[2] https://www.congress.gov/119/bills/hr2591/BILLS-119hr2591ih....
[2] https://www.congress.gov/119/bills/hr2591/BILLS-119hr2591ih....
Pilots deactivate the fuel cutoff at the end of the final taxi to the gate. This makes flipping these switches a practiced maneuver, capable of being performed without conscious thought, regardless of whether they came with safety locks installed.
Brain farts are a real phenomenon, and an accidental fuel cutoff most closely resembles the transcript from within the cockpit.
The report is actually a little cagey about whether the locks were properly installed on these switches. Said locks are supposedly optional. Until I receive a more direct confirmation that the switches were installed with their full safety features, I will assume that it is more likely for the plane to have had improperly installed switches than not, given that the shutoff was the reason for the crash, and if they turn out to have been installed, I will assume that simple pilot error is responsible until a motive for murder is found. The pilots lives are under quite a lot of scrutiny, and I do not believe that a motive for murder is likely to be found.
I don't fly a lot of planes, but I do know what muscle memory is like, and sometimes it misfires. Misfires are rare, but then, so are plane crashes.
The emergency fuel cutoff should not be a practiced maneuver.
This is a bit like someone parking their car, pulling the handbrake, turning off the car and putting their keys in their pocket, then arguing that it’s a practiced maneuver because it happens at the end of every car ride.
This is like pulling the handbrake on the highway when you’re trying to use your high beams
Plenty of crashes have resulted from Pilots not acting 100% by the book.
> and as far as I know there were no callouts here (e.g. “gear up”)
Unfortunately we don't have a full CVR transcript.
The locks/gates on the switches are definitely NOT optional. There was an SAIB about some switches that may have been installed improperly. It didn't result in an AD, which likely means the extent was limited or potentially even nil.
The switches were moved to cutoff with a one second delay between the first and second switch. That's pretty suggestive of deliberate movement. I've flown a Max9 simulator, which has the same switches. Moving one of them by accident would be impossible, let alone two of them.
I agree with not jumping to conclusions about the pilots and possible motives or circumstances, but I will bet a lot of money that the switches were just fine.
The CVR will likely have audio of the switch movement to confirm as well.
did the report say a one second delay or that the two switches were turned off at consecutive seconds? The latter is what I remembered, but I'll check again.
> did the report say a one second delay or that the two switches were turned off at consecutive seconds?
The report states, on page 14: The aircraft achieved the maximum recorded airspeed of 180 Knots IAS at about 08:08:42 UTC and immediately thereafter, the Engine 1 and Engine 2 fuel cutoff switches transitioned from RUN to CUTOFF position one after another with a time gap of 01 sec.
"with a time gap of 01 sec" seems fairly clear. The final report will have more granularity, but I don't think that's very ambiguous.
Not at all. First of all writing it as "01" begs the question if there is a typo (is that really supposed to mean 1 or 0.1?) but even without that only specifying the interval to a second precision makes is much more likely that the difference is between samples of the switch state that are recorded at that rate.
I second that it’s not an accidental motion, you must actively manipulate the switch. But just like your turn signal in your car, it is muscle memory when you use it. I just wonder what action the pilot mistook the fuel cutoff for. Looking around the cockpit shows just how unique those switches are and not something you mistake with another common activity.
Pretty sad day if this was an intentional action
Improbable, not impossible.
I HAVE sometimes “lost” my phone in my own backpack though (lol).
Here’s my take as a non-pilot. Takeoff is a sequence of checklists and procedures that are repeated. Often. If it’s muscle memory, a brain fart seems very unlikely… that’s why i’m skeptical of your theory.
A better analogy would be “have you ever forgotten to put on shoes before leaving your house?” And no, i have not, even during emergencies or when i’m very tired (like when i had to rush my wife to the ER). Why? because that’s something i do daily, and is part of my checklist when departing my house.
Or “have you ever forgotten how to get to work?” that also is extremely unlikely, because one typically follows the same exact steps and route daily. And i don’t randomly turn off my engine while driving, even if i’m multitasking or im forced to take a slightly different route due to a detour.
To be clear, i’m not saying it’s physically impossible. I just find it inconceivable.
You say muscle memory. No muscle memory is involved in fuel cut off for both engines seconds after take off. There is no procedure remotely similar.
The report specifically mentions SAIB No. NM-18-33 which would be a very odd thing to do if the investigators didn't at least consider this to be a possibility.
> You say muscle memory. No muscle memory is involved in fuel cut off for both engines seconds after take off.
It doesn't matter when the action is normally done - muscle memory means that the complex action of flipping a guarded switch doesn't really need a bigger brain fart than any other input because once the action is initiated you're acting on autopilot.
Well I'd Never sputter Good Ma'am or Sir, ARE you implying something like a "MAIN BATTERY EXHAUST"¹ retrofitted to a flagship product because management was impatient and wanted the lighter, better, faster, stronger lithium-ion-battery for their rushed 787-sized baby?
¹) https://media.cnn.com/api/v1/images/stellar/prod/14011413401...
Investigation and preliminary report is not showing critical evidence that would help clarify. Like the full transcript of pilot conversations that is clearly already available, and if these switches had any maintenance in the last year.
The fact that both pilots denied moving the switches, combined with the extremely short timeline, makes mechanical/electronic failure the most probable cause.
Note the Critical Sequence:
08:08:39 UTC: Aircraft lifts off (air/ground sensors transition)
08:08:42 UTC: Maximum airspeed of 180 knots reached
08:08:42 UTC: IMMEDIATELY after max speed, both fuel cutoff switches transition from RUN to CUTOFF (1 second apart)
08:08:47 UTC: Both engines below minimum idle, RAT deploys
08:08:52 UTC: Engine 1 switch returns to RUN
08:08:56 UTC: Engine 2 switch returns to RUN
So only 3 seconds between liftoff and fuel cutoff. Extremely short window for deliberate pilot action...
Another possibility is a foreign object like a personal item sliding back during acceleration.
I looked at both pilots background, and unless a story of medical depression on the part of the captain emerges, I dont see the pilot suicide as plausible.
Seems like the evidence is starting to become fairly one sided…
>> The switches are not software controlled.
That is what unethical people, like Captain Steeeve - Who changed his "accident clear cause" story four times since the accident - keep saying.
But on the 787, fuel switches are part of the electronic cockpit interface and toggling one sends a command via AIMS to the Engine Interface Unit, then over AFDX to the FADEC. The FADEC actuates the spar and engine fuel shutoff valves who are both electrically controlled with no mechanical linkage.
The switch itself doesn’t cut fuel, it initiates a command interpreted and executed by software. Additionally, software logic can override or block the command based on conditions like fire, overspeed, or sensor faults so its software-controlled end-to-end.
A faulty sensor could trigger even if so far evidence points to the Captain.
"Understanding the Boeing 787 Fuel Control Switch: Function, Operation, and Safety Mechanisms" - https://aeropeep.com/boeing-787-fuel-control-switch-explaine...
"How do the fuel cutoff switches on the Boeing 787 work?" - https://aviation.stackexchange.com/questions/110938/how-do-t...
"Full Authority Digital Engine Control (FADEC)" - https://skybrary.aero/articles/full-authority-digital-engine...
"Full authority digital engine controls have no form of manual override available, placing full authority over the operating parameters of the engine in the hands of the computer.
- If a total FADEC failure occurs, the engine fails.
- Upon total FADEC failure, pilots have no manual controls for engine restart, throttle, or other functions."
What transcript? We only got a few potentially re-phrased bits of what was said. That the preliminary report is very careful about not implicating either pilot is not evidence of anything except that the investigative team is not yet 100% sure on the matter.
Secondly, yes, it was likely a deliberate action to cut off the fuel switches, as you say.
You are absolutely right that there’s an epidemic in the airline industry that forces pilots to stay quiet rather than risk their careers if they’re dealing with mental health issues.
In a sibling comment: “shouldn’t they be given alternate career paths?” No. Perpetuating the myth that people with mental health issues are somehow broken beyond repair is mistaken. Current policy lead directly to that one fellow to lock the cockpit door and slam the plane into a hillside. If Air India 171 has any chance of being a mental health issue today, it should be highlighted and explored. You’re exactly right to be doing that, and thank you.
Anyone who disagrees with this should watch https://youtu.be/988j2-4CdgM?si=G39BwNy1zJEeUi2k. It’s a video from a well-respected pilot. The whole point of the video is that aviation forces people to conceal their problems instead of seek treatment, and that this has to change.
The problem is that many people in aviation imagine that they need to conceal their problems. And they point to videos like this one as proof of that, ignoring that the events of discussed in the video are actually proof of the opposite.
Emerson (the suicidal pilot in the video from Alaska Airlines Flight 2509) self-medicated himself using hallucinogenic substances and developed suicidal ideations, because he didn't seek treatment (like therapy) for his mental issues after the death of a friend. If he had sought treatment, he'd still be flying today because he wouldn't have tried to kill several dozen people, and he would have learned to cope with his depression.
I have no idea how this video’s chapter 6 can be titled "a call for change" and then you still deny that the video is saying there’s something desperately wrong with the aviation industry. All I can think of saying is that you’re mistaken. It’s proof of exactly what the video is saying needs to change.
We’ll have to agree to disagree. I feel bad for all the pilots who have to deal with this kind of attitude about mental health issues, as if suicidal ideation should somehow disqualify someone from working in their chosen profession. People in the military are allowed to feel suicidal. Your doctor is allowed to feel suicidal. The guy next to you on the road is allowed to feel suicidal. But pilots? Nope. It’s treated as this unspeakable awful thing, and you’re forcing people to get "treatment" where they report "yes, that totally worked" (a lie) or else suffer consequences. If you don’t see how backwards that is, no words of mine will persuade you otherwise.
Why argue so vehemently that treatment should be denied to people? That’s what you’re doing by saying there’s no problem and that nothing needs to change. I assure you, the pilot in the video likely knows far better than your friends. That’s why he made the video.
While obviously the incidents are terrible, do you really think he would self-report, voluntarily endure 6+ months of therapy and come back like new, if only the current policy didn't lead him to do what he did?
Totally armchair, but I think people like the German dude and allegedly (but who knows) the Malaysian Zaharie are far gone. The only thing that can help is mandatory health checks, and even then who knows if it's possible to screen for everything.
You have your facts wrong. Pilots can and do fly if they have mental health diagnoses, as long as they are well managed and there is no history of psychosis or suidical ideation. This is how it should be.
https://www.faa.gov/ame_guide/app_process/exam_tech/item47/a...
The whole reason a pilot made that video is because there’s a huge problem in the airline industry right now.
Many of her videos were about her dream of being a pilot, and a few trolls on the internet reporting her grounded them
But a pilot with suicidal ideations, or taking hallucinogens, like Emerson from Alaska Airlines Flight 2509 (the flight discussed in the linked video), would not be allowed to fly. And that's exactly the way it should be...
The issue is that many pilots don't seek treatment for mental issues because they imagine that they'll be grounded if they do, even though FAA policy, and most airlines' policy, is to allow them to continue flying.
You’re forcing people to pretend like they don’t have suicidal thoughts. That doesn’t work. Attitudes that it somehow does work are backwards.
You can’t imagine what it’s like to worry about losing your career because of something you’re forced to keep secret, and is entirely treatable. That’s the kind of barbarism that future generations will look back on us and shake their heads at.
I hope you never have to worry about being de-yourjob’d. In the meantime, let the people who are worried about it campaign for change.
I imagine women had to face similar discrimination when campaigning to be allowed to fly. There were likely a bunch of people saying that the current system was fine, and besides, they didn’t trust a woman to do the job. Just because we’ve moved from discrimination against sexes to those with mental health issues doesn’t mean the system is perfect.
Take your argument to the extreme. Suppose someone has a physical or mental issue that renders them unable to reliably judge a certain type of situation or undertake some action that must be made consistently and repeatedly for safe flight. Presumably such a person has no business in a cockpit, let alone on a plane with hundreds of passengers on board?
The above clearly demonstrates that there are certain minimum requirements for practical reasons and that not everyone in the population is necessarily expected to meet them. It isn't a value judgment but rather an observation about the reality of the world we inhabit.
So the person you are responding to here is suggesting that suicidal ideations might be incompatible with the safety expectations of piloting a passenger airliner. Meaningful disagreement would need to somehow address the practical concern as opposed to deflecting with an appeal to emotion.
A related example that might be worth considering would be someone who suffered from severe and debilitating panic attacks. Or someone deemed to be at particularly high risk of having a heart attack. Or any number of other potentially debilitating conditions that can have sudden and unpredictable onset.
I’ll counter your argument with this: a bus driver is allowed to feel suicidal ideation, yet they safeguard the lives of everyone on board. Maiming everyone would be as easy as accelerating on the highway and swerving off the road. Yet we don’t worry about this, because it’s rare enough not to matter.
Meanwhile if you say "a suicidal bus driver has no business behind the steering wheel", congratulations, you’ve just forced all the suicidal bus drivers to hide their condition.
You’re not going to be able to detect this illness the way you can detect the ones you name. Your policy is going to force people to hide it. It’s a dumb policy. That’s not an appeal to emotion.
That line of reasoning isn't an appeal to emotion but your earlier focus on dehumanization and discrimination most certainly was.
I think it's a reasonable point that such a policy exhibits a severe perverse incentive. So the question becomes, how many lives are lost due to the perverse incentive versus if the policy didn't exist? Someone with the right knowledge and resources can at least make an objective attempt at estimating that.
Regarding bus drivers I'll observe there is a stark difference in both scale and certainty of death. The degree to which safety risks are tolerated almost invariably scales with such metrics. Pilots operate in a domain where an unmitigated failure not resulting in the deaths of everyone on board is far closer to the exception than the norm.
There are also public perception and financial angles to consider. People are rather paranoid about hurtling through the air in metal tubes. The equipment is also rather capital intensive, with a 787 and a hyperscale data center falling vaguely in the same order of magnitude. As such many of the practices surrounding that activity go a bit overboard from an actuarial perspective at least in comparison to other common daily pastimes (but not in comparison to aforementioned data centers).
Which circles back around nicely to your leading statement. It is the act itself, the attempt to commit suicide, that I think is reasonable to view as a sudden and debilitating condition. Those with suicidal ideations are statistically more likely to suffer from that. I think it's extremely similar to the heart attack example, and policy certainly requires commercial pilots to have regular physicals. The primary difference (and potential point of contention) is that there's no straightforward way to hide a physical condition whereas you probably can hide a mental one and (unlike a physical one) doing so is likely to exacerbate it.
There is also the question if they are better ways to reduce the perverse incentives.
1. If the pilot hides his mental illness, a mentally ill person is flying the airplane.
2. If the pilot gets treatment for his mental illness, a mentally ill person is flying the plane.
P.S. When I was a teenager, I tried to join the Air Force to be a pilot like my dad. But since I wear glasses, there was no way. The AF was perfectly justified in not taking me, I understood that. I empathize with the rejected pilots, but that's the way it has to be. Life isn't fair. So I chose another career.
And to your other point, it's easier to give up on your dream job when young and start with a career that you are a fit for, than to be kicked out after a huge sunk cost and maybe even half way to retirement (illnesses might not be known until later in life). Just as disappointing, but not nearly as life destroying.
But I salute you, fellow four-eyes!
I was prescribed glasses when I was 5. Since then, they have preserved my eyes from damage from at least 3 incidents. I no longer mind them - I like the protection!
Pilots who develop a heart condition get their license revoked. Every pilot knows this. There's nothing fair about that, either.
Fun fact - my Air Force dad told me that when an airplane was overhauled, the chief mechanic went up on the check ride. That ensured the job was well done.
For option 2 I'll confess to not being sufficiently familiar with the gamut of what can be considered a mental illness, such that I couldn't tell you whether a person under management for such is a safer pilot than someone undiagnosed, or the median pilot. I'd be mildly surprised if you were, but stranger things have happened.
As it stands, I expect these would be the same diagnostics that until ~2013 considered sexual preferences as mental health issues.
As pragmatic rule, if one is prescribed drugs for it, one is not fit for being a pilot.
I know several people who are prescribed drugs for mental conditions. I would not get on an airplane if they were the pilot. Nor would I get on one with a pilot with a heart condition. It doesn't mean they are bad people, it's just the way it is.
Wearing glasses still has issues. I have astigmatism, and so if I turn my eyes but not my head, I receive a warped view of the world. This is why I was simply terrible at baseball, tennis, etc. My brain could not adapt to this. I have difficulties with depth perception as a result, too.
I was more or less born to be a nerd. It's pointless to fight my fate :-)
You don't get to choose "no mental illness" because of the bad incentives of hiding them!
It looks like the FAA has within the last few years gotten chiller about some antidepressants, but that they still require an elaborate and complicated process to approve use of them.
Psychotherapy significantly reduces the risk of suicide. https://pmc.ncbi.nlm.nih.gov/articles/PMC6389707/
Personally, found it simultaneously one of the greatest and most insane seasons of television ever. YMMV.