Was it human mistake, design error, or regulatory oversight that converted a normal takeoff into disaster? Air India 787 crash on June 12, 2025, in Ahmedabad has been a case study in the harsh collision of cockpit procedure, engineering protection, and the subtle realm of aviation regulation.
The last moments of the aircraft went with terrifying exactness. At 08:08:42 local time, the Boeing 787-8, with First Officer Clive Kunder flying and being controlled by Captain Sumeet Sabharwal, had attained a speed of 180 knots. Three seconds after departure, both engine fuel control switches under the thrust levers and spring-loaded interlocks for protection were toggled from “RUN” to “CUTOFF,” each within a second of one another, the AAIB preliminary report said. This intentional act, which took a four-step movement to bypass the locking system, instantly starved both GE GEnx-1B engines of fuel, depriving the plane of thrust at its most critical stage.
In the cockpit, there was chaos. The cockpit voice recorder picked up one pilot saying, “Why did you cut off the fuel?” with the other responding that he hadn’t. The lack of other conversation in the last seconds, except for a desperate “mayday” call, creates a crucial missing link to understand coordination and decision-making among the crew under pressure. As aviation safety expert John Cox said,“You can’t bump them and they move.” The switches’ design requires intent.
The chronology was unforgiving. Only five seconds after fuel cutoff, the ram air turbine (RAT), a backup device that supplies minimal hydraulic and electrical power when both engines stop, deployed. The RAT, as technical analyses describe it, is spring-actuated and swings into the airflow, providing barely enough power to sustain critical flight controls and communications. And at so low an altitude, even this emergency provided no promise.
Attempts to restore fuel pressure were initiated, but the seconds ticked away ten for the first, fourteen for the second. One engine started to recover before the 787 crashed into a medical hostel, killing everyone aboard except one of the 242, and 19 on the ground. The lethal wait to relight the engines a direct result of the low altitude and instant thrust loss highlighted the merciless realities of dual engine failures following takeoff.
The probe soon focused on the Boeing 787’s fuel control system design and safety aspects. These switches, as described in engineering documents, are designed with mechanical protection and redundant wiring. Nevertheless, a 2018 FAA Special Airworthiness Information Bulletin (SAIB) had cautioned against a weakness: the lock could theoretically release, allowing inadvertent movement. The bulletin, however, was advisory, not regulatory a distinction with far-reaching implications.
Air India, along with most operators, failed to conduct the recommended checks, citing the advisory nature of the SAIB. The AAIB report attested to, “The suggested inspections were not carried out as the SAIB was advisory and not mandatory.” This regulatory neutrality, as deconstructed in industry analysis, invites the query: Should safety management systems apply the same level of zeal to all formally recognized hazards irrespective of regulatory obligation?
Human factors weighed heavily. The division of crew responsibilities Kunder as flying pilot, Sabharwal as monitoring pilot was in accordance with accepted procedure, but the failure of communication and delay in taking corrective action illustrate the role of stress, time pressure, and mental overload in high-risk crises. As SKYbrary Aviation Safety reminds us, Workload can be extremely high, especially in the initial stage. High stress levels are often experienced. There is a sense of personal danger. Simulator training and strong crew resource management are intended to neutralize these effects, but the cockpit voice recording indicates that in this instance they failed.
The Air India disaster has fueled discussion on the sufficiency of engineering protections, the reading of regulatory warnings, and the ever-present problem of human fallibility in aviation. The probe persists, with worldwide attention riveted on the interaction between technology, procedure, and the human factor in the cockpit.
