Insights from AAIB Report on Boeing 787 Accident

Now, we know more about the most tragic aviation accident of recent years. The report by India’s Aircraft Accident Investigation Bureau (AAIB) about the June 12 fatal accident of a Boeing 787 raises new questions.

The careful wording of the preliminary report[1] is eminently sensible. The facts are what they are, but it remains difficult to construct a scenario around these facts. I suspect that all the parties involved in this fatal accident investigation had a hand in ensuring that the words used where as clear as can be at this early stage. As I said, the facts are what they are.

It’s good that the report shuts down some of the fervent and erroneous speculation that was filling the international media. For this accident, fuel supply being the substantive issue, decisions around flying controls and other aircraft performance issues can be put to one side.

The crew encountered, or were responsible for a situation that once established led to one inevitable sad outcome. The time available to react, at such low altitude, was less than that which was needed to continue a safe flight.

A focus at this point is on the Boeing 787 aircraft’s fuel control switches. These switches are installed in the flight deck and used by a pilot to cutoff fuel to the engines. When correctly installed, these fuel control switches have a locking feature to prevent inadvertent operation.

Clearly unintended switch movement between the fuel supply and fuel cutoff positions can be hazardous. Inadvertent operation of one or both switches could result in an unintended consequence, e.g. engine(s) shutdown. What we know is that sufficient fuel was supplied to the aircraft engines to conduct a take-off. Then for some unknown reason that fuel supply did not continue as it should.

So far, the respectable technical speculation I’ve read (pilot and aircraft engineer led), raises a limited number of possibilities.

One being that the crew acted in an inappropriate or inadvertent manner. Another being that the aircraft’s fuel control switches failed or were caused to fail. Another being that aircraft’s fuel control system (including wiring) failed or were caused to fail. The movement of the flight deck switches may or may not have been involved. What we know is that the record on the accident flight recorder shows a condition occurred that should not occur.

There is no doubt that this would have been a highly stressful situation in the cockpit whatever the root cause. Normally, immediately after the aircraft is leaving the runway the pilot-in-command would have no good reason to look at the aircraft’s fuel control switches. They would be looking forward at the aircraft instruments.

We can take it that every aviation authority/agency/administration with a Boeing aircraft on its aircraft register will be closely watching the progress of this accident investigation. Since, to date, no Airworthiness Directive (AD) has been issued, related this fatal accident, it is reasonable to assume that aircraft systems and equipment failure or maintenance error has not been found. That said, it is worth noting FAA Special Airworthiness Information Bulletin (SAIB) No. NM-18-33 dated December 17, 2018.

We cannot rule out the possibility that this fatal accident was intentional. However, in the whole history of civil aviation this is one of the most extreme explanations. Looking at evidence, a situation when a competent and sane pilot is found to choose to act in an irrational manner is hard to diagnose.

POST: Just over 3-years ago, I wrote “The case for video”. That case to update the rules is now stronger than ever. The case for video.


[1] https://aaib.gov.in/

Avoiding Contrails and Enhancing Operations

Here I’m expanding on my earlier words on aircraft Contrails.

Airspace is a busy place. It’s most busy over Europe and the US. Over the oceans there’s more room, although on certain routes, like the North Atlantic, there’s plenty of daily air traffic.

Those who manage the airspace are primarily concerned with ensuring that aircraft collisions do not occur. The impact of mid-air collisions is devastating. There’re few people in aviation who can forget the events of an evening in July 2002. Over Überlingen, Germany[1], 71 people lost their lives at a time when the sky was not busy at all.

Managing the use of airspace is more than collision avoidance. Flying is perpetually concerned with the weather. What’s it doing, how is it changing and is it a hazard? It’s not just the safety of flying that demands up-to-date meteorological information. Knowing about the winds can enable more efficient operations, and that’s less fuel use for a given route.

Large thunderstorms need to be avoided. Regions of the world (example: intertropical convergence zone) make this a dynamic challenge. Manoeuvres may be planned but flight crews must be ready to act based on the information they have, like weather radar.

Turbulence is another phenomenon to be avoided, if possible. This can occur in clear air. It can be difficult to detect. Which explains the unpleasant examples that hit the News now and then[2].

Back in 2010, aviation had a reminder that avoidance encompassed any hazardous airspace. That was when an unpronounceable volcano in Iceland was spewing out ash at high altitudes. Plumes of volcanic ash, if ingested into aircraft engines, can cause major difficulties.

I’ve written these words to emphasise that the avoidance of contrail formation cannot be done as a stand-along consideration. It becomes one factor in a whole mix of factors.

Avoidance of contrail formation is about considering the mechanism that cause them to form. Clearly, the warmer the air is the harder it is for a contrail to form. The more humidity there is in the air, the easier it is for a contrail to form. Outside Air Temperature (OAT) and atmospheric humidity vary at each altitude. That relationship interacts with the aircraft inflight, and the outcome may be different for each aircraft type.

At least one academic study[3] says that adjustments of aircraft altitude of around 2000 ft could have a useful effect on contrail formation. That’s good to know but let’s not forget that Reduced Vertical Separation Minima (RVSM) [4] means a vertical spacing of 1000 ft in busy airspace.

My take on this fascinating subject is that there both a tactical and operational approach that can be practically taken by aviation.

At the tactical level, airlines can factor contrail avoidance into flight planning. Creating an algorithm that will weigh all the relevant flight factors. Improved sources of accurate and timely meteorological data and predictions will be needed.

At the operational level, it’s down to the flight crews to take advantage of environmental conditions as the opportunity arises. Much as dealing with turbulence, that is when safety and operational rules permit. To change altitude when its beneficial, computational help is likely to be needed. Over the ocean, air-ground communications systems may need to be further improved. An altitude change that avoids contrail formation but increases fuel consumption would not be a sustainable solution.

These computational tasks may well be well suited to machine learning. A useful application of artificial intelligence. I can imagine a cockpit weather radar display with a new set of symbology that indicates a low probability contrail formation zone ahead.

[Back in the 1990s, I worked on RVSM when the ARINC organisation was creating international standards. Safely increasing traffic in the North Atlantic region. Additionally, I participated in the certification of Future Air Navigation System (FANS) 1/A for use over the ocean. FANS led to more efficient aircraft operation due to shorter flying times and decreased fuel burn.]

POST: Looks like data crunching is underway Flight plans, but greener: The ICCT and Google’s mission to refine the Travel Impact Model – International Council on Clean Transportation


[1] https://www.bfu-web.de/EN/Publications/FinalReports/2002/Report_02_AX001-1-2_Ueberlingen_Report.pdf?__blob=publicationFile&v=1

[2] https://www.flightglobal.com/safety/turkish-777-rapidly-descended-during-crews-aggressive-response-to-turbulence-encounter/162937.article

[3] https://www.imperial.ac.uk/news/195294/small-altitude-changes-could-contrail-impact/

[4] https://skybrary.aero/articles/reduced-vertical-separation-minima-rvsm

Future of Single Pilot Operations in Aviation

Flying embraces automation. Now, there’s a statement that didn’t ought to be controversial, but it can be. Even before we became engulfed by the modern digital age, analogue autopilots could assist in the task of flying. Some early ones were mechanical.

The need for full-time hands-on piloting of the physical controls that linked a human and an aircraft’s control surfaces is not fundamental. Large transport aircraft have stepped further, somewhat mimicking what their military counterparts did, and fly-by-wire systems have become commonplace.

As far as technological evolution is concerned, we remain in a transitionary phase. Commercial aircraft that fly overhead are a mixed community. Some, like the Boeing 737 series continue to have cables and pulleys that link aircraft systems and controls. Others, like the Airbus A320 series are the fly-by-wire digital aircraft types in regular service.

Between the pilots in the cockpit and the motion of an aircraft there is a computer. In fact, several computers arranged in a manner so that they continue to work even when subject to failures. A great deal of thought and effort has gone into designing aircraft systems that will be reliable in-service.

Looking at the safety numbers, starting in the 1980s when fly-by-wire was introduced, the overall service experience is extremely good. The practice of system safety assessment has delivered dependable and robust aircraft. Rigorous certification processes are applied. 

Through the technical developments that marched on from the 1980s one requirement has remained. That is that two pilots are needed in the aircraft cockpit. Granted there are exceptions to this rule for smaller transport aircraft. Single pilot operations are not new. For example, in many countries, the Cessna Caravan[1] is approved for a single pilot.

It’s 2025. It’s difficult not to notice the debate around Single Pilot Operations (SPO). That is to open large transport aircraft operations to a new rule. Lower operating costs may be achievable by making a change. It’s even said that this move is a way of continuing aviation’s growth as it becomes more and more difficult worldwide to increase the number of qualified pilots.

It’s good to see this subject being taken up in a forthcoming conference.

RAeS Flight Operations Conference 2025: Single Pilot Operations – Logical Progression or a Step Too Far?[2] 19 March 2025 – 20 March 2025. Royal Aeronautical Society Headquarters in London.

SPO may be enabled by use of complex systems to help make mission-critical decisions. The next step maybe with real-time “artificial” copilots and intelligent monitoring. Will this move the aviation industry toward safer and more efficient aircraft operations? That is the question.


[1] https://cessna.txtav.com/en/turboprop/caravan

[2] https://www.aerosociety.com/events-calendar/raes-flight-operations-conference-2025-single-pilot-operations-logical-progression-or-a-step-too-far

Advancements in Flight Recorder Technology and Regulations

My last posting addressed accident flight recorders and airworthiness requirements. That’s not enough. It’s important to note that aircraft equipage standards are addressed in operational rules. So, the airworthiness requirements define what an acceptable installation looks like but as to whether an operator needs to have specific equipage or not, that’s down to the operational rules in each country.

Internationally, the standards and recommended practices of ICAO Annex 6 are applicable. These cover the operation of aircraft. Flight recorders are addressed in para 6.3.1. and Appendix 8. Let’s note that ICAO is not a regulator. There are international standards but operational rules in each country apply to each country’s aircraft.

One of the major advances in accident flight recorders technology is the capability to record more data than was formerly practical. This has led to standards for Cockpit Voice Recorders (CVRs) advancing from 2-hour recording duration to 25-hours.

Proposed rule changes have been hampered by the impact of the global pandemic. Some new operational rules apply only to newly built aircraft. That means some existing aircraft can retain their 2-hour CVRs.

Another technology advance is what’s known as Recorder Independent Power Supply (RIPS). RIPS can provided power to the CVR for at least 10 minutes after aircraft electrical power is lost. The RIPS is often offered as a relatively straightforward aircraft modification.

I do not know if the South Korea Boeing 737-800 was required to have accident recorders with the capabilities listed above. If they were not, then there’s a good basis for recommending that changes be made to existing aircraft.

Spectacular Sighting

There’s steep hills. Some more interesting than others, you might say. In my youth this one was known for the road that climbed the hill. That’s the B3081, if you want the detail. It’s an opportunity to journey through wonderful English countryside. The area being Cranborne Chase, a protected landscape.

Zigzag hill was great fun for us as children. Probably not so much fun for my parents as our jet black Wolseley16/60 strained to get around the corners and climb to the top. The car packed with the six of us. This was a route we’d take to get from home to Bournemouth, and the seaside.

On the way, I remember the finger post signs to Compton Abbas Airfield[1]. My thought being what an interesting place for an airfield, right up here high on the chalk hills. Looking down on the surrounding Dorset countryside and the town of Shaftsbury.

Normally, I have to go to flying displays to see historic aircraft fly. This Sunday afternoon, I travelled no further than my back door. Sitting outback in the steaming 30C-degree summer weather all I had to do was look-up. Not that I’d planned to look skyward.

That doesn’t happen every day. First there was a distant rumbling sound. Then it developed into the hum of multiple piston engines. It’s only when the distinctive sight of a Lancaster bomber appeared over the roof of my house did all become clear what was happening.

As soon as I fixed my eyes on the aircraft it was already off over the garden and out across the neighbouring field. This was Avro Lancaster PA474 passing right overhead[2]. It was heading off in a north easterly direction at a notably low altitude. Quote a spectacular sight.

I had to do a little research once the aircraft had disappeared over the horizon. Looking at what was happening on Sunday, I assume it was flying back from Compton Abbas Airshow[3] to its home in Lincolnshire. Given the high summer weather, this was a great day for flying.

This Second World War heavy bomber first flew in 1941. It’s part of the Battle of Britain Memorial Flight (BBMF), based at RAF Coningsby. It’s the only Avro Lancaster that remains airworthy and flying in the UK. It’s only recently returned to the air after a tragic accident involving the BBMF.

Later in the day, off in the distance, looking north, three other historic aircraft trundled across the sky. After dark, with the heavens clear, I caught the Perseid meteor shower. So, for watchers of the skies, 11th August was a noteworthy day.


[1] https://www.comptonairfield.com/

[2] https://www.bbc.co.uk/news/articles/clyg7e7x319o

[3] https://comptonabbasairshow.co.uk/participants/

Objects falling from the sky

In so far as I know, no person on the ground has been killed by an object falling from a commercial aircraft in flight. I’m happy to be corrected if that situation has changed. Strangely, in contrast there are plenty of reports of people falling from aircraft and being killed as a result[1]. Additionally, there are cases of parts shed by aircraft that subsequently contribute to an aircraft accident[2].

The most frequent reports of falling objects, in and around airports are not parts of an aircraft but that which is in the atmosphere all the time. Namely, ice. When it hits the ground in the form of a hailstorm it can be damaging. In flight, it can be seriously damaging to an aircraft.

What I’m writing about here are the third-party risks. That’s when an innocent individual finds themselves the target of an improbable event, some might call an act of God. Ice falls are rare. However, given the volume of worldwide air traffic there’s enough of them to be alert to the problem. As soon as ice accretes to create lumps bigger than a kilo there’s a real danger.

Can ice falls be prevented? Here again there’s no doubt some are because of poor maintenance or other preventable factors, but others are just nature doing its thing. Regulators are always keen to collect data on the phenomena[3]. It’s something that goes on in the background and where the resources allow there can even be follow-up investigations.

Near misses do make the newspaper headlines. The dramatic nature of the events, however rare, can be like a line from a horror movie[4]. Other cases are more a human-interest story than representing a great risk to those on the ground[5].

It’s worth noting that falling objects can be quite different from what they are first reported to be. That can be said about rare events in general.

I remember being told of one case where a sharp metal object fell into a homeowner’s garden. Not nice at all. The immediate reaction was to conclude it came from an aircraft flying overhead. Speculation then started a new story, and the fear of objects falling from aircraft was intensified.

Subsequently, an investigation found that this metal object had more humble terrestrial origins. In a nearby industrial estate a grinding wheel had shattered at highspeed sending debris flying into the air. Parts of which landed in the garden of the unfortunate near-by resident.

One lesson from this tale is that things may not always be as they first seem. Certainly, with falling objects, it’s as well to do an investigation before blaming an aircraft.  

POST 1: There’s a threat outside the atmosphere too. The space industries are ever busier. That old saying about “what goes up, must come down” is true of rockets and space junk. More a hazard to those on the ground, there is still the extreamly unlikly chance of an in-flight aircraft getting hit Unnecessary risks created by uncontrolled rocket reentries | Nature Astronomy

POST 2: EASA Safety Information Bulletin Operations SIB No.: 2022-07 Issued: 28 July 2022, Subject: Re-Entry into Earth’s Atmosphere of Space Debris of Rocket Long March 5B (CZ-5B). This SIB is issued to raise awareness on the expected re-entry into Earth’s atmosphere of the large space object.


[1] https://nypost.com/2019/07/03/man-nearly-killed-by-frozen-body-that-fell-from-plane-is-too-traumatized-to-go-home/

[2] http://concordesst.com/accident/englishreport/12.html

[3] https://www.caa.co.uk/Our-work/Make-a-report-or-complaint/Ice-falls/

[4] https://metro.co.uk/2017/02/16/10kg-block-of-ice-falls-from-plane-and-smashes-through-mans-garage-roof-6453658/

[5] https://www.portsmouth.co.uk/news/national-ice-block-falls-aircraft-and-smashes-familys-garden-1078494