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The Ahmedabad crash: accidental or deliberate?

David Learmount Uncategorized , , , , , , , , , , , , , , , , , ,

The movement of two small switches on the aft end of the flight deck centre console, reachable easily by both pilots, appears to hold the key to what happened to the Air India Boeing 787-8 that crashed fatally just after take-off at Ahmedabad on 12 June.

It seems that one of the pilots selected these switches from “Run” to “Cut Off”, stopping the engines at a critical point just after the aircraft became airborne. The purpose of this article is to examine the arguments for and against deliberate action (compared with unintentional error) on the part of one of the Air India pilots.

On 11 July the Indian Air Accident Investigation Bureau published its preliminary factual report on Air India Flight AI171, a Boeing 787-8 registration VT-ANB. This has revealed the movement of the fuel control switches (FCS) mentioned above, and the resulting consequences of that movement. The data confirming this was derived from the two Enhanced Airborne Flight Recorders (EAFR) in the accident aircraft.

There are two FCSs, one for each engine in a 787. They have two settings: Cut Off and Run. The first act by any crew in starting a 787’s engines on the ground is to set the switches to Run. On the ground or in the air, setting the switches to Cut Off stops the fuel flow to the engines. (See photograph below, showing the switches just behind and below the engine power levers)

According to the AAIB report, just after take-off at Ahmedabad, these switches were moved from Run (up position) to Cut Off (down position). The left switch was moved first then, one second later, the right switch. This action cut off the fuel flow to both engines. There is no automatic function that could move these switches, so they must have been moved manually, or by something physically impacting them. Each switch has a locking mechanism so it cannot be moved accidentally, and there are guard brackets either side of the pair to deflect inadvertent contact by objects. To select the switches from one setting to the other, they must first be pulled out against a spring force to release a locking mechanism, then moved up or down.

Timeline (UTC):

08:07:37 VT-ANB begins take-off roll. 08:08:39 Lift-off at 155kt. 08:08:42 Max airspeed achieved 180kt, also No. 1 FCS switch was moved from Run to Cut Off, followed by the FCS for engine No. 2. 08:08:47 the Ram Air Turbine began supplying hydraulic power. 08:08:52 No 1 engine FCS moved from Cut Off to Run. 08:08:56 No 2 engine FCS moved from Cut Off to Run. 08:09:05 Mayday call transmitted. 08:09:11 EAFR recording stopped.

The report says: “In the cockpit voice recording, one of the pilots is heard asking the other why did he cutoff [sic]. The other pilot responded that he did not do so.” Each pilot is recorded on a separate channel, so the AAIB must know which pilot made each statement, but has decided not to release the information at this preliminary stage, The report confirms that the copilot was the pilot flying, the captain the pilot monitoring. So it seems that one of them, apparently, moved both FCS from Run to Cut Off (see Timeline above), and the other noticed him doing it. Then, about 10 seconds later, one of the pilots attempted to restart the engines by restoring both FCSs to Run.

The report explains the effect of restoring the FCSs to Run, first in 787s generally, then specifically what happened in this case: “When fuel control switches are moved from CUTOFF to RUN while the aircraft is inflight, each engines full authority dual engine control (FADEC) automatically manages a relight and thrust recovery sequence of ignition and fuel introduction. The EGT [exhaust gas temperature in VT-ANB] was observed to be rising for both engines indicating relight. Engine 1’s core deceleration stopped, reversed and started to progress to recovery. Engine 2 was able to relight but could not arrest core speed deceleration and re-introduced fuel repeatedly to increase core speed acceleration and recovery. The EAFR recording stopped at 08:09:11 UTC.”

Take-off and early climb is a period of intense concentration by both pilots, the joint task being to ensure the aircraft maintains a steady climb while allowing the airspeed to increase gradually in a controlled way.

Under normal circumstances, after unstick there is only one actionable task for the pilots to carry out quickly: to check that a positive rate of climb is confirmed by the flight instruments, then select the undercarriage up. This task is normally carried out by the pilot monitoring on orders from the pilot flying, and it would entail moving the undercarriage control lever – located on the forward instrument panel – manually upward. In this case, according to the report, no-one called for the gear to be retracted, and no-one selected it up.

Instead, at about the time the gear would normally have been retracted, the FCS were moved downward from Run to Cut Off, the left switch first, the right switch a second later.

It is difficult to imagine that a crew member would have made such a gross error as reaching down and slightly back to move two small switches downward, one after the other, as a substitute action for a well established routine which would have involved reaching forward to move a single lever upward. And there was no cueing request from the pilot flying to pull the gear up anyway.

Pilots have occasionally, however, carried out inadvertent gross errors that almost defy credibility. You can see here the description of how, in January 2023, a Yeti Airlines ATR72 scheduled passenger flight was inadvertently set up for disaster during a visual circling approach to land at Pokhara airport, Nepal. I wrote that linked piece based on the preliminary report, but when the final report was published by the Nepal authorities it gave the following verdict: “The most probable cause of the accident is determined to be the inadvertent movement of both condition levers to the feathered position in flight, which resulted in feathering of both propellers and subsequent loss of thrust, leading to an aerodynamic stall and collision with terrain.” The check pilot had been asked by the pilot flying to increase the flap setting from 15deg to 30deg, but instead of moving the flap lever, he moved the pair of engine condition levers (picture supplied in linked article) to the position that demands the propellers to feather and stop turning.

If one of the pilots of AI171 did know what he was doing when he moved the FCS, he must have known that his action would have more or less guaranteed the result the world has witnessed, because there was insufficient time to restore usable power once it had been cut. VT-ANB was airborne only 3 seconds before the first FCS was switched to Cut Off, followed a second later by the second FCS, then ten seconds after that the FCS were both switched back to Run. The total airborne time was 42 seconds before colliding with the buildings that began break-up of the aircraft.

As for the likelihood that professional pilots would want to cause the destruction of the aeroplane they are flying, history provides evidence that it happens from time to time.

This was the summary of the situation as presented in the FlightGlobal annual safety review for calendar year 2023, which points out that deliberate acts by pilots to bring down airliners have been carried out by aircrew from all regions and cultures: “Pilot suicide on commercial flights in the last three decades has not involved only Europeans and North Americans. A Japanese, a Moroccan, an Egyptian, a Mozambican, a Botswanan, and a Singaporean, among others, have all been involved. The Flight Safety Foundation’s Aviation Safety Network accident database shows that, in its records beginning the 1950s, there has been a marked acceleration in the numbers of flights brought down by pilot suicide since the beginning of the 1990s, and this acceleration has continued in the new century. It is undoubtedly a modern flight safety hazard.” Since that time, although China has not confirmed it, the rest of the world has reason to believe that the March 2022 loss of a China Eastern Airlines Boeing 737 was not an accident.

It is inevitable that deliberate action by flight crew should be considered when a disaster like AI171 occurs. The India Air Accident Investigation Bureau will undoubtely investigate this possibility. But just one part of the trajedy is that, when all the flight crew die, their intentions will never be known for certain.

AI 171: the system is beginning to leak under pressure

David Learmount Uncategorized , , , , , , , , , , , , , , , , , , ,

Air India flight 171 crashed immediately after take-off from Ahmedabad on 12 June, and today, two weeks later, with no news about causes, the system is beginning to leak.

This is what happens naturally when information which people know is available to the authorities is withheld from the media and the public.

It’s easy for authorities like the Indian Directorate General of Civil Aviation to believe they can justify withholding information on the grounds that it’s very complicated, and they intend to release it quite soon anyway. Unfortunately for the DGCA, today’s media environment does not have that kind of patience any longer, especially in a case like this.

This fatal accident, a first for the Boeing 787 of any marque, killed 241 people on board and many on the ground. Whatever the cause was, it was highly unusual – maybe unique. For that reason, the industry and its regulators are desperate to know if there might be an unknown latent failure in the 787, so they can stop it happening again.

This pressure is what causes the system to leak. The Air India 171 flight data recorder has been downloaded by the National Transportation Safety Board for the DGCA at the Air Accident Investigation Bureau in Delhi, so some outstanding data will already be clear, even if not fully analysed yet.

Meanwhile the NTSB is sworn to secrecy according to the International Civil Aviation Organisation protocol which states that the nation in which the accident occured is responsible for the investigation. So in this case, the NTSB provides all its data to the DGCA, but as an agency of the nation in which the accident aircraft was designed, built and certificated, the NTSB has a particular responsibility to ensure that all operators of Boeing 787s throughout the world – there are about 1,000 of the type flying today – learn as fast as possible what, if anything, they should do.

That NTSB responsibility is a heavy one, but at the same time they want, if possible, to stick to the protocols to ensure the investigation proceeds calmly.

The NTSB obviously has to tell Boeing any details that are emerging. Then Boeing has an urgent duty to provide advice to 787 operators, particularly if any system failure detected might possibly repeat. This information will be received at Boeing by many engineers and technicians who must act rapidly to frame a plan for inspections and corrective action, then communicate with the operators, where an even larger group of airline technicians must carry out the Boeing advisories, or any directives that the Federal Aviation Administration may see fit to issue.

The pressure on the DGCA is of a different kind, and arguably less urgent. It is, after all, a regulator, a bureaucracy, with the responsibility to oversee the investigation and ensure it is conducted properly and according to law. It does, however, face the reality that a lot of highly relevant information is being shared right now by hundreds of experts all over the world, and the media knows it. So if the DGCA delays release of established facts, it will face increasing censure, especially if it delays release beyond one calendar month from the date of the accident.

A month is now firmly established as the time it should take for an air accident investigator to establish the basic facts of the case, and release a “preliminary factual report”. The final report can take more than a year.

Meanwhile, what of all those FDR facts whizzing around the world between experts at the manufacturer, the investigator, the world’s civil aviation authorities, and all the airlines that operate 787s? Well, they leak, of course, because they are important and everyone knows it. But most of the time the precise source of emerging information isn’t obvious, because individuals discussing them do not want to be recognised, so responsible journalists have to be careful what we do with what we hear.

What happens, however, is that it gradually becomes clear, among the plethora of opinions and guesswork always out there, which facts are beginning to establish themselves.

Some are simple, almost obvious. For example, the one emergency radio call made by the AI 171 crew said they had lost power, and an observation of the flight path almost immediately after unstick corroborates that puzzling fact.

But double engine failure immediately after take-off is almost unheard of, so what caused it? That is less obvious.

The DGCA has issued a list of checks it required Indian 787 operators to carry out. Unfortunately it lists checks that – mostly – are routine and would be carried out anyway.

The exception to that is the requirement to test the Electronic Engine Control System. These are computers called Full-Authority Digital Engine Controls (FADEC) that monitor the engines’ performance and react to demands by the pilots via the power levers or the flight control panel (autopilot input). These are vital, but have been established since the 1980s as highly dependable devices, and more reliable by far than the old mechanical connections.

So if both FADECs failed that would be extraordinary. In fact it makes more sense that something else failed or malfunctioned and disabled both FADECs. There is a lot of credible information gathering that backs this up, but since its precise source is not certain, I will not run it here.

Suffice to say we will soon learn what the problem was, because the DGCA knows it would look very bad to sit on it beyond 12 July 2025.

Awful Airlines, says Which?

David Learmount Uncategorized , , , , , , , , , , , , , , ,

Ryanair has been identified in the UK Consumers Association publication “Which?” as the air carrier against which airline awfulness is benchmarked, and it has found that – by one particular measure, British Airways is even worse.

Airlines examined in this survey are among those offering services to or from British airports, and Which? says it is based upon a survey of 6,500 passengers who travelled in the last year. The consumer champion reports “a gulf in standards between the best and the worst”, and it places Jet2 comfortably at the top of short-haul ratings, with Ryanair at the bottom (and Wizz almost as bad).

In long-haul, Singapore Airlines tops the league, with British Airways firmly at the bottom of the nineteen carriers listed, and Air Canada close to it. Indeed, the mighty American Airlines scores much the same as BA, but can claim a Customer Score of 65% against BA’s 62%.

Which? scores all the airlines on 12 categories across the service spectrum. In each category airlines can win from one to five stars, and an overall customer score out of 100. As an example, Jet2 (short-haul) earned five stars for customer service, four in several categories, and in none of the cateories did it win fewer than three stars. Ryanair, on the other hand, didn’t earn more than two stars for anything, and scored one for boarding, seat comfort and food.

Asked by Which? to comment on the survey results, Ryanair had this to say: “Ryanair this year will carry 200m passengers…Not one of our 200m passengers wish to pay “higher prices” as Which? falsely claim.”

Indeed, Ryanair has always been totally unapologetic, as I pointed out in my recent obituary for enjoyable air travel “Surly Bonds (Part 2)”. Quote: “One of the industry’s extant personalities, Ryanair’s chief exec, Michael O’Leary, almost encourages the impression that he chuckles at the pain he can persuade his passengers to undergo to knock a Euro or two off their fare! They just keep coming, he crows. And he’s right, they do – in ever larger numbers!”

But what excuses can British Airways field? It scored lower even than Ryanair on its response to customers who ask for assistance of any kind. Meanwhile on short-haul its highest score was three stars, with a mere two for boarding, seat comfort, food and value for money. On its long-haul routes BA earned four stars for its booking process, but only two on seat comfort, food, cleanliness and value for money.

The UK flag carrier responded: “This research from Which? is entirely at odds with comments from the hundreds of thousands of customers who we know do travel with British Airways and then tell us about their experience.” BA then, in a style reminiscent of recent UK politicians attempting to mitigate dire poll results, lists all the investment it has recently made in cabins and customer service, finally adding: “This [feedback] is also reflected in a recent independent study from Newsweek, which surveyed 17,000 people who voted us their Most Trusted Airline Brand.”

Great brands – and British Airways was indeed a great brand not long ago – can survive a period in the doldrums, but trust can quickly be squandered.

This blog has already vented about the deadly tediousness of air transport today, and the complacent acceptance by the industry of mediocre standards. Flying used to be considered a glamorous and exciting mode of travel, and could be again if spiced with a little imagination.

If that imagination is not invested, the air travel industry will be self-limiting, and environmentalists will be able to celebrate its shortcomings.

Surly bonds (part 2)

David Learmount Uncategorized , , , , , , , , , , ,

“Oh I have slipped the surly bonds of earth and danced the skies on laughter-silvered wings” (Pilot Officer John Gillespie Magee Jr RCAF)

There are probably millions of people aged in their twenties who have flown many times and never felt the magic. Before the new century arrived, almost all air travellers would have felt that frisson at the moment of unstick.

What has changed? That is the question.

Where is the excitement? Where is the airfield? Where are the aeroplanes?

For at least two decades now, economy air transport has been far cheaper than it was twenty or 30 years ago. But, Humble Traveller, you sacrifice much for that privilege! Almost certainly far more than you realise, especially if you are less than 30 and have never experienced anything different.

Today, from the moment of clicking into the online booking process to the point of your expulsion into your destination arrivals hall, the total air travel experience feels as if it is designed to humiliate air travellers. There are definite parallels between the way the low cost carriers (LCCs) treat their passengers and the way reality television shows test minor celebrities’ capacity to cope with public acts of debasement for the entertainment of viewers.

But it doesn’t have to be like this! Dear Ryanair (et al), it’s quite possible to deliver the absolute basics of air travel without making passengers feel they they are being punished for their parsimony!

Indeed one of the industry’s extant personalities, Ryanair’s chief exec, Michael O’Leary, almost encourages the impression that he chuckles at the pain he can persuade his passengers to undergo to knock a Euro or two off their fare! They just keep coming, he crows. And he’s right, they do – in ever larger numbers!

Why do passengers accept it?

Consider, Humble Traveller, what you are persuaded to undergo to purchase this flight.

At the website, you choose your departure point and destination, then scan the flights for the best value trip. That done, you decide what baggage – if any – you will check in, and what you may carry on board. Both these choices will add to your fare.

Then select the seat you want. Airlines, of course, are obliged to provide seats, but choosing a specific seat may drive your fare yet higher.

Finally, you are asked whether you want to pay a premium for the privilege of boarding ahead of other passengers. Quite why anyone would want to occupy a cramped seating space for any longer than necessary is not clear, but some people volunteer to pay for it, which adds to the impression that the airline, having successfully captured you, is playing with you like a bored cat.

You may, by now, have paid a total price for your trip that is up to three times the face-value of a luggage-free flight. And you haven’t even made it to the airport.

Airports, once exciting places to visit, with open-sky vistas of aeroplanes doing what aeroplanes do, are now a challenge to reach, hidden within concentric zones of increasing security designed to deter all but the most determined passengers.

Friends or family delivering you to the airport by car are confronted, on approach, with signage directing drivers to specific lanes for short-stay parking, long-stay parking, public transport drop-off lanes, VIP drop-off lanes, private drop-off lanes, all monitored by video-cameras with number-plate recognition software. Don’t dare get into the wrong lane or security men will swarm your vehicle and direct you around the system a second time to collect a second drop-off charge – or at least the fear of it!

Finally, when you drop off your passengers, the terminal entrance is several hundred metres away, with no porterage. Trolleys – if available – are distant.

A particularly awful airport to deliver to is London Gatwick North Terminal. It used to be light and easy, but now the infrastructure surrounding it has burgeoned, and innocent passengers find themselves dropped off in a skyless concrete chasm between the row of multi-storey car-parks and the terminal itself. This underground labyrinth feels like one of those abandoned warehouses in which criminals and cops have their final shoot-out in the movies.

Within this scary underworld the hapless travellers – rapidly abandoned by their driver who fears being charged for exceeding the permitted drop-off duration – are challenged to find a terminal entrance that will, hopefully, deliver them to a well-lit space for check-in.

The relief, when they do make it to the check-in hall, is overwhelming.

But that’s only the first hurdle. Now they have to negotiate the self-service bag-drop and baggage-labelling process, plus hefting 23kg bags onto a raised belt. Heaven help people who are old, frail, or partially sighted, because the airline won’t.

Having dispatched their bags – an act of faith – to god knows where, the travellers submit to robot-managed identity checks followed by security searches. Bags and belongings need to be hefted into trays, laptops separated, valuables exposed to public view, jackets off, watches off, pockets emptied, belts, shoes and spectacles removed, and all this personal kit is travolated away from you into the dark maw of the X-ray machine. Will you see it again, you wonder?

You, meanwhile, have to stand in a scanner arch with your hands held high, then undergo a pat-down check while your shoes are prodded by a hand-held sniffer wand designed to detect explosive traces.

All this is immediately followed by getting dressed again, in public, and recovering and re-packing your scattered possessions.

You have now made it to “airside”.

The assaults on your senses are not yet over. Immediately you are forced along a long and winding path through blindingly floodlit displays of costly bottles of scent, malt whisky, and other non-essentials before making it to the departure concourse, where you are confronted with the information that your flight has not yet been allocated a gate.

In most terminals, at this point, there is still no view of the outside world. There is still no sense that you will soon be “slipping the surly bonds of earth” in your sleek, 21st century version of a magic carpet. Still absolutely zero sense of anticipation.

Suddenly your flight is allocated a stand, and you have ten minutes to walk about a kilometre along blind corridors to a gate lounge which may – if you are lucky – provide a first glimpse of your flying machine.

At this point the boarding charade begins. The passengers all know they have an allocated seat, yet many choose to stand in a queue for the final security check before shuffling slowly down a blind, steeply sloping boarding pier toward the door of an aeroplane they are – seemingly – not permitted to see.

The last act before take-off is stowing bags and getting into a seat row so tightly spaced that, once there, the ability to move any appendage is painfully limited.

Remember, all this suffering has been entirely voluntary on your part. You knew it would be like this, but you chose it. Don’t blame O’Leary!

Or should you?

Yes you should. This has to change. You don’t have to endure this.

The LCCs have made their point, and have delivered cheap flying. We, the passengers, are educated now, and will not demand expensive privileges on the basic A to B service we can reasonably expect.

But the airlines and the airports have now to deliver that service with respect for their customers. They could. It would cost little, and improve business.

For the airlines, that will start with respecting their crews. A happy airline attracts happy customers, and that’s good business.

The airports have more work to do, starting with better design of the passenger spaces from drop-off to boarding. Retail maximisation should not dominate policy. Stressed, bored passengers are not in the mood for spending money en route.

Finally, make use – once again – of the natural glamour of flying to attract people back to the sky, by letting them see the airfield and its activity. Give them space to dream – along with Pilot Officer John Gillespie Magee – of “topping the wind-swept heights with easy grace”.

Surly Bonds (Part 1)

2024 airline accidents are up

David Learmount Uncategorized , , , , , , , , , , ,

There are still two months to go before the end of 2024, but the number of fatal airline accidents worldwide this year already comfortably exceeds the 2023 total. We’re not in disaster territory yet because the previous year’s total was exceptionally good.

Prominent risks facing the airlines today, according to incidents this year, include repeated runway incursions and airport air traffic control errors causing collision risk, and a rising number of in-flight turbulence incidents in which passengers and crew are severely injured or – in one case – killed.

Two countries that have had bad safety performance levels for many years – Indonesia and Nepal – have each suffered fatal accidents already this year, suggesting they have yet to get to grips with their national aviation safety cultures.

Each year for the last 44 years I have produced the world airline safety review for FlightGlobal and Flight International, and I have been commissioned once again to carry out their reviews for the current year. As usual, in January, it will provide fine detail of significant accidents and incidents, and analyze changes, trends and safety culture issues around the globe. The last annual review is here.

We wait to see whether November and December will add to the year’s accident total. Or not.

Solution to cabin air contamination looms

David Learmount Uncategorized , , , , , , , , , , , , , , , , , , ,

Aircraft cabin air contamination, a persistent issue for airlines because their crew and passengers face the risk of consequent neurological harm, may soon be alleviated by advances in chemical science, according to a new scientific paper published in the UK-based Journal of Hazardous Materials.

The study, sponsored by French industrial lubricant manufacturer NYCO, says: “The research underscores the urgency to replace hazardous industrial OPs [organophosphates] due to their documented neurotoxic effects and associated risks.” The study states analysis of OP chemical structures reveals that “one of the identified clusters had a favourable safety profile, which may help identify safer OPs for industrial applications”. Those applications include aero-engine lubricants, which at present are proven to be the source of contaminants released into aircraft air conditioning systems when “fume events” occur. NYCO has, for years, been researching the possibility of producing aero engine lubricants that are as effective as existing ones, but less toxic.

Findings and consequences from the paper, entitled “Organophosphate toxicity patterns: A new approach for assessing organophosphate neurotoxicity”, will be revealed at the 17-18 September 2024 Aircraft Cabin Air Conference at Imperial College, London.

Also to be presented at the conference is the detail of new tests on passengers and crew that can reveal “biomarkers” in their blood proving that they have been exposed to toxins specific to aircraft cabin air contamination, enabling appropriate remedial actions to be taken by those affected.

In terms of mitigation options while the OP risk to airline passengers and crew remains at its present level, also presenting at the conference are Sweden-based CTT on the subject of cabin air humidification and active carbon filters; BASF on dealing with volatile organic compounds and ozone conversion; and PTI Technologies which will reveal its latest bleed air filtration capabilities.