印度民航部飛行事故調(diào)查局正式發(fā)布了6月12日印航423航班空難事故的第一版事故調(diào)查報(bào)告。

一般空難的第一版事故調(diào)查報(bào)告往往比較概略，很難有細(xì)節(jié)，但這次的報(bào)告卻有非常多且重要的細(xì)節(jié)，悲劇的迷霧被驅(qū)散了很多，事故原因變得很具體了。

目前來(lái)看，飛機(jī)在起飛前一切正常，一切都發(fā)生在飛機(jī)離開(kāi)地面后的

31秒里

世界協(xié)調(diào)時(shí)2025年6月12日8時(shí)7分33秒，飛機(jī)收到起飛許可。
8時(shí)7分37秒，飛機(jī)開(kāi)始滑跑。
8分39秒，飛機(jī)離地。
8分42秒～43秒，飛機(jī)兩臺(tái)發(fā)動(dòng)機(jī)的燃油開(kāi)關(guān)被關(guān)閉，一名飛行員問(wèn)“為什么關(guān)閉燃油開(kāi)關(guān)？”另一名回應(yīng)“我沒(méi)有?！?/strong>
8分47秒，兩臺(tái)發(fā)動(dòng)機(jī)轉(zhuǎn)速低至怠速以下，飛機(jī)最后的應(yīng)急動(dòng)力-空氣沖壓渦輪自動(dòng)釋放并工作。
8分52秒，一號(hào)發(fā)動(dòng)機(jī)燃油開(kāi)關(guān)被重新打開(kāi)。
8分56秒，二號(hào)發(fā)動(dòng)機(jī)燃油開(kāi)關(guān)被重新打開(kāi)。
兩臺(tái)發(fā)動(dòng)機(jī)相繼點(diǎn)火成功但無(wú)力逆轉(zhuǎn)空速下降。
9分5秒，飛行員呼報(bào)mayday。
9分11秒，飛機(jī)墜毀。機(jī)上230名乘客中的229人，10名空乘，2名飛行員和地面19人喪命。

什么是發(fā)動(dòng)機(jī)燃油開(kāi)關(guān)？

顧名思義，它是控制油泵向發(fā)動(dòng)機(jī)輸送燃油的開(kāi)關(guān)。在波音787上，兩個(gè)開(kāi)關(guān)并排，位于駕駛艙中部控制臺(tái)油門(mén)桿的后方，是兩個(gè)蘑菇頭型的開(kāi)關(guān)，向前推是開(kāi)位，向后撥是閉位。

為了防止誤操作，這兩個(gè)開(kāi)關(guān)都有限位裝置，飛行員必須先向上提起蘑菇頭，再前后撥動(dòng)。

兩個(gè)開(kāi)關(guān)的距離大約是10厘米。此前也發(fā)生過(guò)飛行員袖口勾掛這個(gè)開(kāi)關(guān)造成的誤操作事件，所幸沒(méi)有釀成事故。但是一秒之內(nèi)兩個(gè)開(kāi)關(guān)相繼被誤操作，是什么情況下發(fā)生的？接下來(lái)還要更多的調(diào)查才能還原這兩個(gè)開(kāi)關(guān)被關(guān)閉的真相。

想看更多細(xì)節(jié)的朋友，我下面翻譯了報(bào)告的事故回顧部分，大家可以參考一下。

Accident Flight

事故航班

On 12th June 2025, Air India’s B787-8 aircraft bearing registration VT-ANB arrived at Ahmedabad airport operating flight AI423 from Delhi. The aircraft touched down at 05:47 UTC (11:17 IST) and was parked at the bay 34.
2025年6月12日，印度航空一架注冊(cè)號(hào)為VT-ANB的波音787-8飛機(jī)執(zhí)飛AI423航班從德里飛抵艾哈邁達(dá)巴德機(jī)場(chǎng)。飛機(jī)于協(xié)調(diào)世界時(shí)（UTC）05:47（印度標(biāo)準(zhǔn)時(shí)間11:17）著陸，并?？吭?4號(hào)停機(jī)位。

The crew of the previous flight (AI423) had made Pilot Defect Report (PDR) entry for status message “STAB POS XDCR” in the Tech Log. The troubleshooting was carried out as per FIM by Air India’s on duty AME, and the aircraft was released for flight at 06:40 UTC.
前一航班（AI423）的機(jī)組人員在技術(shù)日志中記錄了飛行員故障報(bào)告（PDR），故障信息為“STAB POS XDCR”。印度航空當(dāng)班維修工程師按照故障排除手冊(cè)（FIM）進(jìn)行了檢修，飛機(jī)于06:40 UTC獲準(zhǔn)放行。

The aircraft was scheduled to operate flight AI171 from Ahmedabad to Gatwick with ETD 07:40 UTC (13:10 IST). The flight was to be operated by the flight crew comprising an ATPL holder PIC, a CPL holder Co-pilot along with ten cabin crew. Both pilots were based at Mumbai and had arrived at Ahmedabad on the previous day. They had adequate rest period prior to operating the said flight. The co-pilot was Pilot Flying (PF), and the PIC was Pilot Monitoring (PM) for the flight.
該飛機(jī)計(jì)劃執(zhí)行AI171航班，從艾哈邁達(dá)巴德飛往蓋特威克，預(yù)定起飛時(shí)間為07:40 UTC（13:10 IST）。機(jī)組由一名持有航線運(yùn)輸飛行員執(zhí)照（ATPL）的機(jī)長(zhǎng)和一名持有商用飛行員執(zhí)照（CPL）的副駕駛，以及10名客艙乘務(wù)組成。兩名飛行員常駐孟買(mǎi)，前一天已抵達(dá)艾哈邁達(dá)巴德，并在起飛前獲得了充分休息。此次飛行由副駕駛執(zhí)行操縱任務(wù)（PF），機(jī)長(zhǎng)負(fù)責(zé)監(jiān)控（PM）。

The crew of flight AI171 arrived at the airport and underwent preflight Breath Analyzer test at 06:25 UTC and were found fit to operate the flight. The crew is seen arriving at the boarding gate in the CCTV recording at about 07:05 UTC (12:35 IST).
AI171航班的機(jī)組人員于06:25 UTC抵達(dá)機(jī)場(chǎng)，并接受了飛行前的酒精呼氣測(cè)試，結(jié)果顯示適合執(zhí)飛任務(wù)。閉路電視錄像顯示，機(jī)組人員于約07:05 UTC（12:35 IST）抵達(dá)登機(jī)口。

There were 230 passengers on board, out of which 15 passengers were in business class and 215 passengers were in economy class including two infants.
機(jī)上共有230名乘客，其中15人在商務(wù)艙，215人在經(jīng)濟(jì)艙（含兩名嬰兒）。

Fuel on board was 54,200 Kgs and as per the load and trim sheet of the flight, the Take-off Weight was 2,13,401 Kgs (Max. allowed - 2,18,183 Kgs). The take-off weight was within allowable limits for the given conditions. There was no ‘Dangerous Goods’ on the aircraft.
機(jī)上燃油為54,200公斤，根據(jù)該航班的載重和配載單，起飛重量為213,401公斤（最大允許為218,183公斤），在當(dāng)時(shí)條件下屬正常范圍。機(jī)上未裝載危險(xiǎn)品。

The calculated V speeds with available conditions at Take-Off were V? - 153 Kts, V? - 155 Kts, V? - 162 Kts.

起飛條件下計(jì)算的V速如下：

V?（決斷速度）：153節(jié)

V?（抬輪速度）：155節(jié)

V?（安全爬升速度）：162節(jié)

The A-SMGCS replay of the flight was also carried out after the accident. The aircraft was observed departing from the bay 34 at 07:48:38 UTC. The taxi clearance was received at 07:55:15 UTC and the aircraft taxied from the bay at 07:56:08 UTC. The aircraft taxied to Runway 23 via Taxiway R4, backtracked and lined up. The take-off clearance was issued at 08:07:33 UTC. The aircraft started rolling at 08:07:37 UTC.
事故后回放了A-SMGCS（高級(jí)地面移動(dòng)引導(dǎo)和控制系統(tǒng)）記錄。飛機(jī)于07:48:38 UTC從34號(hào)停機(jī)位推出。07:55:15 UTC收到滑行許可，07:56:08 UTC開(kāi)始滑行，通過(guò)R4滑行道前往23號(hào)跑道，掉頭并對(duì)正跑道。08:07:33 UTC收到起飛許可，08:07:37 UTC開(kāi)始滑跑。

As per the EAFR data, the aircraft crossed the take-off decision speed V? and achieved 153 kts IAS at 08:08:33 UTC. The V? speed (155 kts) was achieved as per the EAFR at 08:08:35 UTC. The aircraft air/ground sensors transitioned to air mode, consistent with liftoff at 08:08:39 UTC.
根據(jù)EAFR（增強(qiáng)型飛行數(shù)據(jù)記錄）數(shù)據(jù)，飛機(jī)于08:08:33 UTC通過(guò)V?決斷速度（153節(jié)），08:08:35 UTC達(dá)到抬輪速度V?（155節(jié)）。08:08:39 UTC，空地傳感器狀態(tài)切換為“空中模式”，表明飛機(jī)已完成起飛。

The aircraft achieved the maximum recorded airspeed of 180 Knots IAS at about 08:08:42 UTC and immediately thereafter, the Engine 1 and Engine 2 fuel cutoff switches transitioned from RUN to CUTOFF position one after another with a time gap of 01 sec. The Engine N1 and N2 began to decrease from their take-off values as the fuel supply to the engines was cut off.
飛機(jī)于08:08:42 UTC達(dá)到最大記錄空速180節(jié)。緊接著，1號(hào)和2號(hào)發(fā)動(dòng)機(jī)的燃油切斷開(kāi)關(guān)在1秒間隔內(nèi)相繼從“RUN”位置切換至“CUTOFF”位置，導(dǎo)致N1與N2轉(zhuǎn)速下降，說(shuō)明燃油供應(yīng)被切斷。

In the cockpit voice recording, one of the pilots is heard asking the other why did he cutoff. The other pilot responded that he did not do so.
駕駛艙語(yǔ)音記錄中，一名飛行員問(wèn)另一人為何切斷燃油，另一人回應(yīng)自己沒(méi)有這么做。

The CCTV footage obtained from the airport showed Ram Air Turbine (RAT) getting deployed during the initial climb immediately after lift-off (fig. 15). No significant bird activity is observed in the vicinity of the flight path. The aircraft started to lose altitude before crossing the airport perimeter wall.
機(jī)場(chǎng)監(jiān)控錄像顯示，飛機(jī)在起飛后初始爬升階段即部署了沖壓空氣渦輪（RAT）（見(jiàn)圖15）。飛行路徑周?chē)窗l(fā)現(xiàn)明顯鳥(niǎo)類活動(dòng)。飛機(jī)在尚未越過(guò)機(jī)場(chǎng)圍墻前就開(kāi)始失去高度。

Figure 15 CCTV screenshot of RAT Deployment

圖15：閉路電視截圖顯示沖壓空氣渦輪（RAT）展開(kāi)

As per the EAFR data both engines N2 values passed below minimum idle speed, and the RAT hydraulic pump began supplying hydraulic power at about 08:08:47 UTC.
根據(jù)增強(qiáng)型飛行數(shù)據(jù)記錄（EAFR）數(shù)據(jù)，兩臺(tái)發(fā)動(dòng)機(jī)的N2值降至最低怠速以下，沖壓空氣渦輪（RAT）液壓泵約在08:08:47 UTC開(kāi)始供給液壓動(dòng)力。

As per the EAFR, the Engine 1 fuel cutoff switch transitioned from CUTOFF to RUN at about 08:08:52 UTC.

根據(jù)EAFR記錄，1號(hào)發(fā)動(dòng)機(jī)的燃油切斷開(kāi)關(guān)約在08:08:52 UTC從“CUTOFF”切換至“RUN”狀態(tài)。

The APU Inlet Door began opening at about 08:08:54 UTC, consistent with the APU Auto Start logic.
輔助動(dòng)力裝置（APU）進(jìn)氣門(mén)約在08:08:54 UTC開(kāi)始打開(kāi)，與APU自動(dòng)啟動(dòng)邏輯一致。

Thereafter at 08:08:56 UTC the Engine 2 fuel cutoff switch also transitions from CUTOFF to RUN.
隨后在08:08:56 UTC，2號(hào)發(fā)動(dòng)機(jī)的燃油切斷開(kāi)關(guān)也從“CUTOFF”切換至“RUN”。

When fuel control switches are moved from CUTOFF to RUN while the aircraft is inflight, each engine’s full authority dual engine control (FADEC) automatically manages a relight and thrust recovery sequence of ignition and fuel introduction.
當(dāng)飛機(jī)在空中時(shí)，燃油控制開(kāi)關(guān)從CUTOFF切換至RUN，發(fā)動(dòng)機(jī)的全權(quán)限雙通道電子控制系統(tǒng)（FADEC）會(huì)自動(dòng)執(zhí)行重新點(diǎn)火與推力恢復(fù)的程序，包括點(diǎn)火與燃油重新引入。

The EGT was observed to be rising for both engines indicating relight.
觀察到兩臺(tái)發(fā)動(dòng)機(jī)的排氣溫度（EGT）上升，表明點(diǎn)火成功。

Engine 1’s core deceleration stopped, reversed and started to progress to recovery.
1號(hào)發(fā)動(dòng)機(jī)的核心轉(zhuǎn)速減速趨勢(shì)停止，隨后逆轉(zhuǎn)并開(kāi)始恢復(fù)。

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.
2號(hào)發(fā)動(dòng)機(jī)雖然重新點(diǎn)火成功，但未能阻止核心轉(zhuǎn)速下降，只能反復(fù)注入燃油以促使加速與恢復(fù)。

The EAFR recording stopped at 08:09:11 UTC.
EAFR記錄在08:09:11 UTC停止。

At about 08:09:05 UTC, one of the pilots transmitted “MAYDAY MAYDAY MAYDAY”.
約在08:09:05 UTC，一名飛行員發(fā)出了“MAYDAY MAYDAY MAYDAY”緊急呼叫。

The ATCO enquired about the call sign. ATCO did not get any response but observed the aircraft crashing outside the airport boundary and activated the emergency response.
空管員（ATCO）詢問(wèn)呼號(hào)，但未收到回復(fù)，隨后觀察到飛機(jī)在機(jī)場(chǎng)圍界外墜毀，并立即啟動(dòng)了應(yīng)急響應(yīng)程序。

At 08:14:44 UTC, Crash Fire Tender left the airport premises for Rescue and firefighting.
08:14:44 UTC，機(jī)場(chǎng)的應(yīng)急消防車(chē)離開(kāi)機(jī)場(chǎng)執(zhí)行救援與滅火任務(wù)。

They were joined by Fire and Rescue services of Local Administration.
地方政府的消防與救援部門(mén)隨后也加入了行動(dòng)。

不管是何種原因，及時(shí)、嚴(yán)謹(jǐn)、透明的事故調(diào)查，都能成為讓系統(tǒng)更加安全的保障。