Such a lack of CRM...
Hi All,
This case is particularly pertinent to me and I have taught it a couple of times at work.
The fault in question was reported as "loud knocking noise heard from the aft (starboard) service door during flt" in the cabin defect log. That was transposed into the tech-log as "aft service door requires full inspection". Without getting into the nitty-gritty, the latter is a very different comment. Crew are advised to write symptoms into the log in order for the engineers to work out the cure.
This lead the engrs to carry out the incorrect task, however, the CAUSE of the pressurisation failure should have been picked up by THE FLIGHT CREW. The engineering checks do not require them to put the a/c back to a "standard flight" condition. As a consequence we (pilots) are generally pretty aware of switch positions post maintenance.
I did my training with Andreas Prodromou who was the number 4 steward and he had swapped onto the trip to be with his girlfriend who was the number 3. Andreas had a job starting with Astraeus at the end of the summer season apparently. He would have known what he was looking at when he finally got into the flight deck: we did our MCC on the 737 at Oxford.
The skipper was an incompitent autocrat who thought CRM was a hinderance.
Helios paid lip service to CRM with little formal training.
Jet2 refused to renew the skipper's contract and he ended up at Helios.
Another mate of mine flew with the skipper and when he heard who it was showed no surprise.
This accident could have been avoided had the captain (notice use of lower case "c"):
a) not had 12 jobs in 12 years. It is questionable whether-or-not the captain had covered all the a/c systems within a 3 year period as a result.
b) believed in CRM
c) levelled off when the "gear" horn sounded (the horn was in fact the cabin press warning).
The Hellenic investigators comment in the report:
"...There was such a lack of evidence of CRM that it was considered a major contributrary cause to the accident..."
Sadly, in my humble opinion, whilst there were failings with the Helios management hierarchy and it is right and proper that punative measures are taken, this accident would PROBABLY have been avoided with any other captain.
I strongly agree with all comments reference Engineers and pilots checking switches but think it is EXCEEDINGLY unfair to punish the engineers. This was solely, after the engineering checks, a flight crew related error.
My summary to the courses usually runs along the following lines:
Captains: write SYMPTOMS not the cure into the tech-log.
Cabin Crew: if the masks drop and you still carry on climbing, do what you can to get onto the flight deck
Cause: One switch was in the wrong place and it should have been picked up about 6 times before FL100.
CRM: As per the Hellenic board, "...there was such a lack of evidence of CRM that it was considered to be a major contributrary cause of the accident..."