Air India Flight AI171 (Boeing 787-8) Crash

Did you guys see this in the report? It might turn out to not have been human error per se but just plain old bad luck considering neither pilot claims to have disengaged the switches.

quote: "The FAA issued Special Airworthiness Information Bulletin (SAIB) No. NM-18-33 onDecember 17, 2018, regarding the potential disengagement of the fuel control switch locking feature. This SAIB was issued based on reports from operators of Model 737 airplanes that the fuel control switches were installed with the locking feature disengaged. The airworthiness concern was not considered an unsafe condition that would warrant airworthiness directive (AD) by the FAA. The fuel control switch design, including the locking feature, is similar on various Boeing airplane models including part number 4TL837-3D which is fitted in B787-8aircraft VT-ANB. As per the information from Air India, the suggested inspections were not carried out as the SAIB was advisory and not mandatory. The scrutiny of maintenance records revealed that the throttle control module was replaced on VT-ANB in 2019 and 2023. However, the reason for the replacement was not linked to the fuel control switch. There has been no defect reported pertaining to the fuel control switch since 2023 on VT-ANB."

I'm certain that there will soon be a updated inspection requirement for these fuel control switches across the board.
Yeah, I saw that. We are a couple of years from actually knowing what led to this.
 
I read on YouTube someone mentioned:

“AC DUAL ELECTRICAL BUS "FULL POWER TRANSFER FAILURE" occurred (as was evidenced by the RAT being deployed and the Landing Gear FAILING TO RETRACT.

Is this even possible on 787 ?
Doesn’t the aircraft have redundant Electrical Bus system ?
 
I read on YouTube someone mentioned:

“AC DUAL ELECTRICAL BUS "FULL POWER TRANSFER FAILURE" occurred (as was evidenced by the RAT being deployed and the Landing Gear FAILING TO RETRACT.

Is this even possible on 787 ?
Doesn’t the aircraft have redundant Electrical Bus system ?
Yes, it’s theoretically possible - and one of the conditions for RAT deployment - but a dual engine failure will also cause RAT deployment, and in this case, the YouTuber is chasing a red herring.

Because, the fuel control switches were both placed in “cutoff”, and not placed back in “run” until 10 seconds had passed, by which time, even with the auto-relight feature on the engines, they did not have enough time to re-start and spin up to provide thrust.

No thrust at 100 feet doomed the airplane.

The landing gear handle was found in the down position among the wreckage.

So, the YouTuber theory has already been debunked.
 
Why would you need to “film” what pilots are doing when CVR and FDR ( plus airlines flight data analysis ) already tell investigators what’s going on in the cockpit?

If the dual power loss was because the PF had his hands in the TL and his seat slid back ( notice there was no pitch change in the video ) , they already have enough information to know as I am sure it will also show up on the CVR.

How about this before they start filming us……don’t allow pilots to keep their hands on the TL below thrust reduction altitude given at least another airline had an upset caused by a pilots seat sliding backwards.

I'm certainly not the only person wondering why there isn't cockpit video, which could show things that data can't.
Commercial airliners are required to have only flight data recorders and cockpit voice recorders, commonly called “black boxes”, but the NTSB has long called for cockpit image recorders, as well. Such video would have been extremely helpful in determining flight crew actions in recent crashes in Texas, Indonesia, and Ethiopia.​
The NTSB believes other types of passenger-carrying commercial aircraft, such as charter planes and air tours, should be equipped with data, audio, and video recording devices. These operators should also have programs in place that analyze the data derived from these devices. Recorders and flight data management programs would not only help investigators solve accidents, but they would also help aircraft operators prevent crashes in the first place by allowing crew actions to be evaluated regularly.​
 
I'm certainly not the only person wondering why there isn't cockpit video, which could show things that data can't.
Commercial airliners are required to have only flight data recorders and cockpit voice recorders, commonly called “black boxes”, but the NTSB has long called for cockpit image recorders, as well. Such video would have been extremely helpful in determining flight crew actions in recent crashes in Texas, Indonesia, and Ethiopia.​
The NTSB believes other types of passenger-carrying commercial aircraft, such as charter planes and air tours, should be equipped with data, audio, and video recording devices. These operators should also have programs in place that analyze the data derived from these devices. Recorders and flight data management programs would not only help investigators solve accidents, but they would also help aircraft operators prevent crashes in the first place by allowing crew actions to be evaluated regularly.​
No. Just.

No.

The idea that you could video me for several hours at a time, watching everything I do, and then download the video and seek to find fault with everything I do, is absolutely unacceptable.

It doesn’t improve safety, because they wouldn’t prevent anything. but it does destroy the concept of privacy, of presumptive innocence, or of decency.

Not even China has cockpit cameras.

Besides, I think you would find those cameras frequently “fail“.

Let me know if I can just put a camera in your kitchen, living room, study, and bedroom, and just watch, just to make sure that you’re not committing crimes.

I’ll allow your employer to download my video content, and if they find you doing a single thing that’s against the employee handbook, ensure that they terminate you.

I mean, it’s all about safety, right?

There is a good reason that Pilot unions, and even Airlines themselves, are opposed to the concept.
 
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A cockpit camera would not have prevented this, however, it would serve to satisfy the voyeurism and morbid curiosity of the public.

And that’s really not something we should encourage.

Further, misinterpretation of the digital images will lead to false conclusions, false accusations, and compromised accident investigations.

It’s often true that what you thought you saw on the video is not actually what happened, and the actual position of things like rudder pedal or throttles, are much better measured using an actual Flight data recorder, and eliminating parallax errors, and other inaccuracies of the video.

Here is the ALPA statement on the subject:

Cockpit Image Recorders (CIR) refers to the use of video cameras to record events in cockpits. Some proponents, including the National Transportation Safety Board (NTSB), advocate the installation of CIRs in commercial airliners. NTSB states that CIRs will benefit accident investigations and improve safety by providing new information for investigators.

While on the surface these may appear to be reasonable and justifiable claims, closer examination proves otherwise.

Current technology already provides investigators with the tools they need to determine the causes of airline accidents. The digital flight data recorder (DFDR) can record hundreds of parameters ranging from basic values such as altitude and speed, to details such as rudder pedal position, the position of every switch, and even the onset of smoke alarms in the lavatory. The cockpit voice recorder (CVR) provides an audible recording of voices, radio transmissions, and sounds in the cockpit. Investigators have a wide array of analytical techniques to tease information out of forensic evidence from the wreckage and other sources. While any accident will leave unresolved questions, the fact is that it is extremely rare for investigators not to be able to reach the findings and conclusions necessary to determine the cause of an accident. Video imaging would add virtually nothing of real value to the investigative process, and could, due to its subjective nature, actually lead investigators down the wrong path.

Contrary to popular opinion, compared to the precise data provided by the DFDR and forensic evidence, video imaging is an imprecise form of information. If an image shows a pilot’s hand moving toward a switch or moving his or her leg, that does not prove that he/she activated that switch or made an input to the rudder, whereas the DFDR will show the exact state of each switch, the exact amount of rudder input. Given the proper sensors, the DFDR can even distinguish between the pilot pushing on the pedal and the pedal pushing on the pilot–a distinction impossible to determine with video.

The goal of accident investigation is not to solve accidents for its own sake, but to improve safety by preventing accidents. Recent developments in data analysis (from accidents, from analysis of data recorded in a separate data recording system used primarily for maintenance, and from voluntary event reporting systems) have shifted the emphasis in accident prevention toward proactive "data mining" methodologies that are far more effective in accident prevention. Again, the precise accident data combed from DFDRs and other sources is far more useful than the problematic, subjective interpretation of video recordings.

While CIR will be of minimal value in analyzing and preventing accidents, it represents a major invasion of privacy for pilots. Having your every move recorded by video cameras is bad enough. Despite strong U.S. laws protecting CVR and CIR tapes from public access, they can be played in court in some circumstances. Tort lawyers will find video recordings to be an irresistible gimmick to increase damage claims for pain and suffering and for alleged negligence. Far worse, though, is the prospect of an accident outside U.S. territory. A CVR tape from a U.S. accident in Colombia has already been played in the US media after the network obtained a copy from sources there. Despite proposals to encrypt images, no encryption scheme is 100 percent secure, especially with continued advances in computer technology. Once out in the open, a video recording can be made available on the Web from anywhere in the world, 24 hours a day, forever. As one pilot bluntly stated, "I don’t want my spouse and children and grandchildren and a million strangers to be able to watch me die."

Pilots accepted cockpit voice recorders because they have proved to be valuable, and sometimes indispensable, additions to accident investigation and prevention. The combined data from CVRs, DFDRs and other forensic evidence has proved to be the right solution for modern accident investigation and prevention. CIR provides no significant additional benefits, while inflicting a far greater invasion of privacy than CVR recordings.

While onboard video cameras may prove to be of some limited use, such as allowing pilots to see exterior views of the aircraft, ALPA is opposed to any use of video recording in the cockpit.
 
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Only thing that cockpit cameras can do is increase accidents. Instead of training reflexes, pilots would first think of Human Resources requirements.
Than video shows up in public and, like with everything today, your local hair dresser is suddenly more vocal and influential than NTSB.
 
"...Contrary to popular opinion, compared to the precise data provided by the DFDR and forensic evidence, video imaging is an imprecise form of information. If an image shows a pilot’s hand moving toward a switch or moving his or her leg, that does not prove that he/she activated that switch or made an input to the rudder, whereas the DFDR will show the exact state of each switch, the exact amount of rudder input. Given the proper sensors, the DFDR can even distinguish between the pilot pushing on the pedal and the pedal pushing on the pilot–a distinction impossible to determine with video..."

I have worked with the NTSB on two separate occasions, but here I totally agree with the ALPA and disagree with the NTSB.

 
No. Just.

No.

The idea that you could video me for several hours at a time, watching everything I do, and then download the video and seek to find fault with everything I do, is absolutely unacceptable.

It doesn’t improve safety, because they wouldn’t prevent anything. but it does destroy the concept of privacy, of presumptive innocence, or of decency.

Not even China has cockpit cameras.

Besides, I think you would find those cameras frequently “fail“.

Let me know if I can just put a camera in your kitchen, living room, study, and bedroom, and just watch, just to make sure that you’re not committing crimes.

I’ll allow your employer to download my video content, and if they find you doing a single thing that’s against the employee handbook, ensure that they terminate you.

I mean, it’s all about safety, right?

There is a good reason that Pilot unions, and even Airlines themselves, are opposed to the concept.

The technology is there and there are all manner of jobs where people know they'll be scrutinized. A supermarket checkout clerk is going to be on video that will be saved. Police are constantly being monitored as to what they're doing with dash and body cams. Bank employees too. Or bus/taxi drivers.

With cockpit video, I would think they would probably just go with the standard 25 hours that voice/data recorders keep. And even then I recall there were complaints about that with fears that airlines might tap the recorders to look for every little thing if it was more than the previous 2 hours. I was under the impression that cockpit voice/data recorders aren't allowed to be checked unless there's an incident worthy of downloading the data.
 
The technology is there and there are all manner of jobs where people know they'll be scrutinized.
It is not a matter of scrutinizing. It is a matter of properly interpreting the actions of those in the imprecise information contained in the video.

Again, "Contrary to popular opinion, compared to the precise data provided by the DFDR and forensic evidence, video imaging is an imprecise form of information."
 
Juan Brown just posted this video on the prelim report:

Watching this video as well as Jeffostroff video highlighting the timestamps for the events in the preliminary report does seem to be missing some information that to me would be important to know. It does NOT mention that the pilot verbally says, “V1 or rotate”. The report only says data extracted from black box achieved Vr at 08:08:35 and lift off at 08:08:39. It does NOT mention that the pilot verbally says, “positive rate or retract gear”. Why this may be significant is at 08:08:42 (time when fuel switch is changed to CUT OFF position) is kind of in the time frame when gear lever is suppose to be retracted if visibly climbing but as we all know the landing gear was always seen down (likely insufficient hydraulic pressure) even though the report says gear lever found in UP position. Is it possible the pilot mistakenly or purposely switched both fuel cutoff instead? Aren’t pilots trained to perform commands and verbally repeat them? When the other pilot questioned improper operation and the RAT is deployed 5 seconds later, engines spooling back, landing gear light still down…could have the offending pilot realizes mistake and switches both fuel switches to RUN position though too late? There should be more dialogue between these two pilots that the preliminary report isn’t mentioning.
 
The technology is there and there are all manner of jobs where people know they'll be scrutinized. A supermarket checkout clerk is going to be on video that will be saved. Police are constantly being monitored as to what they're doing with dash and body cams. Bank employees too. Or bus/taxi drivers.

With cockpit video, I would think they would probably just go with the standard 25 hours that voice/data recorders keep. And even then I recall there were complaints about that with fears that airlines might tap the recorders to look for every little thing if it was more than the previous 2 hours. I was under the impression that cockpit voice/data recorders aren't allowed to be checked unless there's an incident worthy of downloading the data.
One thing is common between those jobs and what you think should happen: video. Nothing else is common.
Standards to become a cashier, bank clerk, or bus driver are low. Most people can do those jobs. Recruiting is not an issue.
The police are the same. Contrary to popular belief, police officers do not have to have some exceptional education, etc. Recruitment depends on each state, different laws, different policies from city to city, etc. We give LEO a weapon and A LOT of discretion, as well as qualified immunity.

You know very well how many kids wash out before coming to USAFA, and once there, how many will give up flying. Then a lot of them who actually go on to become pilots won't make it. Then some will stay in the military, and some, maybe, go to airlines. A few years back, I had a conversation with my good friend who was the commander of the air force academy in a small European country, and they graduated 1 cadet that year! They had people in 50's in fighter jets because of recruiting problems. Putting cameras in the cockpit would definitely change the dynamics and maybe discourage the best from going to look for jobs elsewhere. We have CVR and CDR, and most things we can get from that.
 
The technology is there and there are all manner of jobs where people know they'll be scrutinized. A supermarket checkout clerk is going to be on video that will be saved. Police are constantly being monitored as to what they're doing with dash and body cams. Bank employees too. Or bus/taxi drivers.

With cockpit video, I would think they would probably just go with the standard 25 hours that voice/data recorders keep. And even then I recall there were complaints about that with fears that airlines might tap the recorders to look for every little thing if it was more than the previous 2 hours. I was under the impression that cockpit voice/data recorders aren't allowed to be checked unless there's an incident worthy of downloading the data.
No, the technology is not there.

The images you see of a cashier are simple and easy to interpret. The actions of a flight crew and environment of the cockpit are far more complex, so what you think you see on the video will be misleading, degrading safety investigations and degrading the performance of the crew.

It sounds very attractive, to those interested in an Orwellian fantasy of watching everyone, but it will absolutely degrade safety in normal operations because the crew will be “performing” for the camera instead of doing their job, knowing that their supervisors could review the tape, and it will absolutely degrade accident analysis because it is misleading.

Did the pilot apply rudder? On the video, because we can’t see foot position, it might look like he didn’t, when he should have. The FDR will capture that unambiguously. The video is a misleading bit of data in a world that already has good data to do the forensics.

So, no cockpit video will degrade the safety margins in normal operations and adulterate the investigation of crashes like this, no matter how attractive it seems to the layman.

It’s a horrible idea.
 
Watching this video as well as Jeffostroff video highlighting the timestamps for the events in the preliminary report does seem to be missing some information that to me would be important to know. It does NOT mention that the pilot verbally says, “V1 or rotate”. The report only says data extracted from black box achieved Vr at 08:08:35 and lift off at 08:08:39. It does NOT mention that the pilot verbally says, “positive rate or retract gear”. Why this may be significant is at 08:08:42 (time when fuel switch is changed to CUT OFF position) is kind of in the time frame when gear lever is suppose to be retracted if visibly climbing but as we all know the landing gear was always seen down (likely insufficient hydraulic pressure) even though the report says gear lever found in UP position. Is it possible the pilot mistakenly or purposely switched both fuel cutoff instead? Aren’t pilots trained to perform commands and verbally repeat them? When the other pilot questioned improper operation and the RAT is deployed 5 seconds later, engines spooling back, landing gear light still down…could have the offending pilot realizes mistake and switches both fuel switches to RUN position though too late? There should be more dialogue between these two pilots that the preliminary report isn’t mentioning.
There may be more dialogue that was not yet released. The report is preliminary.

The important dialogue is there - the discussion of the fuel control switches to cutoff.

Let’s wait for the final report.
 
I think the American Airlines DC-10 that crashed at O'Hare, when one of it's engines came off the pylon, had a cockpit video that showed the takeoff to the passengers.

I doubt it could have showed much detail as far as actions by the flight crew. For one thing it was 1979, and TV monitors were horrible compared to today's 4K LCD screen technology.

I'm just guessing, but I think that idea quietly died after that accident.
 
I think the American Airlines DC-10 that crashed at O'Hare, when one of it's engines came off the pylon, had a cockpit video that showed the takeoff to the passengers.

I doubt it could have showed much detail as far as actions by the flight crew. For one thing it was 1979, and TV monitors were horrible compared to today's 4K LCD screen technology.

I'm just guessing, but I think that idea quietly died after that accident.
"I don’t want my spouse and children and grandchildren and a million strangers to be able to watch me die." - anonymous

Look, the point is that the cockpit video idea is a giant red herring. It is attractive only to people with voyeuristic tendencies, people with dreams of Orwellian oversight, or those who are completely ignorant of all of the safety initiatives that we already have. In addition to the flight data recorders, every major airline has a quality assurance program (we call it FOQA) that tracks all of those parameters.

Every flight is already downloaded and analyzed.

I will say that again, because it bears repeating: every flight already has the recorded data, downloaded and analyzed.

We are already doing that, and we can carefully control the de identification, so that it is not used for punitive purposes.

In some countries, and I’m looking at India and China, that data is used for punitive purposes. Pilots are fined, by their own companies, for not using the auto pilot as much as those companies want, for example. Yes, there are airlines that punish their pilots financially for trying to become better pilots through development of their hand flying skills.

So, every action that every pilot takes at my airline is already recorded, identified, downloaded, and analyzed so that we can track things like exceedances and mistakes, on order to do the trend analysis and become better. Those initiatives have created the safest operation in the world. Air travel in the west, so I’m including most of the European carriers, companies like Air Canada, and the major American Airlines, operate the safest airlines in the world by a long shot.

It is this proactive approach that will continue to advance safety. Finger pointing in the aftermath of an accident, using a video of dubious value, that could be misidentified, will only serve to degrade safety.

The cockpit video is an initiative that deserves to die a quick and painful death. Much better systems are already in place, and have already yielded huge benefits.

Let’s focus, develop and improve that which works, instead of dredging up ideas that will degrade safety.
 
No. Just.

No.

The idea that you could video me for several hours at a time, watching everything I do, and then download the video and seek to find fault with everything I do, is absolutely unacceptable.

It doesn’t improve safety, because they wouldn’t prevent anything. but it does destroy the concept of privacy, of presumptive innocence, or of decency.

Not even China has cockpit cameras.

Besides, I think you would find those cameras frequently “fail“.

Let me know if I can just put a camera in your kitchen, living room, study, and bedroom, and just watch, just to make sure that you’re not committing crimes.

I’ll allow your employer to download my video content, and if they find you doing a single thing that’s against the employee handbook, ensure that they terminate you.

I mean, it’s all about safety, right?

There is a good reason that Pilot unions, and even Airlines themselves, are opposed to the concept.
Video has long been used in manufacturing process control to correlate what is actually done at the control panel. They typically do not show the operator at all just their hand adjusting settings and controls - thats it. It does two things - understand what the operator is doing right or wrong, and also if the machine does in fact what the operator told it since there is usually a second camera on the process synced to a common clock. Since thats all it shows, I don't know why anyone would feel there right to privacy has been violated.

We don't use it much anymore. We just automated those people out. The robots record everything they do now.

Surgeries more and more often are also being recorded now. LEO wear body cams, etc.
 
Video has long been used in manufacturing process control to correlate what is actually done at the control panel. They typically do not show the operator at all just their hand adjusting settings and controls - thats it. It does two things - understand what the operator is doing right or wrong, and also if the machine does in fact what the operator told it since there is usually a second camera on the process synced to a common clock. Since thats all it shows, I don't know why anyone would feel there right to privacy has been violated.

We don't use it much anymore. We just automated those people out. The robots record everything they do now.

Surgeries more and more often are also being recorded now. LEO wear body cams, etc.
Keep reading. It’s attractive only to those who don’t understand aviation. Video in the past has provided misleading evidence of what actually took place.

Your manufacturing system does not have sensors on every single component touched by those people, but the aircraft does.

We have much more detailed, accurate sources of information than video.

Manufacturing does not. In fact it never can because every step of the process, and every component touched is not instrumented the way an aircraft is. You don’t have flight data recorders, capable of withstanding a crash.

Video is a red herring and a mistake.

It may be attractive to those who don’t already have a better system. Aviation already has a better, more accurate, system.
 
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Keep reading. It’s attractive only to those who don’t understand aviation. Video in the past has provided misleading evidence of what actually took place.

Your manufacturing system does not have sensors on every single component touched by those people, but the aircraft does.

We have much more detailed, accurate sources of information than video.

Manufacturing does not. In fact it never can because every step of the process, and every component touched is not instrumented the way an aircraft is. You don’t have flight data recorders, capable of withstanding a crash.

Video is a red herring and a mistake.

It may be attractive to those who don’t already have a better system. Aviation already has a better, more accurate, system.
I don't understand aviation, but your wrong about industrial - everything that moves has feedback on it, and if a person can be injured it must be SIL rated. What we found years ago is the controller logs would tell the story but the operator would claim they told the machine to do something else and it was the machine that was broken. Then you looked at the video and of course it showed the operator doing exactly what the controller logs said it did.

Our solution was as the tech got better, we replaced the operator.

If everything is logged, perhaps it tells the whole story. I understand no one wants to be recorded at work.
 
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