Report points to human intervention as cause of crash

The preliminary report on the tragic fatal crash of Air India’s London flight (flight no. AI 171) soon after taking off from Ahmedabad on June 12 was released late last night. Did the Aircraft Accident Investigation Bureau (AAIB) release it voluntarily or under intense International pressure? The stories in Air Current and the Wall Street Journal about fuel switches and the threatened walkout by U.S. National Transportation Safety Board and maybe by the AAIB of the U.K. from the investigation seem to have accelerated the release. The report has given details, but there are several issues that are not covered.

For the past one month, the electronic media had been full of YouTube narratives painting the Boeing 787-8 Dreamliner, the type of the aircraft that crashed, with a black brush. But the aircraft is safe, and several other factors could have caused the crash. When authorities appointed a Director-General of Police in the inquiry committee and threw in a sabotage angle, it harked back to several cases of pilot suicide events. The preliminary report, with several shortcomings, does give an indication in that direction.

Page 14 of the report, which has an image from the CCTV footage of AI 171 taking off and an inset, shows that the RAM air turbine was deployed. This image was available to the authorities even on the day of the accident. The digital flight data recorded (DFDR) is not required to identify its deployment. Thirty days of misinformation since the accident have increased anxiety among passengers and stress levels of operating crew on Dreamliners worldwide.

Clarity needed

The report contains several vague statements. On Page 13, it is clearly mentioned that the captain was pilot monitoring and the first officer was the pilot flying. The pilot flying handles the controls during take-off, and both his hands will be on the control column during take-off and climb, until autopilot is engaged. The only pilot whose hands are free is the pilot monitoring — in this case, the captain. The report attempts to give an impression that either of them could have manipulated the fuel switches. Only the captain could have moved the fuel selector to cut-off position and not the first officer.

The report says, “In the cockpit voice recording, one of the pilots is heard asking the other why did he cut off the fuel. The other pilot responded that he did not do so!” This is such an amateurish attempt to hide the fact. It is mandatory for all pilots to wear their headphones during take-off or landing. The cockpit voice recorder will record any transmission from the captain’s mike as CAM 1 and the copilot’s as CAM 2. The investigator can identify, positively, who said what. Here again, a very poor attempt to divert from facts is seen.

Page 11 of the report gives another clear indication of wrong information being mentioned. In Item 7, the details about the captain mentions he is an airline transport pilots licence holder. His licence number is not mentioned. The date of issue of the licence is May 14, 2021. His flying experience on Boeing 787s is given as 8,596.43 hours and as pilot-in-command on this type of aircraft is 8,260.43 hours.

To fly any large aircraft, the airline transport licence is mandatory. The captain’s licence was issued on May 14, 2021, and the crash was on June 12, 2025. By the Civil Aviation Requirements on flight and duty time limitations of the Directorate General of Civil Aviation, a pilot can fly a maximum of 1,000 hours a year. The report indicates the captain has flown more than 8,200 hours in four years and 21 days. Can one believe any of the figures given in the report as authentic? On the day of the crash, the DGCA had given the experience level of the captain as 8,200 hours and the first office as 1,100 hours. This report gives the captain’s total hours as 15,638 hours and the first officer’s as 3,403 hours. The report, as in all air accidents over the years, do not conform to International Civil Aviation Organization Annex 13 Standards, and India’s aviation sector is thus proving to be an embarrassment to the safety world.

Airport services

There is no mention of findings on the airport and its deficiencies in mandatory safety features and facilities. The notices to airmen, NOTAMS, issued immediately after the crash clearly mentions RFFS ZERO. This means that rescue and fire fighting services at the airport is zero, meaning all the foam and chemicals required for fighting a fuel fire was zero. ICAO Annex 14, Volume 1 Standards mandates that the Ahmedabad airport required CATEGORY 9 RFFS. When the foam and chemicals used during the firefighting of the crash is replenished to make the RFFS to Category 9, the airport authorities must issue a fresh NOTAM cancelling the earlier one and indicating that Category 9 is available. There was no such NOTAM issued when the airport was opened for operation in just three hours. Flights were departing and arriving with zero firefighting and rescue services available. This is a grave safety violation and the report is silent on airport failings. Every airline that operated flights after the crash without rescue and fire fighting available has endangered the lives of all on board. None of the pilots who operated those flights had not even noticed such a serious deficiency, and had not been aware of the danger to everyone.

Data in the digital flight data recorder and cockpit voice recorder have been downloaded and the details are available with the investigators. It is the international agencies that have pushed the preliminary report to mention the movement of the fuel control switches. The vague language deployed by the AAIB has left people wondering why the fuel selectors moved, and raised doubts about the safety of the Boeing 787s.

It is time India published factual reports and addressed the human factor in monitoring of crew instead of treating them like machines. The regulator, airlines and even judiciary must understand that fatigue and stress of any kind can be a dangerous cocktail. India has suffered a major tragedy, and the families of the departed souls deserve a honest closure. Many more such accidents will follow unless these issues are addressed urgently. Let us move from the ego-filled commercial aviation system to civil aviation with a heart for the human factors affecting the crew.

Captain A. (Mohan) Ranganathan is a former airline instructor pilot and aviation safety adviser. He is also a former member of the Civil Aviation Safety Advisory Council, India