Criminal liabilty of the ground engineer
 

I am SLF and a (now retired) legal academic with some publications in the criminal aspects of safety in aviation -- an interest I still feed by lurking on PPRuNe and being grateful for the hospitality of the professionals it serves.

I beg patience, seek clarity, and apologise if I have mis-understood something.

Is it correct to state that, had the valve on the flight deck been set in the correct position for flight, then the tragedy would not have happened in the normal course of events (ie, in the absence of other unrelated causes)?

Is it correct to state that the routine pre-takeoff check list on that a/c includes ensuring that the valve is set in the correct position for flight?

Would it then be correct to conclude that the position in which the valve had been left by the maintenance engineer, who was convicted, would have been irrelevant if the flight crew had correctly and conscientiously carried out the necessary routine checks and acted on what they found -- ie, either set it appropriately for flight, or confirmed that it was already appropriately set?

Would it be correct to say that in principle this analysis could be extended to any other safety-critical switch or valve or lever etc etc forming an item in the routine and prescribed pre-flight checks?

bubbers is spot on The check on the first flight of the day can be assumed ok with just residual pressure. I know, i checked just after this incident. From memory not all aircraft had the shut off valve in the flight deck but it should be wire locked open and function checked.

An accident waiting to happen in my book.

Oxygen systems should be checked for pressure and flow before each flight.If the engineers have to top it up now and then ,so be it.

Connetts is bang on with this statement. Almost every time I receive an aircraft from maintenance I find switches in the wrong position or just turned off, it is my responsibility to set the panel in the correct configuration, that is why I do a preflight.

Apologies for dragging this back to the piloting side from the very important legal issues - the other thread appears to have 'faded':

I see reference to the 3 bleed switches being found 'OFF' - where is this documented and what do folk offer as an explanation?

Some reference to the oxy valve being 'OFF' or 'half-open' - again, is this investigation evidence or gossip?

I personally discount as inconclusive the fact that the pres valve was in 'AUTO' and the 'MAN' light out at impact. We need to remember we had a 737 MCC trained steward in the cockpit at the end.

It seems the CVR would tell the story if all bleeds were off because at 10,000 ft cabin altitude high warning, if the same model 737 I flew, went off you get the takeoff warning horn as I did once. Outflow valve in manual or no bleed air would cause this but why would they continue to climb. The oxygen bottle would only be a factor if they continued climbing without rectifying the cabin alt high warning and ignoring the passenger masks dropping which seems highly unlikely. They should have been fine until over 20,000 ft before any hypoxia symptoms set in.

The only thing that makes sense to me is they depressurized at altitude and had no oxygen. If the bottle was only part way on the mechanic who didn't properly turn it full open was at fault. Cracking it open will give you pressure but no volume of flow when you need oxygen. I have no proof of this but it is the only thing that makes any sense.

What an MCC trained steward?

- I recall the report saying they were discussing the horn at around 10,000' with company?

MCC - bugspeed post #27 refers to it. It is a mandatory part of EU pilot training - 'Multi-crew Cooperation' course. It would have given the steward several 737 sim training hours.

Edit to say that from a report they appear to have been discussing an E&EE cooling failure at 12000' with maintrol. It is worth trying to follow the erratic reports as they flow though the old thread http://www.pprune.org/rumours-news/2...stigation.html

"The cabin altitude warning horn sounded at 12,000 feet, four minutes from takeoff. A few seconds later (09.11.50), the captain reported an air-conditioning problem and requested clearance from ATC to hold at 16,000 feet, which happens to be the maximum for APU bleed supply. "

The accident still remains a mystery to me. Has anyone seen ANY of the Canadian/Boeing or other reports (with links?)

Connets, this should be good. Refresh my glass memsahib & some crispies to accompany would delight. Damn, I told myself not to start like this. Look, I love the legal take but it really starts to complicate in the search for clarity. You throw in the words routine and routinely. Boy, open the flood-gates for discussion. We have, in professional Air Transport Aviation a set of guidelines in our Operations Manual. Normal, Supplementary Normal, Non-Normal and Emergency. Since we study, get regularly checked, have the opportunity to regularly practice most considered events, one might venture to question what is considered to be routine.

For example, a critical failure is the loss of a powerplant at Decision speed on a limiting runway. I was thrown this failure routinely on every check I ever had to perform. It was a failure that would be routinely briefed for & even rehearsed in the form of briefing & touch drills to the point that it was almost expected on take-off & should not cause surprise.

As others have expressed, it is our responsibility to check that the aircraft is correctly configured & switches are in the normal position as a matter of routine. If we are presented with an aircraft that is being dispatched by Engineers in accordance with the Minimum Equipment List for any number of reasons, we are, again, responsible for total understanding & accepting the aircraft with a full brief as to what is expected of us. see what I mean Connets ? It might be routine to accept a supplimentary non-normal or even non-normal configuration of switches.

Most pilots would not expect to see the Px control in Manual during pre-take off checks. If it was, we would ask Engineers to explain. Manual would require manual control of the outflowvalve through the Clb/Dec switch & requires practiced and even artful technique. I would not consider this to be a routine practice.

Loss of PX at any stage requires the operating crew to don Oxy masks & regulators & establish communications (with each other) . That part is a memory drill. We would then try to establish the cause & take manual control of the outflow valve, if that was the problem, by first, placing the PX Control switch to MANUAL.

BOAC, all bleeds off wouldn't half be felt in most ears. Engine bleeds off might be used in the supplementary normal case where max thrust from the engines is required. Remember the old Boeing procedures of configuring the system in the form of a letter "C" & then re-configuring, after take-off in the "reverse C" ? Switches, definitely in a non -normal position but, from Connet's point of view (legal-eagle), possibly a routine event outa some airfileds ?

Trust that might help clarify your question Connets.

I had an E&E outflow valve stick open the day I was operating on one air conditioning pack because of a write up and got the intermittent horn, same as take off warning horn, once in a B737. It took a few seconds to realize that the warning was also for cabin altitude above 10,000 ft which it was at idle thrust descending. Adding a little power and putting on the second pack fixed it. I remember a couple of years ago the crew talking to their maintenance people about the beeping but seems they would have figured it out as we did. I don't believe they would have continued climbing to high altitude with pressurization inop. Also why call maintenance unless you just thought it was an inop takeoff warning horn?

- yes, but we have at least one poster 'claiming' all bleed switches were in the off position in the wreckage (don't know the 'provenance' for this statement) and another that Helios commonly used bleeds off or APU for this trip as a tanker.

This is why some links to some sort of 'official' investigation/s would be really useful.

If all the bleeds were off would that include APU? Maybe they made a bleeds off take off and forgot to switch bleeds. Quito was where we made bleeds off takeoffs but once in climb you had to switch to engine bleed on the 757.

All three bleeds - check the reports in the link. We do not even know if the APU was serviceable for starters. We know very little.

Back to the 'what if', 'maybe they were ?' 'Poster "claims" ' , etc. BOAC you are right in stating that we know very little & I wonder how much more the Courts knew ? Bubs, I am doing it now (!); if the crew were in contact with control & discussing the situation, they might have responded to Control asking them to "try " this or "try" that to resolve a developing situation. That can lead to all sorts of non-normal switch positions and failure to re-configur after resolution was not effected.

My input was more to demonstrate to our Lawyer associate that once in the leagal arena, Lawyers can have a field day with words like "routine" .
Don't you love it when they come out with stuff like " Is it not true.........?" ! No disrespect intended Conetts.

- I have just revisited the Greek accident report and there is a puzzle. The report states that the APU bleed was off, but the picture at page 50 clearly shows the APU bleed switch at 'ON' while the text says

"The left engine bleed toggle switch (BLEED 1) was found in the OFF position. The right engine bleed toggle switch (BLEED 2) was visually found in the OFF position. The APU toggle switch was found in the OFF Position. The isolation valve toggle switch was found in the AUTO Position. The left air conditioning pack switch appeared to be in the AUTO position. The position of the right pack switch could not be determined because of impact damage. The air conditioning panel was packaged and shipped to the Boeing Company, along with other systems components, for additional examinations (See section 1.16 for additional information)."

Edited to note: The report also confirms (I think!) that the Outflow Valve WAS in manual at impact based on the bulb filaments.

No offence taken, Slowjet.

However, your answer raises questions for me but I will not --at least, for the moment -- pursue the point as I feel that I may be thought to be intruding. Following up what you have written might look as if I am cross-examining, and this might not be appropriate conduct for an outsider.

I shall continue lurking and trying to learn...... and thank you all for tolerating this.

Connetts, don't be too self demeaning. You were never considered to be "lurking" and your input would always be interesting to us professional pilots. I got my Law degree from Oxford but never practiced. Became a self appointed Perry Mason, Armchair Lawyer & professional Air Transport Pilot. Very dangerous Debating Society position. Trust that you appreciated the diffuculty we have with court-room banter and fact. This Greek case stinks. Any legal system that finds guilt, administers punishment but then offers a cash for walk-away deal is stomach churning.

Keep looking at this case. It is FULL of anomolies & contradictions. Just look at BOAC's latest offering. Puzzling indeed. I like photographic evidence over written reports but both can be interfered with.

As pilots, we are all interested in knowing what exactly happened so that any similar disaster can be avoided. The Lawyers must keep looking at the legal implications and methods used to extract the truth.

For the time being, as I said to the Easyjet Check-in popsy as I weighed in my carry-on................" I rest my case".

So now going full circle was the pressurization in auto or manual. Were the proper bleeds on. Did the CVR have the 10,000 ft cabin altitude beeping, same as take off warning horn recorded. What did they talk about with their engineers about the problem and what did they say. Why did they continue climbing if the cabin altitude dropped the masks? Did they just depressurize at altitude and the oxygen bottle wasn't turned fully on? It must be in the report somewhere. It probably is somewhere in these hundreds of posts. I will not spend hours going through them again but something doesn't make sense.

My guess is the mechanic opened the oxygen bottle just enough to show pressure and didn't open it fully as required. Just my opinion but only thing that makes sense. Please, anybody that has a better opinion join in.

Welcome to the mystery.

Bubbers 44. The problem with this system is that residual pressure in the oxygen line can produce a brief satisfactory flow test. Regardless of that, the valve in question is positioned on the flight deck and is an item in the pre-flight checklist for the flightcrew to check regardless of what the engineer may or may not have done.

greg47
 

Im a friend and colleague with one of those charged from our Eva days . I lost touch with him when we went our seperate ways. Ive only just learnt hes in the fix hes in. I would like to get in touch to offer my support. Id hope he may read this and reply. Can anyone offer how i may be able to make some contact.

This was all discussed ad infinitum
 

Its not a mystery although there are aspects that will never be known.
It was crew error.Mis-identification of the intermittent warning horn whilst airborne(from the report).Light aircraft climbing @ 3000fpm so hypoxia onset was quick.Crew-training error also.Rapid depressurization is only scenario trained.No hypoxia training(alt chamber) either for civilian crews,only military.No dissemination of data from similar incidents(lingus etc) to B737 operators.Use of master caution system.Identify,priority to most crucial NNC,RESET.Risk of masking etc etc.It was a crew training accident,not CRM.The role language played in the crash.The role SOP's played in the crash.Slavish obedience of procedure over airmanship favored by modern airlines due poor training,invasive in-flight FDM,pressure from insurance companies,wrong guys becoming trainers etc etc.Its one of the misunderstood crashes of our time.

Forget all the myths;the engineer asking them if AUTO was selected.The discussion with Maintrol centered on equip cooling.Switch(es) position at impact...the male FA was a licensed pilot,he may have changed switch positions after everyone was already dead.Its immaterial.The rubbish about the airline and the country's CAA being unsafe to operate in EU.All red herrings.The crew Oxygen setting..doesnt matter,they never donned masks.

Keep it simple.Aircraft climbs,horn sounds,Captain retards thrust lever(s) to silence horn(wrong mindset-training issue),horn is never RESET,the first action(yes even before masks) to a cabin pressure problem.Horns,bells whistles quickly scramble the brain,especially so if theyre unidentified by the crew.Captain focuses on equip cooling and talks to Maintrol while plane climbs at 3000fpm and everyone dies.Master caution never reset seals their fate.FA's sit there while plane climbs,waiting to die.Weak Captain?Weak FO?(both very contentious issues because other crews have been caught in same trap-hypoxia onset is insidious killer)Boeing design?changes were made(red CAB ALT light,change to pre-flight checklist etc) but master caution system,if used properly,would have identified the problem.FA's were the last chance but acted in accordance with SOP's.

None of these guys should be on trial.For what?The system is what should be on trial.Airmanship,good training etc sacrificed at the altar of political correctness,SOP's and modern-day rote flying.Good airmanship and training saves lives,nothing else.CRM,SOP's etc,are very over-rated.Useful tools and they make the insurance companies and the politically-correct managers happy but both are of very little help when chips are down.Knowledge,judgment,experience..thats what counts.

Greg47
 

Try a search on 'Linked in' and send a message. Worked for me.

I took off from San Diego once and the outflow valve in the 737 went full closed as we were saturated with clearance info so opened up the outflow valve fully to comply with ATC instructions with turn and altitude changes. since we were taking off to the east. Finally when we had time we used manual pressurization to complete our flight. My FO just looked at the ceiling so lost him for a few minutes. If you are below 10,000 ft just shut pressurization down and aviate.

Helio Plane Incident.
 

The air steward had a CPL.
Why couldnt he descend the plane to 10,000ft so that the pilot can regain consciousness and save the plane?

From memory I seem to recall that by the time he managed to get into the flight deck they were nearly out of fuel. I suggest you read the report.
You can find it here - https://aaiasb.gr/en/aaiasb-reports/...87-112006.html

Local paper focused on the anniversary and the fact that four Management staff were indicted and found guilty. They all received reduced sentences and got off with no jail time after paying hefty fines.Highly emotive comments from families who lost loved ones but I did wonder why, what to me appeared to be pilot error, resulted in conviction of four Management bods.