Helios Crash
Join Date: Sep 2007
Location: Paris, France
Posts: 350
Likes: 0
Received 0 Likes
on
0 Posts
Accident investigation committee should equally address airplane manufactures about shortcomings in sytem design.
A simple, inexpensive voice generated aural warning: "don oxygen masks," intermittently announced with the cabin altitude warning horn, would have saved the day. Pilots wouldn't have to "think" and waste precious time interpreting any of the conventional aural warning bells, whistles, whalers, beeps and horns.
A simple, inexpensive voice generated aural warning: "don oxygen masks," intermittently announced with the cabin altitude warning horn, would have saved the day. Pilots wouldn't have to "think" and waste precious time interpreting any of the conventional aural warning bells, whistles, whalers, beeps and horns.
These pilots heard the alarm, but spent their efforts on trying to find a way to shut off that pesky alarm instead of trying to find out what it meant.
Many will be surprised to know that in this modern aviation days and in respected airlines, there are cargo pilots out there believing and preaching that it is possible to survive a cabin decompression just by donning the mask and continue the flight until the oxygen level is low. No need to do an emergency descent, it’s only for passenger planes….
Of course, if they are flying high enough, they may need oxygen under pressure, or even pressure suits, and since they won't have these, an immediate descent will be necessary.
I'm not sure what the advantage would be to continuing, in any case, since the oxygen may not last for an entire flight, and when it runs out there may not be much opportunity to take evasive action. An immediate descent would still be prudent. Why would any pilot be tempted to do something that isn't prudent? Nobody's going to die if they descend and land as soon as possible. Sounds like a bit of a dangerous cowboy attitude to me.
Join Date: Jan 2008
Location: Denver, CO
Posts: 265
Likes: 0
Received 0 Likes
on
0 Posts
Depending on the altitude at which the loss of pressurization occurs (below FL250, if I remember correctly), they are right as far as being able to survive and continue with oxygen. As long as the oxygen supply lasts, they can continue flying in a depressurized cabin indefinitely. But it's not a good idea if the aircraft and flight procedures are not designed from the outside for flying without pressurization. And some of the cargo might be sensitive to low pressures. And their ears might persuade them to descend promptly.
Along with this, IIR, the 73 had suffered pack failures and / or outflow valve issues before, and apparently the problems weren't solved.
Wasn't it sort of figured out at one point that this flight slowly decompressed?
Join Date: Feb 2008
Location: DORSET
Posts: 191
Likes: 0
Received 0 Likes
on
0 Posts
Safety Concerns lays out the facts. I doubt any of this is disputed (in this forum):
The court case seems similarly clear-cut: the prosecution arguing the airline was at fault, the airline arguing it was the manufacturers.Neither side could realistically accuse Boeing without going through this process first. Whoever eventually is found to be at fault is going to have to dig deep into their pockets.
It was obviously not the pilots fault. No-one is suggesting they deliberately lost control of their aircraft. No prior leadership skills or CRM would equip them to deal with an emergency they could not recognise.They had an alarm going off which should not be, in their judgement and experience (they weren't sitting on the ground with a door open), so the only explanation to them was that the alarm was at fault. Hypoxia gave them only a short time to remedy the situation.
well the armchair enthusiasts full of little or no fact are out in force again.
The facts are:
Helios was poorly regulated from day one
All aspects of the operation were sub standard
The UK CAA was actually advising the Cypriot NAA at the time (if you can call it that)
There were serious questions marks about the maintenance setup and the relationship and interaction between quality, ops and maintenance
There were serious question marks about crew training
Helios were to be placed on the EU blacklist but the politicians lost their nerve
The aircraft had a fault prior to the fateful flight but the engineer and everyone else involved did everything correctly
The fact is the aircraft departed serviceable
The fact is it is a disgrace that the accident report cites regulatory failings and no one single regulator is being charged
The facts are:
Helios was poorly regulated from day one
All aspects of the operation were sub standard
The UK CAA was actually advising the Cypriot NAA at the time (if you can call it that)
There were serious questions marks about the maintenance setup and the relationship and interaction between quality, ops and maintenance
There were serious question marks about crew training
Helios were to be placed on the EU blacklist but the politicians lost their nerve
The aircraft had a fault prior to the fateful flight but the engineer and everyone else involved did everything correctly
The fact is the aircraft departed serviceable
The fact is it is a disgrace that the accident report cites regulatory failings and no one single regulator is being charged
It was obviously not the pilots fault. No-one is suggesting they deliberately lost control of their aircraft. No prior leadership skills or CRM would equip them to deal with an emergency they could not recognise.They had an alarm going off which should not be, in their judgement and experience (they weren't sitting on the ground with a door open), so the only explanation to them was that the alarm was at fault. Hypoxia gave them only a short time to remedy the situation.
Join Date: Oct 2009
Location: Greece
Age: 84
Posts: 63
Likes: 0
Received 0 Likes
on
0 Posts
What's wrong with making pilots think? If they can't bother to do that, why are there pilots in the cockpit in the first place? Anything that doesn't require thinking can be done by a computer.
These pilots heard the alarm, but spent their efforts on trying to find a way to shut off that pesky alarm instead of trying to find out what it meant.
These pilots heard the alarm, but spent their efforts on trying to find a way to shut off that pesky alarm instead of trying to find out what it meant.
YOU
ARE
B
O
U
TO DIE
What are the symptoms of Hypoxia?
You may not even recognize the symptoms of hypoxia because hypoxia is insidious in its onset. The signs and symptoms can be different for every person and may not occur in the same progression as listed below. Therefore, it is important to be aware of all the signs and symptoms.
Signs:
* Rapid Breathing
* Cyanosis
* Poor Coordination
* Lethargy/Lassitude
* Executing Poor Judgment
Who knows how long the oxygen deprivation must have been before the alarm kicked in, and the time frame while they eliminated the wrong problem? each second down the wrong path doomed them further because the lack of oxygen progressively made the one thing that could save them, their skills as pilots erode and gasp away.
What's wrong with making pilots think? If we cant seem to get that done in the relaxed atmosphere of this thread, we must demand calculus in the rarefied air ?
dont hold your breath.
Join Date: Sep 2007
Location: Paris, France
Posts: 350
Likes: 0
Received 0 Likes
on
0 Posts
What's wrong with making pilots think? If we cant seem to get that done in the relaxed atmosphere of this thread, we must demand calculus in the rarefied air?
These pilots were alert enough to contact their company in an attempt to find out how to silence the alarms. They were energetic enough to get up to try to pull circuit breakers. They just weren't competent enough to actually locate the source and nature of the alarm and take remedial action in consequence. While they did all the wrong things, the cabin altitude continued to increase, and eventually they did succumb to hypoxia. But they had plenty of time and alertness to do the right thing prior to that, if only they had been good enough at their jobs to do it.
And they could have avoided the problem entirely if they had been good enough at their jobs to actually complete all the checklists before departure (they left pressurization on manual, which implies that they skipped items on the checklists). They were at nearly sea level pressure at the time.
Join Date: Jun 2009
Location: US
Posts: 497
Likes: 0
Received 0 Likes
on
0 Posts
The older 737s used the same beep beep warning as the takeoff warning horn. We had a dual pressurization problem descending with power at idle one day and at first we thought we had a warning problem. In a few seconds I remembered cabin alt. above 10,000 sounds identical so checked the cabin and it was above 10,000 so added enough power to start the cabin back down.
Join Date: Oct 2009
Location: Greece
Age: 84
Posts: 63
Likes: 0
Received 0 Likes
on
0 Posts
so the first occurrence of 'pilot error' for these two was cashing their pay checks it seems.Pilots do need to think -they sure learned their lesson huh?
So maybe the justification for putting in unambiguous alarm systems is not to coddle unthinking pilots but to save lives. Who knows, perhaps with an audible alarm, these pilots would have put the masks on backwards...
Join Date: Sep 2007
Location: Paris, France
Posts: 350
Likes: 0
Received 0 Likes
on
0 Posts
The older 737s used the same beep beep warning as the takeoff warning horn. We had a dual pressurization problem descending with power at idle one day and at first we thought we had a warning problem. In a few seconds I remembered cabin alt. above 10,000 sounds identical so checked the cabin and it was above 10,000 so added enough power to start the cabin back down.
In contrast, assuming from the beginning that the warning is a malfunction of the warning system instead of a legitimate warning and then trying to silence it is very poor judgment. The pilots who made that assumption are no longer with us, whereas you are alive and safe.
Isn't there any kind of visual annunciation to go with the alarm for cabin altitude?
Join Date: Feb 2003
Location: Mt. Olympus
Age: 59
Posts: 80
Likes: 0
Received 0 Likes
on
0 Posts
HAF F16 interception video
Link to the 38 minute interception video by the two HAF F16 (callsigns Perseus 400 & 401).
Gnews f16 - Video
Shocking and disturbing beyond belief
Comms on civil (Athina Control), military ("Mambo" radar) and emergency frequencies. It doesn't add anything new. It just re-affirms what we already know from the report, so apologies if this is inappropriate.
Main points (rough) transcript from Greek:
_____________________________________
0:55 F16s set mode C off
1:49 Approaching from the left, 2 miles
5:05 Interception signals and identification
5:33 F16 pilot reports no response, 500 ft to his left, a/c continues in right turn
6:30 Interception signals
7:25 Radar instruction to proceed forward left of a/c, signal and call on emergency freq
7:59 Pilot reports no response, a/c continues right turns over KEA
8:39 Calling Helios on emergency frequency
10:17 Radar instruction to call again and request following
11:00 Another call to Helios
12:15 Another call to Helios and interception signals
13:20 Radar instruction to approach to close formation position and issue hand signals to follow for landing
13:36 F16 pilot reports aircraft identification marking (reg and type)
14:34 F16 pilot reports "no one in the flight deck, F/O seated with head tilted forward towards the controls, masks in the passenger cabin, one passenger wearing mask"
17:28 F16 reports 200ft to the left, confirms empty flight deck
18:59 F16 reports passenger wearing mask and moving in his seat
22:45 F16s report 1h10' fuel remaining, continuing in right turns
23:10 F16 confirms rubber jungle in passenger cabin and man wearing mask.
23:50 Visual check on rhs
24:41 Radar check, a/c transmitting code 5627
25:25 Radar speed check 250kts
25:27 F16 reports "Man entered cockpit, seated in captain's seat, strapped in, lost 1000ft descending left, now climbing right to FL340, speed dropped to 180kts, descending now through FL270
26:16 F16 reports "man in cockpit, sitting in captain's seat, FL230, heading 330
26:50 FL210, 330deg, 320kts
27:24 FL180 descending 10deg pitch down
27:30 350kts, heading 330deg, 10deg pitch down, descending over sea
27:53 Interception signals, no response
28:40 heading 310deg towards dry terrain FL130
29:15 F16s fuel check
29:38 F16 reports man in cockpit wearing vest and blue shirt, flying level at FL100, 310deg, 300kts, then continues descent at 10deg pitch down
30:55 FL100, 250kts, turning left, 20nm south of KYMI
31:31 heading 270deg, descending towards hills, east of Tanagra A/B, 7500ft
32:15 Levels off at 7000ft, heading 238deg
32:50 F16 pilot reports "Man in cockpit seems to acknowledge my presence"
33:07 "I can see a second person in co-pilots seat"
33:18 "5000ft, heading 218, no response to optical signals, he indicated with his hand that he can see me"
33:40 Call on emergency frequency
34:20 Heading 185 south towards Athens, 3500ft
34:37 Reporting north of station, 3500ft, maintaining visual, heading 146
35:12 "3000ft"
35:25 "2500ft, flying too low over terrain!"
35:35 "Heading for terrain!"
35:59 "Mayday! Mayday! We have civilian aircraft collision with terrain!"
36:00-END: reports coordinates, instructs second F16 to climb above 10000ft, describes terrain and surrounding area.
_______________________________________
TR
Gnews f16 - Video
Shocking and disturbing beyond belief
Comms on civil (Athina Control), military ("Mambo" radar) and emergency frequencies. It doesn't add anything new. It just re-affirms what we already know from the report, so apologies if this is inappropriate.
Main points (rough) transcript from Greek:
_____________________________________
0:55 F16s set mode C off
1:49 Approaching from the left, 2 miles
5:05 Interception signals and identification
5:33 F16 pilot reports no response, 500 ft to his left, a/c continues in right turn
6:30 Interception signals
7:25 Radar instruction to proceed forward left of a/c, signal and call on emergency freq
7:59 Pilot reports no response, a/c continues right turns over KEA
8:39 Calling Helios on emergency frequency
10:17 Radar instruction to call again and request following
11:00 Another call to Helios
12:15 Another call to Helios and interception signals
13:20 Radar instruction to approach to close formation position and issue hand signals to follow for landing
13:36 F16 pilot reports aircraft identification marking (reg and type)
14:34 F16 pilot reports "no one in the flight deck, F/O seated with head tilted forward towards the controls, masks in the passenger cabin, one passenger wearing mask"
17:28 F16 reports 200ft to the left, confirms empty flight deck
18:59 F16 reports passenger wearing mask and moving in his seat
22:45 F16s report 1h10' fuel remaining, continuing in right turns
23:10 F16 confirms rubber jungle in passenger cabin and man wearing mask.
23:50 Visual check on rhs
24:41 Radar check, a/c transmitting code 5627
25:25 Radar speed check 250kts
25:27 F16 reports "Man entered cockpit, seated in captain's seat, strapped in, lost 1000ft descending left, now climbing right to FL340, speed dropped to 180kts, descending now through FL270
26:16 F16 reports "man in cockpit, sitting in captain's seat, FL230, heading 330
26:50 FL210, 330deg, 320kts
27:24 FL180 descending 10deg pitch down
27:30 350kts, heading 330deg, 10deg pitch down, descending over sea
27:53 Interception signals, no response
28:40 heading 310deg towards dry terrain FL130
29:15 F16s fuel check
29:38 F16 reports man in cockpit wearing vest and blue shirt, flying level at FL100, 310deg, 300kts, then continues descent at 10deg pitch down
30:55 FL100, 250kts, turning left, 20nm south of KYMI
31:31 heading 270deg, descending towards hills, east of Tanagra A/B, 7500ft
32:15 Levels off at 7000ft, heading 238deg
32:50 F16 pilot reports "Man in cockpit seems to acknowledge my presence"
33:07 "I can see a second person in co-pilots seat"
33:18 "5000ft, heading 218, no response to optical signals, he indicated with his hand that he can see me"
33:40 Call on emergency frequency
34:20 Heading 185 south towards Athens, 3500ft
34:37 Reporting north of station, 3500ft, maintaining visual, heading 146
35:12 "3000ft"
35:25 "2500ft, flying too low over terrain!"
35:35 "Heading for terrain!"
35:59 "Mayday! Mayday! We have civilian aircraft collision with terrain!"
36:00-END: reports coordinates, instructs second F16 to climb above 10000ft, describes terrain and surrounding area.
_______________________________________
TR
Join Date: Aug 2009
Location: Germany
Age: 67
Posts: 1,777
Likes: 0
Received 0 Likes
on
0 Posts
Hi,
This video was removed ! 
Found it in cache
Gnews f16 - Video
Link to the 38 minute interception video by the two HAF F16 (callsigns Perseus 400 & 401).
Found it in cache
Gnews f16 - Video
Join Date: Apr 2009
Location: Melbourne, Australia
Age: 40
Posts: 73
Likes: 0
Received 0 Likes
on
0 Posts
Nearly 5 years on, it's quite chilling even listening to the F16 pilots and how frantic he sounds when the plane impacted terrain.
Would have been shocking to witness (even for an air force pilot).
Would have been shocking to witness (even for an air force pilot).
Join Date: Feb 2003
Location: Mt. Olympus
Age: 59
Posts: 80
Likes: 0
Received 0 Likes
on
0 Posts
HAF F16 interception video
Uploaded again here:
RapidShare: 1-CLICK Web hosting - Easy Filehosting
RapidShare: 1-CLICK Web hosting - Easy Filehosting
According to the source (?? ???????????? ?????? ??? F16 ??? Helios) the F16 HUD video and transcripts we recently declassified and released by the MOD on March 16, 2010, following a request by the Cypriot Attorney General.
Google translation (with a little intervention for clarity):
<<The breath of the F16 pilot, squadron leader Panagiotis Athanasopoulos at the moment of the Helios Boeing 737-300 collision with the Black Mountains in Grammatiko, is not something that can be forgotten easily. His cry of "we have a collision", is shocking. Gnews.gr reveals the shocking and possibly unique in world history of aviation the videos taken from the F16 squadron leader during the 22 minutes he followed the Boeing of Helios. The last moments of Boeing 737 as recorded in picture and sound from the cockpit of a Greek Air Force fighter jet, which took off from Tanagra airbase to intercept the fatal flight, which cicled over Kea without responding to calls of Athina Flight Control Center (KEPATH). You may see images of the Boeing 737 with 121 passengers and crew crossing in front and at times lower than the F16.
We disclose the dialogues between the F16 pilots and the civil and military radar control centers. The documents are available individually as originals and recently declassified by the rating "Highly Confidential".
Please note that according to some very serious reports, the video is missing the section on the squadron leader talking with the Chief of Defence.
Particularly tragic is the fact, however, that while it seems in the dialogue, giving instructions to the commander of the F16 to call the aircraft on the emergency frequency, the calls are not made in the frequency of 121.5 (the emergency frequency to civilian aircraft) - as testified by the squadron leader to the Cyprus Court. Also, while it was found that 737 captain and copilot were unconscious, no one thought to offer the squadron leader to call the aircraft on the frequency of Nicosia, where they had left the system during the incapacitation by hypoxia. Should this have happened, Prodromou may have had sufficient time to change the route by following the instructions he would have received. Nor did they ever heard the MayDay issued by the heroic flight attendant - and recorded on the cockpit recorder - shortly before the squadron leader Panagiotis Athanasopoulos shouted with anxiety that still rings in our ears "MAMBO, WE HAVE IMPACT OF CIVILIAN AIRCRAFT, MAYDAY, MAYDAY, WE HAVE COLLISION TO THE MOUNTAIN TOP " >>
TR
RapidShare: 1-CLICK Web hosting - Easy Filehosting
RapidShare: 1-CLICK Web hosting - Easy Filehosting
According to the source (?? ???????????? ?????? ??? F16 ??? Helios) the F16 HUD video and transcripts we recently declassified and released by the MOD on March 16, 2010, following a request by the Cypriot Attorney General.
Google translation (with a little intervention for clarity):
<<The breath of the F16 pilot, squadron leader Panagiotis Athanasopoulos at the moment of the Helios Boeing 737-300 collision with the Black Mountains in Grammatiko, is not something that can be forgotten easily. His cry of "we have a collision", is shocking. Gnews.gr reveals the shocking and possibly unique in world history of aviation the videos taken from the F16 squadron leader during the 22 minutes he followed the Boeing of Helios. The last moments of Boeing 737 as recorded in picture and sound from the cockpit of a Greek Air Force fighter jet, which took off from Tanagra airbase to intercept the fatal flight, which cicled over Kea without responding to calls of Athina Flight Control Center (KEPATH). You may see images of the Boeing 737 with 121 passengers and crew crossing in front and at times lower than the F16.
We disclose the dialogues between the F16 pilots and the civil and military radar control centers. The documents are available individually as originals and recently declassified by the rating "Highly Confidential".
Please note that according to some very serious reports, the video is missing the section on the squadron leader talking with the Chief of Defence.
Particularly tragic is the fact, however, that while it seems in the dialogue, giving instructions to the commander of the F16 to call the aircraft on the emergency frequency, the calls are not made in the frequency of 121.5 (the emergency frequency to civilian aircraft) - as testified by the squadron leader to the Cyprus Court. Also, while it was found that 737 captain and copilot were unconscious, no one thought to offer the squadron leader to call the aircraft on the frequency of Nicosia, where they had left the system during the incapacitation by hypoxia. Should this have happened, Prodromou may have had sufficient time to change the route by following the instructions he would have received. Nor did they ever heard the MayDay issued by the heroic flight attendant - and recorded on the cockpit recorder - shortly before the squadron leader Panagiotis Athanasopoulos shouted with anxiety that still rings in our ears "MAMBO, WE HAVE IMPACT OF CIVILIAN AIRCRAFT, MAYDAY, MAYDAY, WE HAVE COLLISION TO THE MOUNTAIN TOP " >>
TR
Join Date: Feb 2003
Location: Zanzi's Bar
Age: 59
Posts: 233
Likes: 0
Received 0 Likes
on
0 Posts
media hype
The release of above document coincides with a new (second) case being opened against Helios Airways as entity and 4 ex-management Helios employees! And is a typical media started hype!
Not only the criminal case in Cyprus, but now another one in Greece has started!
Pilots from all over the world - the next victim on the bench could BE YOU!
Our medieval EU laws allow the same person to be criminally prosecuted in more than one EU country for the same reason!!! Even before one trial is over!!!
Forget about the impact on safety of any ruling against these people, who have to live with the tragedy for the rest of their lives! This is a drastic infringement of our basic human rights...
God help us all
Not only the criminal case in Cyprus, but now another one in Greece has started!
Pilots from all over the world - the next victim on the bench could BE YOU!
Our medieval EU laws allow the same person to be criminally prosecuted in more than one EU country for the same reason!!! Even before one trial is over!!!
Forget about the impact on safety of any ruling against these people, who have to live with the tragedy for the rest of their lives! This is a drastic infringement of our basic human rights...
God help us all
I haven't looked at this accident closely.
Has there been any mention of duty hours, rest periods, number of flts operated over the weeks prior to this very sad accident?
Has there been any mention of duty hours, rest periods, number of flts operated over the weeks prior to this very sad accident?
Join Date: Aug 2009
Location: Germany
Age: 67
Posts: 1,777
Likes: 0
Received 0 Likes
on
0 Posts
Hi,
swish266
Methink .. if they have the choice many pilots will go for be on the bench instead choice the fate of the Helios pilots
At least when you are alive you can speak.
swish266
Pilots from all over the world - the next victim on the bench could BE YOU
At least when you are alive you can speak.
The 737 after take off checklist does not ever mention the requirement to check the pressurisation instruments of Cabin Rate of Climb, cabin altitude, and pressurisation differential.
Boeing "assumed" and obviously wrongly, that as part of the after takeoff checklist challenge and response which states:
Engine Bleeds....ON
Packs...............AUTO.
Landing Gear......UP and OFF.
Flaps................UP, No lights
the checklist reader would have the sense to also observe the two pressurisation instruments for correct indication.
However, as a simulator instructor I have seen on countless occasions, check list readers will often only check the items specifically published on the checklist. The cockpit pressurisation system includes not only the packs, isolation valve switch, the APU Bleed Air switch and the two Bleed switches BUT the two pressurisation instruments.
Boeing made the mistake a few years ago of deliberately removing from the after takeoff checklist the words "Air-Conditioning and Pressurisation....SET" and thus set the scene for the two pressurisation instruments to be ignored by future crews. In addition, having the PNF challenge himself and Respond to his own challenge neatly removed the other pilot from the loop in thoery allowing him to "concentrate" on the priority of flying or monitoring the automatics.
Read the FCOM 1 Normal Procedures for after takeoff scans and all it says re amplification of the the pressurisation system is
"Set or verify that the engine bleeds and air conditioning packs are operating".
Nothing about also scanning the two pressurisation instruments. Is it any wonder therefore, that very few pilots deliberately check those two vital pressurisation instruments during the after takeoff scan -and which will give you the first indication of a potential pressurisation problem?
How many times can you as the PF honestly attest you always listen closely to the PNF challenging and answering his own words during the after take off checklist? And how many look up and across at the two pressurisation instruments to personally confirm the aircraft is indeed pressurising normally?
Boeing should never have made the after takeoff checklist a single man challenge and response policy. Readers would be amazed how many occasions I have seen in the simulator the aircraft take off inadvertently unpressurised and this fact was never picked up by either pilot - despite checklist reading - until the cabin warning sounded at 10.000 ft. One of the reasons being the PF was too engrossed in his own flying duties to actively confirm the PNF scan and checklist reading to be correct.
Boeing "assumed" and obviously wrongly, that as part of the after takeoff checklist challenge and response which states:
Engine Bleeds....ON
Packs...............AUTO.
Landing Gear......UP and OFF.
Flaps................UP, No lights
the checklist reader would have the sense to also observe the two pressurisation instruments for correct indication.
However, as a simulator instructor I have seen on countless occasions, check list readers will often only check the items specifically published on the checklist. The cockpit pressurisation system includes not only the packs, isolation valve switch, the APU Bleed Air switch and the two Bleed switches BUT the two pressurisation instruments.
Boeing made the mistake a few years ago of deliberately removing from the after takeoff checklist the words "Air-Conditioning and Pressurisation....SET" and thus set the scene for the two pressurisation instruments to be ignored by future crews. In addition, having the PNF challenge himself and Respond to his own challenge neatly removed the other pilot from the loop in thoery allowing him to "concentrate" on the priority of flying or monitoring the automatics.
Read the FCOM 1 Normal Procedures for after takeoff scans and all it says re amplification of the the pressurisation system is
"Set or verify that the engine bleeds and air conditioning packs are operating".
Nothing about also scanning the two pressurisation instruments. Is it any wonder therefore, that very few pilots deliberately check those two vital pressurisation instruments during the after takeoff scan -and which will give you the first indication of a potential pressurisation problem?
How many times can you as the PF honestly attest you always listen closely to the PNF challenging and answering his own words during the after take off checklist? And how many look up and across at the two pressurisation instruments to personally confirm the aircraft is indeed pressurising normally?
Boeing should never have made the after takeoff checklist a single man challenge and response policy. Readers would be amazed how many occasions I have seen in the simulator the aircraft take off inadvertently unpressurised and this fact was never picked up by either pilot - despite checklist reading - until the cabin warning sounded at 10.000 ft. One of the reasons being the PF was too engrossed in his own flying duties to actively confirm the PNF scan and checklist reading to be correct.
Join Date: Mar 2001
Location: I wouldn't know.
Posts: 4,498
Likes: 0
Received 0 Likes
on
0 Posts
Some companies have their own check around FL100 where, amongst other things like lighting and fuel balancing/pump setup, the cabin pressurisation instrument will be checked for differential pressure and cabin rate of climb.
Join Date: Feb 2003
Location: Mt. Olympus
Age: 59
Posts: 80
Likes: 0
Received 0 Likes
on
0 Posts
Human factors played a dooming role in this accident and Boeing's 73 design and procedures somewhat contributed to that (at least in so far as to allowing the holes in the swiss cheese to align).
Centaurus makes some valid points. In fact the report lists Boeing as a latent cause to the accident (quoting from page 159: "Ineffectiveness and inadequacy of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft, both with regard to modifications to aircraft systems as well as to guidance to the crews")
For the benefit of those who have not read the accident report, here is an extract from the Conclusions/Findings page (page 155) addressing the manufacturer.
3.1.4 Manufacturer
1. The description in the Boeing AMM for the procedure for the pressurization check (under the heading “Put the Airplane Back to its Initial Condition”) was vague. It did not specify an action item that the pressurization mode selector be returned to the AUTO position after the pressurization check.
2. The manufacturer’s Preflight procedure and checklists (Before Start and After Takeoff) for checking and verifying the position of controls on the pressurization panel were not consistent with good Human Factors principles and were insufficient to guard against omissions by flight crews.
3. The manufacturer’s procedures should have contained enough redundancy to ensure that the pressurization system was properly configured for flight. Because the position of the pressurization mode selector was critical for pressurization, the specific action should have been explicitly listed in the checklists referring to the pressurization system (Before Start and After Takeoff).
4. The use of the same aural warning to signify two different situations (Takeoff Configuration and Cabin Altitude) was not consistent with good Human Factors principles.
5. Over the past several years, numerous incidents had been reported involving confusion between the Takeoff Configuration Warning and Cabin Altitude Warning on the Boeing 737 and NASA’s ASRS office had alerted the manufacturer and the aviation industry..
6. Numerous incidents had been reported world-wide involving cabin
pressurization problems on the Boeing 737. A number of remedial actions
had been taken by the manufacturer since 2000, but the measures taken had been inadequate and ineffective in preventing further similar incidents and accidents.
There were 5 recommendations made by the Greek investigators (AAIASB) to the NTSB that concerned Boeing:
4 RECOMMENDATIONS
4.1 Safety Actions Taken or in Progress
4.1.1 To NTSB
4.1.1.1 2005 – 37 On 25 August 2005, the AAIASB recommended to the NTSB that the Boeing Company consider taking action to emphasize flight crew training and awareness in relation to (a) the importance of verifying the bleed and pack system configuration after takeoff and (b) the understanding and recognition of the differences between cabin altitude and takeoff configuration warnings.
Response/Action: On 25 August 2005, the NTSB responded that the Boeing Company was prepared to issue an October 2005 revision to 737-
300/400/500/600/700/800/900/BBJ Flight Crew Training Manuals (FCTM) to include a new section entitled Air Systems/Cabin Altitude Warning reminding flight crews on how to understand and recognize the differences between the two meanings of the warning horn and reminding them of the importance of verifying the bleed and pack system configuration after takeoff.
4.1.1.2 2005 – 38 On 25 August 2005, the AAIASB recommended to the NTSB that the Boeing Company clarify the Aircraft Maintenance Manual (AMM) maintenance procedure for Cabin Pressure Leakage Test (05-51-91) to explicitly specify the actions necessary to complete the maintenance test. Currently, under the title of section F “Put the airplane back to its initial condition”, there were three action items but none of them referred for the pressure mode selector to be placed in the position AUTO.
Response/Action: On 12 October 2005, the NTSB responded that the Boeing Company had released a Temporary Revision to 737-300/400/500 AMM 05-51-91/20 on 29 September 2005 to include a specific step to put the pressure mode selector in AUTO at the conclusion of the cabin pressure leakage test. This change was planned for official release in the 12 January 2006 revision cycle of that manual. The same change to the corresponding 737-600/700/800/900/BBJ and 737-100/200 AMM were planned for official releases in the 21 October 2005 and 1 August 2006 revisions, respectively.
4.1.1.3 2005 – 39 On 13 September 2005, the AAIASB recommended to the NTSB that the Boeing Company consider revising the Aircraft Maintenance Manual (AMM) 05-51-91 by adding an additional step associated with section F (“Put the airplane back to its initial condition”): to re-install the oxygen mask regulators (if removed) per AMM 35-12-00.
Response/Action: On 1 September, 2006, the FAA responded to the Safety Recommendation. The FAA informed the Board that the Boeing 737
Maintenance Review Board Chairman had advised Boeing of the AMM
missing steps in December 2005. Boeing revised the 737-300/400/500 AMM with the 12 January 2006 revision, and added to AMM 05-51-91, paragraph 161 2.F, a step 4 which stated “Move the pressurization mode selector on the forward overhead panel to AUTO”, and a step 5 which stated “If the crew oxygen mask regulator was removed, then install and test the mask demand regulator (AMM 35-12-86/401).” As a result, the FAA (Office of Accident Investigation, Safety Recommendation Review Board) classified the corresponding FAA recommendation as “Closed – Acceptable Action”.
4.1.1.4 2005 – 41 On 23 December 2005, the AAIASB recommended to the NTSB that the Boeing Company consider enhancing the design of the
Preflight checklist to better distinguish between items referring to the air
conditioning and the pressurization systems of the aircraft and to include an explicit line item instructing flight crews to set the pressurization mode
selector to AUTO.
Response/Action: On 10 January 2005, the NTSB responded that the Boeing Company was preparing to issue enhancements to the flight crew procedures associated with the Boeing 737 Cabin Altitude Warning System by issuing a revision to 737-200/300/400/500/600/700/800/900/ BBJ Flight Crew Operations Manuals (FCOM)/Quick Reference Handbooks (QRH). The changes included modification of an existing Normal Checklist (NC), deletion of an existing Non-Normal Checklist (NNC), addition of a new NNC, and change in terminology.
4.1.1.5 2005 – 42 On 23 December 2005, the AAIASB recommended to the NTSB that the Boeing Company reconsider the design of the Cabin Pressure Control System controls and indicators so as to better attract and retain the flight crew’s attention when the pressurization mode selector position is in the MAN (manual) position.
Response/Action: On 30 June 2006, in its comments on the draft Final
Report, the Boeing Company responded that a change in the colour of the
indicator, as specifically suggested by the AAIASB, could provide a
misleading indication to the flight crew that another failure had occurred
requiring additional action
---------------------------------
TR
Centaurus makes some valid points. In fact the report lists Boeing as a latent cause to the accident (quoting from page 159: "Ineffectiveness and inadequacy of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft, both with regard to modifications to aircraft systems as well as to guidance to the crews")
For the benefit of those who have not read the accident report, here is an extract from the Conclusions/Findings page (page 155) addressing the manufacturer.
3.1.4 Manufacturer
1. The description in the Boeing AMM for the procedure for the pressurization check (under the heading “Put the Airplane Back to its Initial Condition”) was vague. It did not specify an action item that the pressurization mode selector be returned to the AUTO position after the pressurization check.
2. The manufacturer’s Preflight procedure and checklists (Before Start and After Takeoff) for checking and verifying the position of controls on the pressurization panel were not consistent with good Human Factors principles and were insufficient to guard against omissions by flight crews.
3. The manufacturer’s procedures should have contained enough redundancy to ensure that the pressurization system was properly configured for flight. Because the position of the pressurization mode selector was critical for pressurization, the specific action should have been explicitly listed in the checklists referring to the pressurization system (Before Start and After Takeoff).
4. The use of the same aural warning to signify two different situations (Takeoff Configuration and Cabin Altitude) was not consistent with good Human Factors principles.
5. Over the past several years, numerous incidents had been reported involving confusion between the Takeoff Configuration Warning and Cabin Altitude Warning on the Boeing 737 and NASA’s ASRS office had alerted the manufacturer and the aviation industry..
6. Numerous incidents had been reported world-wide involving cabin
pressurization problems on the Boeing 737. A number of remedial actions
had been taken by the manufacturer since 2000, but the measures taken had been inadequate and ineffective in preventing further similar incidents and accidents.
There were 5 recommendations made by the Greek investigators (AAIASB) to the NTSB that concerned Boeing:
4 RECOMMENDATIONS
4.1 Safety Actions Taken or in Progress
4.1.1 To NTSB
4.1.1.1 2005 – 37 On 25 August 2005, the AAIASB recommended to the NTSB that the Boeing Company consider taking action to emphasize flight crew training and awareness in relation to (a) the importance of verifying the bleed and pack system configuration after takeoff and (b) the understanding and recognition of the differences between cabin altitude and takeoff configuration warnings.
Response/Action: On 25 August 2005, the NTSB responded that the Boeing Company was prepared to issue an October 2005 revision to 737-
300/400/500/600/700/800/900/BBJ Flight Crew Training Manuals (FCTM) to include a new section entitled Air Systems/Cabin Altitude Warning reminding flight crews on how to understand and recognize the differences between the two meanings of the warning horn and reminding them of the importance of verifying the bleed and pack system configuration after takeoff.
4.1.1.2 2005 – 38 On 25 August 2005, the AAIASB recommended to the NTSB that the Boeing Company clarify the Aircraft Maintenance Manual (AMM) maintenance procedure for Cabin Pressure Leakage Test (05-51-91) to explicitly specify the actions necessary to complete the maintenance test. Currently, under the title of section F “Put the airplane back to its initial condition”, there were three action items but none of them referred for the pressure mode selector to be placed in the position AUTO.
Response/Action: On 12 October 2005, the NTSB responded that the Boeing Company had released a Temporary Revision to 737-300/400/500 AMM 05-51-91/20 on 29 September 2005 to include a specific step to put the pressure mode selector in AUTO at the conclusion of the cabin pressure leakage test. This change was planned for official release in the 12 January 2006 revision cycle of that manual. The same change to the corresponding 737-600/700/800/900/BBJ and 737-100/200 AMM were planned for official releases in the 21 October 2005 and 1 August 2006 revisions, respectively.
4.1.1.3 2005 – 39 On 13 September 2005, the AAIASB recommended to the NTSB that the Boeing Company consider revising the Aircraft Maintenance Manual (AMM) 05-51-91 by adding an additional step associated with section F (“Put the airplane back to its initial condition”): to re-install the oxygen mask regulators (if removed) per AMM 35-12-00.
Response/Action: On 1 September, 2006, the FAA responded to the Safety Recommendation. The FAA informed the Board that the Boeing 737
Maintenance Review Board Chairman had advised Boeing of the AMM
missing steps in December 2005. Boeing revised the 737-300/400/500 AMM with the 12 January 2006 revision, and added to AMM 05-51-91, paragraph 161 2.F, a step 4 which stated “Move the pressurization mode selector on the forward overhead panel to AUTO”, and a step 5 which stated “If the crew oxygen mask regulator was removed, then install and test the mask demand regulator (AMM 35-12-86/401).” As a result, the FAA (Office of Accident Investigation, Safety Recommendation Review Board) classified the corresponding FAA recommendation as “Closed – Acceptable Action”.
4.1.1.4 2005 – 41 On 23 December 2005, the AAIASB recommended to the NTSB that the Boeing Company consider enhancing the design of the
Preflight checklist to better distinguish between items referring to the air
conditioning and the pressurization systems of the aircraft and to include an explicit line item instructing flight crews to set the pressurization mode
selector to AUTO.
Response/Action: On 10 January 2005, the NTSB responded that the Boeing Company was preparing to issue enhancements to the flight crew procedures associated with the Boeing 737 Cabin Altitude Warning System by issuing a revision to 737-200/300/400/500/600/700/800/900/ BBJ Flight Crew Operations Manuals (FCOM)/Quick Reference Handbooks (QRH). The changes included modification of an existing Normal Checklist (NC), deletion of an existing Non-Normal Checklist (NNC), addition of a new NNC, and change in terminology.
4.1.1.5 2005 – 42 On 23 December 2005, the AAIASB recommended to the NTSB that the Boeing Company reconsider the design of the Cabin Pressure Control System controls and indicators so as to better attract and retain the flight crew’s attention when the pressurization mode selector position is in the MAN (manual) position.
Response/Action: On 30 June 2006, in its comments on the draft Final
Report, the Boeing Company responded that a change in the colour of the
indicator, as specifically suggested by the AAIASB, could provide a
misleading indication to the flight crew that another failure had occurred
requiring additional action
---------------------------------
TR