Premature to assume human error: Captain Prashant Dhalla on Air India crash preliminary report

New Delhi: Former Directorate General of Civil Aviation (DGCA) Flight Operations Inspector Captain Prashant Dhalla on Saturday floated the idea of “startle effect” in play before the Air India flight 171 crashed in Ahmedabad shortly after departure while noting that it was “premature” to assume human error.

Discussing the importance of understanding human factors in crash incidents, he noted that the preliminary report by the Aircraft Accident Investigation Bureau (AAIB) states the Ram Air Turbine (RAT) was “out”. On this basis, he pushed a theory that refers to pilots trying to engage and disengage the engines after realising the possibility of technical issues.

Having said this, Captain Dhalla stated that it was “too premature” to assume there was a human factor error as well in this crash incident, even though it might be a possibility.

“We have studied the startle effect under human factors. This can be a situation where, due to the startle effect, pilots can do things inadvertently. This is one of the possibilities, which might be a theory, that an electrical failure occurred in the aircraft. In that situation, the pilots must have thought that there was some technical issue with the engines. They tried to turn on or turn off the engines. I can substantiate this with the findings in the report, which mentions that RAT was deployed. Therefore, there is a possibility of human factor errors as well. However, it is too premature to say this,” Dhalla told ANI.

When asked whether fuel switches are protected against accidental activation or mechanical malfunction, the Captain said that they have a locking mechanism in place that prevents any inadvertent action. He added that these switches can’t be turned off automatically, even in the case of Foreign Object Damage (FOD).

“Fuel switches have a locking mechanism in place. This means that if there is an inadvertent push and pull of switches by mistake, these switches won’t automatically turn off. We need to understand that there are many types of switches, including push-pull and guarded switches. This switch had protection to deter damage. Even in the case of FOD, these switches couldn’t be turned off automatically,” Dhalla said.

When asked about cockpit coordination and situational awareness based on conversation between pilots, the Captain argued that there was confusion in the cockpit and said that the entire transcript from the Cockpit Voice Recorder (CVR) must come out.
“There was confusion in the cockpit. They had very little time to tackle the situation. The transcript from the cockpit voice recorder must come out before the public,” he said.

“There are many aspects that the government and the agencies look into. The report will be divided into many phases. If we examine the minute details, we can see the conversation between the pilots, their flying hours, what was mentioned about the engine, and the procedures they followed. This is a preliminary report, and several factors will be seen in this. Second-by-second analysis will be done,” he added.
Dhalla said that the actions of the pilots flying the crashed Air India Flight 171 clearly indicate that there were issues with the engine.
“The fuel cutoff switches are primarily given by the manufacturer. Boeing has designed it so that you use it while starting the engine, and when you need to turn it off, you simply cutoff. It has two modes: Run and Cutoff. The system of restarting the fuel cutoff is a process where the pilot tries to regain power in the engine. This clears it that there were issues with the engine,” he added.

Focusing on the possible situation in the cockpit before the crash, Dhalla said that the aircraft was merely 400-600 feet above ground, which gave pilots only seconds to act while simultaneously contacting the ATC.

“Pilots have to follow a checklist after encountering problems on the screen. Human factors must also be considered in this case. The time is very critical. The aircraft was at a height of only 400-600 feet above ground…this was a matter of seconds…in that moment, they tried connecting with the ATC also while performing their actions. They were very experienced pilots,” he said.

“This could be a rarest of rare accidents, where dual engine flame out could have happened. However, the report is silent since it doesn’t mention a dual-engine flameout in this incident. This remains a matter of investigation,” he added.

On Friday, India’s AAIB released the preliminary report into the tragic crash of Air India flight 171, a Boeing 787-8 aircraft, which crashed shortly after takeoff from Ahmedabad’s Sardar Vallabhbhai Patel International Airport on June 12.

The AI-171 flight, which was bound for London’s Gatwick airport, crashed soon after takeoff from Ahmedabad’s Sardar Vallabhbhai Patel airport. 260 people lost their lives in the accident, which included 229 passengers, 12 crew members and 19 people on the ground.

The report outlines a harrowing sequence of events that unfolded within 90 seconds of takeoff, as both engines of the aircraft shut down unexpectedly during the initial climb, leading to a catastrophic loss of thrust and rapid descent.