throwing a Master Caution or requiring an extra step during a time when a fuel cutoff is particularly unreasonable, would be fairly simple?
Well … I came across this Indian (not wild!) report this AM. They’re intimating that operating those switches doesn’t DIRECTLY shut off the fuel … e.g., operate a fuel flow solenoid. Software control is in between those switches and and actual fuel flow shutoff function. And, it appears that this HAS happened once before without dire consequences on a landing sequence. That the RAT was deployed signals that both fuel flows were turned off within a very short period of time … not likely. And the CVR seems to confirm this.
SO, I amend my opinion … looks like Boeing (or someone’s?) software may be the culprit. IF that’s true … we have another 737MAX problem here, boys ?? Automation … it’s a wonderful thing … until it isn’t.
MSN?
Irrational behavior is a mental health behavior; it’s important.
You are correct that there is also the “cultural” component when the pilot asks “why did you throw those switches” and the immediate responses was “no I didn’t”.
Once again, Arthur - even if there was a mental health component to this accident, chances are that it may take years to be found out - if ever.
I am not willing to hazard a guess about the real number of pilots with untreated and undiagnosed depression, however I am willing to bet the true (unofficial) number of pilots, crewmembers, controllers, mechanics and safety critical aviation staff with depression may cause some severe sweating…
And the fun fact, nobody would know about it. According to doctrine, flying with untreated/ undiagnosed depression provides a paycheck…
No matter what ultimately caused the issue, 250+ people are dead and many thousands are affected.
If the fuel shutoff was possible during a highly critical phase of the flight, it will be legitimate to ask why, given the electronics and the incredible mass of data being monitored during operation of the aircraft.
Simple plausibility check. Is it plausible/ justifiable to cut fuel to both engines during departure or landing of the aircraft, considering the time it takes to restart and get these engines back into performance mode?
If the answer is no, then why was it possible?
I have never flown a plane in my life where this was not possible and I bet you haven’t either.
My max number of bodybags was limited to 12 + collateral. Piston and some Turboprops.
Here’s a video of someone operating those switches:
Data matters, Larry. If both switches moved within 1 second, I’d fly with human interaction. Initially the breathless media reported (referring to compiled data in the initial assessment) that the switches moved within 0.1 seconds.
Initiial article has been removed…
Yeah … I noticed the main body removed as well, Jason. Curious? Are we getting too close to reality here or … ??? It sure looks like the two options in this tragedy are that one of the crew moved the switches OR there’s a problem with the airplane’s automation? IF it’s the later, Boeing has another BIG problem. Given that we now know that both crew were very high time competant aviators, I’m going with the later. Hopefully, the data analysis is capable of providing the info needed for a determination? As an engineer, I STILL question why those switches are so close to the power levers and why there isn’t secondary protection to prevent inadvertent activation. Even just a clear plastic door or similar. That said, I cannot be convinced that one of the two pilots could inadvertently activate BOTH switches in that short period by accident.
Above SAIB gives a bit of background on those switches. Someone, somewhere mentioned a previous incident during a less critical phase of flight with a 787, however I was unable to duplicate this via source.
The preliminary accident report has potentially triggered news outlets to read the two fuel switches being turned to off within 0 1 (0.1 or 1) seconds. As everything else in the report is timestamped - down to the second, not more precisely, except for the exact time the fuel was shut off.
At this point, the suicide narrative looks a bit flimsy.
I’m pretty sure flight data recorders record control and switch states (inputs), not just software states (outputs) so it would be pretty clear if this were an automation error which doesn’t sound likely.
I bet both switches could pulled and be moved simultaneously with one hand, but regardless I don’t think moving both switches within 1 second of each other is anything exceptional.
Skylor
Initial press releases stated that the switches had been moved to off within 0.1 seconds.
One question I haven’t seen addressed. Was there anyone in a jump seat during that final takeoff? Someone besides the captain and fo who could have shut down the engines?
You have it completely backwards. The current situation is what is promoting that “mental health pilots keep flying” because for all but a few very specific cases, it means the end of their jobs. So, what does one do when they’re worried about losing their job over something related to themselves? They hide the condition.
There’s no way around it. If a mental health condition is permanently disqualifying, rather than seeking treatment a career pilot simply does not disclose it on their medical and keeps flying as though nothing is wrong. The fix is to allow these pilots to seek the treatment they need without fear of losing their jobs permanently (except for some extreme cases, just as any other extreme medical case would clearly mean the loss of flying privileges).
"So, what does one do when they’re worried about losing their job "
You nailed it.
Sane pilots with good mental health are problem solvers, both in the air and in their personal life.
Mentally ill pilots (who have trouble even managing their personal life) just might destroy 100 million in property and kill 228 people because they are not.
GaryB beat me to it. Arthur, you live in a world that doesn’t exist. In the real world, mental illness exists and may not be apparent to anyone except the pilot him/herself.
Some people who become pilots will need treatment for depression, anxiety, substance abuse, etc. The only choice is whether we either take away their livelihood and create a powerful incentive for them to hide the problem and not get needed treatment or we create an incentive for reporting by providing treatment and allowing those who are able to continue flying.
Your goal of preventing people with mental illness from flying is a fantasy. Either they fly without disclosure and without treatment or they fly with disclosure and with treatment. Those are the only two options.
Ps: plenty of people with mental illness are “sane.” In fact, you no doubt rely on them daily. They are your trusted doctors, engineers, lawyers, carpenters, nurses, etc.
Did the fully autonomous cockpit light just get a little bit brighter???
First off, you’re lumping every possible mental health condition as a single “mental illness”, equivalent to lumping a sprained ankle with a major heart attack. It’s a spectrum, not a binary condition. I guarantee that you know at least one person who has a mental health condition but you don’t even realize it because they don’t have trouble managing their personal life.
Secondly, you still completely missed my point that the current situation is what is allowing pilots with mental health conditions to continue flying without treatment or diagnosis. Currently, even going to a specialist to determine if one even has a mental health condition will raise all sorts of red flags with the FAA (and as I understand, most other aviation authorities), so who in their right mind would even go through the process if they feel they can just struggle along on their own and get through it?
It is precisely the near-complete zero-tolerance of mental health conditions in obtaining an aviation medical certificate that leads to all of the possible-or-confirmed cases of a professional pilot “losing” it while in flight.
I guess you’ve never seen how crazy a hallucinating AI agent can get.
" The only choice whether we take away their livelihood and create a powerful incentive for them to hide the problem "
EVERYONE knows going in that physical/mental problems will stop you from flying.
It’s no surprise. If you chose flying as a career then you know that your career is always no more secure than your chances of contracting a debilitating disease or having a serious car accident.
What’s disgusting are people who know the rules but then lie and cheat because they put money above both morals and the safety of others.
“Why did you do that?”. That question on the recorders implies that one of the pilots saw the other pilot shut off the fuel! The question would not have been asked if the issue had not been actually seen. So, it is known who asked and who replied. It is also know what was the tone, urgency with that request. Answer. One of the two deliberately shut off the fuel. Why? We might never know.
Gary, I think the topic of mental health issues in aviation is more a “Chicken & Egg” topic.
February 28, 1927, the Department of Commerce’s Aeronautics Branch published a list of the first 57 physicians qualified to give medical examinations for pilot licenses. Scattered over the United States, these physicians (soon to be known as aviation medical examiners) had been selected and qualified by Aeronautics Branch Medical Director Louis H. Bauer.
Given that psychology did not evolve beyond the range of lobotomies until the early 50’s, mental health issues were widely frowned upon topics. Only then, chemical/ pharmaceutical psychology evolved.
People have always tended to steer clear of people with a “issue”. Back then it was normal to declare anyone hysterical or under siege by dark forces.
Depression, Anxiety Disorders, PTSD, OCD and so many personality disorders were largely unknown territory, with people suffering being locked away.
We count in excess of 200 psychological disorders these days, which are treated by (likely) tens of thousands of medications.
While we slowly figure out, that a lack of psychiatric care/ personal therapy mixed with highly psychoactive drugs may not solve our societal issues, we nevertheless truck on. Prescribe a pill.
Unfortunately, people born in the 40’s to 60’s will be tending to dismiss psychiatric issues as humbug and in their minds, pilots are among the “leaders of society” like doctors, lawyers or other highly specialized professionals. While this is highly delusional, it nevertheless sticks.
These people are fully expected to be immune and above reproach, psychologically fully balanced, starry eyed healthy, fit problem-solvers - unaffected by real life. Heros!
The FAA (or any other regulatory entity) has never been very flexible with its determination of any individual pilots fitness for flight. There are black and white standards which are applied. Take the “wrong” medication and your AME is off the hook and powerless. There is a process to follow that will (1) put you out of work (2) cost time and (3) incredible amounts or money and nerves. Not for no reason, people avoid using their AME as their primary healthcare practicioner. Its often best if these two people never meet… issues are remaining secret, undiagnosed, untreated. That cannot be the purpose of a safety relevant regulation.
Newsflash: Psychological disorders are in a steady climb. Your level of immunity may temporarily vary, but there is no escaping reality…
While on topic, I am reminded of the airline captain who walked out of a fresh Class I ATP Medical Examination and passed away on the way home from a brain aneurism. He was fit to fly until he wasn’t.
If the scenario of a simultaneous dual mechanical failure of the fuel cutoff switches is supported, why didn’t they fail during taxi out or initial takeoff roll instead of the precise time when there would be insufficient response time for an air relight?
Anyone who’s flown with a captain trying to catch his commute flight home knows they can shut both engines down, run a shutdown checklist, grab their bag and blow through the door in a few seconds!
The safety features with start switches generally try to prevent inadvertent starting not shutdown.
I had two thoughts. One was a suicide/mass murder. The other was that this happened right when the gear should have come up. Was this a situation of not having adequate sleep and just going thru the wrong rote motion?
I can see accidentally raising flaps instead of the gear, but even if it was a matter of lack of sleep… why would whoever did it “raise 2 gear levers”?
Hey all you armchair psychiatrists, was the flight crew wearing their jackets at takeoff? Was there a required noise-abatement power reduction after TO? With a weak or disabled detent, it could have been an accident, completely compatible with the CVR. As a design engineer, I would have designed the quadrant with a switch cover linked to Idle Throttle for each engine.
That’s what I said above. I spent some time dealing with human factors in the USAF and thereafter on a major airplane program … those switches either need to be moved OR – as you said – have a SECONDARY protective mechanism so that there’s no possible way to make a mistake; requiring a conscious effort to get at them. They’re too far into the open.
Even though the airplane massively crashed, I’d hope they could find those switches ?? AND … I STILL wanna know if software exists between activation of those switches and some solenoid operated valve closing off the fuel flow. IF so … I’d wager big $$ that was the cause? This AM, they’re saying Boeing stock is up because Air India is saying that the airplane wasn’t at fault. I don’t believe it until Boeing says that the switches are DIRECTLY connected to a valve.
Turning both fuel cutoff switches within 1 sec is quite possible in normal operation. Turning both off simultaneously with one hand is possible with sufficient hand size, but would be difficult.
The AFDR can only record the electrical state of the switch, not the physical position. Since these are electrical switches that send a signal down a wire to an electromechanical device (with or without a software intervention) it is possible for a wire fault (e.g. short) to cause the fuel cutoff valve to close regardless of the switch position. It is not clear where the AFDR gets the fuel cutoff switch state from. It could just be the shutoff valve position.
Having the fuel cutoff switches/levers below the throttles has been a feature of jet transport aircraft design from the very beginning. If this is a design fault leading to inadvertent shutting off of engine fuel supply, it should have cropped up before this accident.
I agree Roger. I have not seen anything regarding what language they were speaking. Is what is being quoted in the English speaking press a direct quote or a translation? If it is a direct quote or a very literal translation, then I think not asking something like “What the hell?” Or “Why did the fuel cutoff?” But instead asking “Why did you switch the fuel off?” seems significant. That’s a specific question indicating he immediately knew exactly what had happened - he knew it wasn’t software or hardware - he knew the switches had been manually switched. I can easily see a scenario where a pilot who intentionally threw the switches might ask that question to obfuscate assigning blame. If that quote is accurate or a very literal translation, then I think that is an indication that the pilot asking the question either directly witnessed the switches being manually switched, looked down and saw them in the off position, or he did it himself.
Boeing has issued an Emergency AD for the 787:
(I HAD to do it!
)
Assuming the lockout bump tabs were present, there can be only two reasons for fuel cutoff … crew commanded shutoff OR system activated via automation. Until Boeing tells us that there is no automation involved, I’m going with the latter.
Replace the word “system activated” with “system accepted”. Simple issue of config alert. Execution requires dual confirmation. The plane probably complains when you try to taxi with a open/ occupied lavatory.
Thanks for reply. I can think of only one reason you might want to hit the cutoff switch before reducing throttle to idle and that would be an explosion in one engine. I’m for direct connect to valve. Like many old-timers, I’m getting increasingly suspicious of software, especially AI, as just as no two things in this universe are exactly alike, no two incidents are identical. Humans can usually deal with that.