Of course, PLovett, but therein lies the problem. It was not just the Helios crew that were 'confused'. You need to read the whole previous thread to understand the psychology involved in why quite a few 'competent' crews had mis-diagnosed the warning as well over the years of the 737. It was not until post-Helios that this became an established teaching point and the subject of a notice from Boeing. Even then it IS possible to have the TOCW sound in the air given certain failures - see other thread.

I do recommend that those joining in here should visit that original thread. You will see there that while they were the final flawed link it was not just the 'crew' that contributed to the accident - there were many failings along the way elsewhere, including the question as to why the Captain had been employed in the first place with his 'record'. Why did the cabin crew not respond earlier? Why was the panel left incorrectly configured. Indeed a classic 'Swiss Cheese'.

I think you're spot on. 'Good habits' [AKA airmanship].
Check lists are there for a damned good reason, but having a regular scan as and when time permits is so important to maybe, just maybe, spot something before you need to read ECAM or a QRH.
PS. Hump, small twins and turbo props may not be as complex, but they can kill you just the same.

Blame The Dead Pilots
 

Well it is easy to blame dead pilots for the accident, lets take a closer look at the processors of the then airline.

Have a look at what Boeing has done since this accident, at least Boeing trying to do something positive.

How easy to blame the pilots:mad:

Yeah and don't get me started about all those people who are demanding airlines should be flying with the risk of volcanic ash shutting down turbines.

"well I paid my money I should be able to fly now god dam it"

These are the same f*cks who are the first to sue claiming pilot error when it is the unthinking majority who blackmail airlines into flying. F*ck the self loading freight who have no idea.:mad:

- quite, but as that well-known ATC after-dinner speaker once said
"Pilots are normally first on the scene of a crash. Aeroplanes do not normally back into mountains"

F*ck the self loading freight who have no idea.

Quality.

Have you taken your pills today, Sir?
 

For b737800capt06:

Having a bad day, are we?

Perhaps you should consider a job that does not involve stupid f*cks and/or SLF?

b737800capt06 perhaps you'd rather blame the SLF for turning up wanting to be flown.

I must say that the user-name of B737800capt06 says something about it's owner.. The rest of the text rather proves it.

A37575

I'm with you on this

I'm warry now of any name with 737 in it due to past experience :)

but just to keep the thread going

My view is not one of blame but what the heck are we going to do to address the causes.

If the accident report can not find a causal chain with a significant weak link other than the pilot then we need to address the crew functions,

Me thinks that a much greater majority would be very unhappy to fly if we were to walk away from many accidents saying it must have been an act of God or alignment of the stars

Now girls , enough handbags for the evening thankyou..........

I have just visited this thread for the 1st time in ages , cannot believe the bickering still going on.

The Airbus pilots giving it stick about the 'archaic' 737 pressurisation system ? Strange that MILLIONS of flights on 73's were ok , including ( the ) 1of the thousands of 73 flights I have commanded which actually had a Press Warning ( documented on this thread ages ok ) and which caused me to don my O2 mask etc etc ......bit of a non-event really , although it was a creeping cabin rise to 10,000+ ' , Why did I not think , even for 1 second , that I had a CONFIG warning ? I do not know , but perhaps one of you experts can advise me ?

I am certainly not happy that the crew are unable to defend themselves , because they paid the highest price for their mistake.

Did they have any feedback from the Cabin Crew ie ' Captain , why have the masks dropped down , is there a problem ? ' ( One of the 1st actions of F Deck is to switch seatbelts sign ON , but NO Emergency Descent announced , normal cruise climb still happening , why would masks drop ?) , this happened at Kegworth too. CRM courses have used that accident as a big stick in the many years gone by .This disaster should be twinned with Kegworth for future safety.

We have all exhausted our excuses for the crew , can we not just accept that this was one of those HUGE accidents which have no real lesson apart from ' WITHOUT COMMUNICATION , WE ARE DOOMED TO MISUNDERSTAND EACH OTHER ' .
.
The continuing Court cases in Nicosia are not helping anybody , the grieving families more so , can somebody please put an end to it all and tell them all that '**** Happens' , nothing can bring them back , how do the crews families feel about all this while they are still also grieving ?

Or is that classic Cypriot thing - blame everybody else , it makes you feel better ?

Very , very sad ................

Most posts seem to be rather subjective on this issue.
The bottom line in this case is that an operator on a tight budget tried to provide air service and it doing so it failed.
You can go around the houses for as long as you want but the truth to the matter is that this crew were ill equipped from the word go.
How many 737 operators around the world have operated the same aeroplane for decades and have had the same problem such as this crew?Not many.In fact not many at all but its easy and convenient to divert attention from the real issue here. Training or lack of it. With proper training these perceived deficiencies would have been ironed out at the training stage and subsequent recurrent training. This operator was not the only operator of such aeroplane that the design of it has to be scrutinised subjectively as it has been here.
One horn for two systems? Ok design flaw. Or from the manufacturer's logic- air and ground. The after take off checklist completion, the way it is carried out it frees the PF to get on with the task of flying the aeroplane at a critical phase of flight, so diverting his attention to the inside should be his last thing on his mind(but we know that we have to do this due airmanship or if the other guy can actually be bothered because.....). But experience tell us that that monitoring the monitoring pilot is highly recommended.
Lastly maybe the system should have just come out and said '' don oxygen masks'' too. But that suggestion would have a flaw in itself, the human might forget to arm it in the first place. So no matter what when it comes to operating an aeroplane, the manufacturer's procedures should be closely followed and one's perception on how it should be, just like how some instructors would like to operate&teach outside of those confines should be taken as airmanship points and not gospel. How many times have we had a question from the checking chap asking '' where is that written?''
The system should not on trial here, it is the operation and understanding of it instead. No matter how poor the design of such system, the operator should be adequately trained in order to operate it competently. Period.
Poorly trained crews will inevitably fail in one form or another should the situation arise.
This accident is a testament to the fact that anyone can start an ''airline'' and hope that the crew will makeup the for the company's intentionally introduced deficiencies. Or so called self funded type rating training agencies pumping out ill prepared crew whilst being too busy conducting an airservice themselves, instead of teaching what they are meant to?

Trying to blame the manufacturer is a poor attempt at exonerating one self from all responsibility. No matter how sophisticated the system might be, the human always attempts to outsmart the system, and on each occasion it has and always failed short of the mark in doing so instead of just following the instructions on the tin. Numerous accidents are available to show that the human element is the weakness in the system and somehow always resorts to blaming the system rather than itself. There is truth to what I once heard from a wise man, that the human is the only animal that repeatedly stumbles on the same stone time and time again.

The sole responsibility should lie with the company for not providing the necessary tools to its workforce,in order for them to be able to carry out their duties in the most safe, efficient and professional manner but as usual in a case like this the management are not on trial!

abc - agree with much of that, but we are treading over old ground here on this accident. There is no attempt solely 'to blame the manufacturer'. You will see that the accident was primarily caused by poor flight and cabin crew performance. HOWEVER, as with all accidents, the other factors are contributory.

Many airlines had inadequate training on the horn activation pre-Helios - BA had several instances of 'confusion' in the simulator lasting varying amounts of time for reasons well-covered in the old thread. Only post-Helios was the manufacturer's information, QRH actions and training emphasis updated. Cabin crew were made more aware of the ramifications of mask drop, door procedures were looked at, engineering procedures amended. Only post-Helios did we discover that a particular failure mode CAN allow the TOCW to sound when airborne (via PPRune?).

We have (hopefully) learnt a lot from this accident.

Centaurus: Fail safe.

A CABIN ALT warning caption is unambiguous and hard to ignore when coupled with flashing red warning captions and the engineering easy enough to implement. Similarly, the convenience item of having the AT command idle at 27' RA shouldn't lead to a situation where the AT will snatch power back to idle due to an otherwise insignificant failure of the RA, when the pilot has manually commanded max thrust while attempting to recover from an inadvertent stall. The Airbus RETARD call design is a much simpler and elegant implementation of the KISS principal, which allows the pilot to determine if actually retarding the throttles is the right call in a particular instance. In both these accidents there is no getting away from the fact that better design implementation by the aircraft manufacturer would likely have allowed the passengers to survive their encounters with an inadequate crew.

Regards.

Who do you think ultimately pays you? No SLF, no job.

Awareness (ref my post #51)
 

For those of you that blame the crew:
Some major f--k-ups, where properly trained and highly experienced pilots were involved:
1977 - KL in Tenerife.
1995 - AA in Cali
2000 - SQ in Taipei.
2009 - FDX in Narita.

And some close call f--k-ups:
1994 - RO A310 stalled over Paris.
1997 - EK A310 sat on its tail at holding position in CDG.
2000 - HF A310 glided into Wien.
2001 - EK A310 almost hit tower in AUH on G/A.
2004 - EK A340 just about took off in JNB.
2009 - EK A340 just about took off in MEL.

How would you feel if you or someone you know was involved in above cases?
Were all crews inadequately trained or below par? Investigations of civil aviation incidents and accidents should be used solely to provide data and experience in improving airline safety.

In the criminal cases in Larnaca (Cyprus) and Athens (Greece) that are presently being heard, lawyers and authorities are trying to set a precedent that will take civil aviation back to the Middle Ages. Our colleagues are standing trial for manslaughter!

Not only this - the Greek and Cypriot authorities are taking a direct part in the blame game by allowing mental and physical abuse of the defendants during the hearings. Mob rule in EU countries in the 21st century!

Why put the Helios employees on trial - just put them on the cross!!!
:mad:

P.S:
from Wiki:
Private investigation

One year after the accident, the Discovery Channel aired a documentary detailing a private investigation, made in cooperation with Advanced Aviation Technology Ltd., arguing that a design failure of the Boeing 737 may have contributed to the accident.

All wiring for the pressurization system was in one wiring loop to the outflow valve in the aft of the Boeing 737. During a Boeing 737-436 G-DOCE flight in May 2003, a failure in this loop opened the outflow valve, which caused the cabin to depressurize. The same wiring failure probably caused erroneous indications to the crew that the standby pressurization system had failed and that the outflow valve was fully closed and unresponsive to pilot input. After seeing indication of the standby pressurization failure, the crew switched the pressurization control to manual mode and made an emergency descent.

Discovery Channel reported its findings on the G-DOCE incident to the Hellenic Republic's Air Accident Investigation & Aviation Safety Board.

The Board reported no evidence of wiring failure in Flight 522, and did not mention the G-DOCE incident. Because all available flight data showed the pressurization control in manual mode and the outflow valve open at a constant angle, and because there was no evidence the flight crew ever changed the pressurization mode, the Board concluded that the pressurization system had been set to manual for the entire flight, which caused the pressurization failure.

Sorry for their faith.
 

Now I am retired and don't know the last QRH but, some common sense issues may be said.
1. SOP discipline. First thing first. HORN IS YELLING :
- "ALT HOLD".
- RECALL ITEMS done: OXYGEN MASK .....ON&100%
- QRH read-out
Period.
NO OTHER ITEM DONE IS in a good SOP LOGIC! Or other habit is tolerable!
2. GOOD COMPANY EXPERIENCE passed on by experienced trainers:
From BAC1-11 days my trainers were saying at every 5000ft.:
- 5000ft.... Cabin Altitude is CLIMBING....PASS. Cabin Temperature is OK.
I was doing the same thing flying with other companies. Some copilots were smiling maliciously, others, considered it a good CRM habit.
May I say that this habit would have save those poor guys?
I know I may!
What a pity the poor speedy training!

Pilot error does seem to be the logical conclusion here.

Checking the tech log once boarding would have been the first warning. There must have been a maint entry stating the work carried out overnight.
- check pressurization system
- normal cockpit preparation checklist
- mistaking the press warning for config warning.

For those blaming the company, lets take it one step further. Who is it that issued this company with an AOC and who is responsible for oversight (making sure they comply with the rules).

Maybe the Cypriot CAA should be the one being sued.


Assy

With respect, the warning horn thing was well known before Helios 522 and had been subject of accident investigation recommendations to change (Norway in 2001 and others). NASA issued a special bulletin on it in December 2004 and another one after Helios 522. Implicitly they were warning that if something weren't done something very bad could happen -- Helios 522 was it.

Boeing refuses to change it, relying on "grandfather" clauses to persist with a warning system that would be permitted on no new aircraft design. It is not a question of endlessly adding new warnings, but of getting rid of bad ones and conforming to modern manufacturing and design standards. And as for the human factors issues, competence etc,. it is a truism that, as remarked above, the best pilots can have the worst accidents. The critical path here is about accurate and unambiguous warning devices, not training or airmanship deficiencies.

And that is the correct answer.

The fact the two pilots were too stupid to see the error is the not the case.

Why make such a ridiculous "fail non-safe" system" ?

To Yaw Damper

Having suffered five years on the 1-11 with it's attrocious air system, I totally agree with you that the 'every 5000' check would probably have caught the problem. It was drummed into me by 'The Skip' in FR (the greatest Training Pilot I have met in 35 years flying) and I carried it with me to Boeing and all it's advanced types until my dotage and to hell with it if it wasn't a standard call.

Frangible I agree with your analysis, changes to checklists and procedures meant to ameliorate design deficiencies belong to the short term during the period when redesign and implementation should take place, they are not a long term panacea. I wonder if Boeing's stubborn refusal to change the pressurization warning system on the 737 might have its roots in type certification issues and/or the potential for increased liability exposure on older models, absent an expensive mandated retrofit.

Maybe it is just me, but a horn that starts wailing in a pressurised aircraft shortly after passing through 10,000ft is a no-brainer, especially when your ears have also been popping. Yet another give-away is a significantly noisier flight-deck.
I flew the succeeding aircraft off the 73-3 production line to the Helios airframe AND (surprise!) on one occasion also had a total failure of the pressurisation controller (same type fitted). Yes I filed an ASR. Come to mention it, I have also had pressurisation controller faults and the cabin altitude horn on DHC8s - IMHO they leave you in no doubt, whether they sound the same as the takeoff config horn or not.
I am an average airline pilot of average ability - no more experienced than the fated Captain on the Helios, and possibly less. He had issues. The pressurisation controller on 737s is far from perfect - but then none are - as with all systems, vigilance and proper procedure would have prevented this accident. We shouldn't be so hard on Mr Boeing.

Weary

Hear hear

(That means "I agree" for all you youngsters

Helios criminal case
 

Dear colleagues,
We are experiencing a bit of a thread drift.
The deficiency of the B737 press system is well known and discussed in many threads on pprune and elswhere.
Another important info - Boeing settled with a major part of the Helios crash victims' families (but not all) out of court at the cost of almost 40 million EUR.
This is another proof of the above deficiency.
This thread was started to bring attention to the disgusting trend of criminalization of commercial aviation accidents.
Noone claims that the pilots were faultless.
Captain van Zanten of KLM 4805 did not make a mistake. He commited a crime that cost the highest ever number of victims in aviation history. Or did he?

Wiki:
The Dutch authorities were reluctant to accept the Spanish report blaming the KLM captain for the accident. The Netherlands Department of Civil Aviation published a response that, whilst accepting that the KLM aircraft had taken off "prematurely", argued that he alone should not be blamed for the "mutual misunderstanding" that occurred between the controller and the KLM crew, and that limitations of using radio as a means of communication should have been given greater consideration.

So should the courts in Larnaca and Athens put the blame only on Helios management? So should the "limitations of the B737 press system have been given a greater consideration"? Or someone hopes that a criminal verdict should facilitate "another compensation" like the Boeing payout?!

:mad:

I think most of us are not complaining about the pressurisation controller which indeed is still being fittet to brand new 737s today (700s that is) but more about the warning system. Yup, i did fly the airplane in question for several years before it went to Helios and had to cope with the problems or pitfalls of the pressurisation system as well, im glad i never had any pressurisation event although a few colleagues in my company did. We still use the same warning system, the only thing boeing has changed is two additional lights that tells you which kind of warning you hear which apparently makes it fool proof as boeing does not require any briefing to the different actions when we hear that sound either in the air or on the ground when those warning lights are installed and operating.

That said, we have to cut Mr. Boeing some slack, after all the aircraft and warning system design is after all over 40 years old by now and should be very well known by all pilots operating this thing, if they are properly trained of course.

A couple of comments:

One reader notes that a horn above 10,000' in a pressurised a/c is a no brainer. I flew for an operator which had the wailer go off at 29.000'. The captain had been in the sim recently where the SFI had introduced a failure of the ground/air sensor. I don't know the full details of the scenario, but suffise to say the takeoff config wailer went off at altitude. I heard the captain in question leapt into the fray and discussed the problem with the F/O saying he had seen this problem in the sim and it was this & that and this was why and this was what to do about it etc. etc. A few moments later the No.1 one rang to ask why all the O2 masks were hanging down.

In past years many of us will have had an indepth recurrent training on communications. Listen and digest etc. etc. How to ask and answer questions. Advocate your position; be clear what is understood. If there is doubt asl again. If the Discovery Channel re-enactment was accurate, and I assume they used CVR tapes, they alledged that the gound engineer asked the captain "the position of the pressuristaion controller." The captain ignored that and kept insisting to know the position of the recirc fan (or altn cooling) C.B's. They alledged the engineer NEVER had his question answered. Makes you wonder. Another captain who was portrayed as allegedly dominering and un-listening and rushing. Does that remind you of KLM Teneriffe or Spanair Madrid; not to mention the B757 crash in Cali? 4 different nationalities and very different cultural backgrounds. Same impatient actions, same result. No doubt there are 100's more examples of where 'less haste more speed' and listen....... would have caused a different outcome.
Trying to lay the most of the blame on a technical design is short sighted. Same goes for Turkish airlines at AMS. To say the technology is more at fault than the humans will cause the medication to be applied in the worng place; treating the symptoms and not the illness.

RAT5 : Very wise comment, but unfortunately not applied . It is quite the opposite we see, almost always putting the" blame" on operators of systems. instead of revisiting the system design.

Here's where I can agree with you and attempt to drag the thread back to the supposed purpose of this particular thread on the Helios accident. Absent clear evidence of criminality that goes well beyond beyond mere incompetence or ineptitude. I don't believe the criminal courts should get involved in assigning blame for an accident by pursuing criminal convictions of flight crew who were just doing their job, however incompetent or inept they proved to be at it. Assigning blame, divvying out compensation to victims and sanctioning those adjudged to have contributed in some way to the outcome ought be the preserve of the civil courts, period.

But here's where I differ with your analysis. Accident investigations should not concern themselves with assigning blame whatsoever. Only in the factual determination of cause/probable cause and contributing factors, be they human failings or technical. The better to prevent the same thing happening again under similar circumstances. Further, I wouldn't claim that design faults were the root cause of either the Helios or Turkish accidents, but they were certainly contributing factors that need to be fixed.

Greetings and thank you for the replies. I agree, blame is often inferred to identifying persons at fault, and causes to the broader spectrum including systems and any inter-actions with humans. Causes are more important in trying to prevent repetition and to help evolve better designs to aid that end.
However, and this touches on another thread regarding the erosion of basic piloting skills. That subject is addressed very forceably in the NSTB report of the Q400 crash in Buffalo. It draws attention to the modern age where too much reliance is placed by crews on the automatics. They can't go wrong..go wrong..go wrong... Often this is due to the method of training by an operator. I have worked for various opertaors where the attitude from upstairs was very different. Some emphasised and encouraged the continuence of excellent handling skills and multi-tasking while doing so. Others have stifled that approach and turned pilots into robotic trained monkeys in the name of crash prevention. They both had significant failure in command up-grades, but for different reasons. The latter, though, saw a weakness in situational awareness and reacting to non standard non-normal situations. Thinking on your feet and making decisions based on your supposed experience to handle some unusual scenario was missing or confused. Basic command requirements. Especially necessary considering that the total experience in some cockpits can be as little as 3500hrs, when basic command requiremenst alone used to be 5000hrs.
What I am nervous about is the march of technology to remove even further the pilot from the operation. A pilot makes an error in managing a system. There is a knee jerk reaction to blame the system or the human-system interplay. Of all the other 1000's of pilots on same type, how many others have nearly made that same error? Is that researched? I've not heard of it very often. The reaction is to say that the system must have an inherent fault and it is redesigned to be even more automatic. Is the training of that individual ever researched? Is the training philosophy of the airline considered? In some cases, such as the fin failure of the Airbus in the USA due to heavy rudder loads being applied, I believe the training program was questioned. There have been other instances where the training has been improved after an incident. The system was not necessarily automated any more to prevent human interference. There have been some superb enhacements of automation. I've flown the most basic of a/c and some of Boeing's finest, not including FBW. I've not felt out of the loop by EFIS & EICAS. I've felt empowered to do a much better job and easier and more relaxed, helped by the information and level of automation, but not neutered by it. Perhaps that is becasue of my background. I never forgot the basics for older technology. I notice that younger pilots, who grew up on EFIS & EICAS, do tend to let themselves be led by the nose. I hear younger trainers teach them to not interfer but trust the automatics and FLY the F.D.
All I'm saying is that if every time there is a prang due to mis-managing the automatics the answer is to increase the level of automation, I wonder if that is going in the wrong direction for the wrong reason. Perhaps the 1 pilot and a dog cockpit is closer than we think.

I agree entirely with this view...

Cheers...FD...:)

DATE:02/05/10 SOURCE:Flight International
 

RAeS calls for better balance between accident investigation and the judicial system
By David Learmount

Air accidents will increasingly be treated as criminal events unless aviation authorities can muster a global push to achieve a better balance between the roles of accident investigators and the judiciary, according to a London aviation law specialist.

Delegates to a Royal Aeronautical Society conference on the criminalisation of air accidents in London on 28 April were warned that it is becoming more common for criminal prosecutions almost automatically to follow accidents.

Charles Haddon-Cave QC said that as a consequence the industry is tending to engage in "defensive engineering, not just technical but personal and administrative".

Procedures are now being designed as "a bulwark against criticism" rather than an improved way of doing things, he added.

The conference examined the tension between the need for operators to run an internal voluntary safety reporting system - without which a safety management system cannot operate - and the judiciary's duty to examine data to determine whether a failure was criminal or not, which tends to kill voluntary disclosure.

Haddon-Cave suggested the system's performance would improve through "simplification of process" and a management structure that clearly defines lines of responsibility. He also called for "balance" in national governance between the purposes of accident investigators and the judiciary, suggesting the law should be used for "prosecution, not persecution".

During the conference a consensus appeared to develop that the International Civil Aviation Organisation is the agency through which this should be achieved, and that its recent High Level Safety Conference in Montreal was the first step along that road.

Meanwhile, the controversial European Commission draft proposal for setting up a European "network" of national air accident investigation agencies that could share resources, was advanced as a more legally practical proposal than creating a centralised supra-national one.

Paris-based lawyer Simon Foreman said the draft offered France an opportunity to redress some of the imbalance in its own system by requiring the judiciary to justify any demand to take charge of evidence, rather than the present system that allows the judiciary to remove evidence for its own purposes, thus impeding the task of the accident investigators.

RAT5 : Excellent post , fully agree. The same tendency is going on in ATC right now, where complexities and incoherences in the advanced automated systems are mitigated by more automation , leaving the controller further away from understanding what the system is doing. I we combine this with the new young generation which was born with a Nitendo next to the feeding bottle , the results are decrease of situation awareness, repetitive tasks to feed the machine, erosion of basic control skills and very, very poor decision making in abnormal situations and/or when automation fails.

Swish 266: Is this rush to find a criminal (humans to blame) driven by the compensation society that has evolved? Is it there in comparable industries, I wonder? Is it caused by the massive payouts that can be achieved in aviation, and has it been driven by the legal profession not the legislators? Until we know the cause of the change we can not start to find an antidote. Can the legislators reverse the trend? I'm sure that in the search for truth and prevention the same attitude of blame-free reporting/investigation, as is found in many airlines, needs to feed across into the public arena. Surely any accident should be investigated as just that. They do happen, in innocence, but it is likely there was a trail of minor events that culminated in an unforeseen accident that was outside the scope of the humans involved.That finds a cause. In doing so the root cause is found and addressed, and may indeed involve a mixture of humans & systems. Should negligence, or other culpable human factors be uncovered, then further action might be taken; but to start assuming someone is for the chop is counter productive and could cloud any judgement as to finding real cause. Just look for the finger on the wrong button and, hey presto, a winner. Mega bucks please.
I have come across an attitude supporting rigid SOP adherence. It was not good communications; any crew can fly together philosophy, but rather a back-side covering attitude. "The SOP's are approved. I followed them; S*!t happened. Not my fault. Ask the company and authority." I wonder what will happen when this attitude is questioned after a survivable accident. "Surely, you as an experinced captain, should have realised that the situation called for a different response? Surely you should have realised that the SOP was not appropriate at this time?" "I was only following orders, guv." I wonder.

In history, we have seen too many accidents, especially where the pilots have not survived to defend themselves, where, perhaps for expediancy, perhaps for compensation reduction, pilot error has been the verdict. The trail of little things, including fatigue, lack of or inadequate training/checking, lack of total experience in the cockpit, etc. etc. has never been fully investigated. Maybe touched upon, but given little importance. Perhaps lack of time or resources? I have marvelled at how some accident investigations have unearthed the most minute and bizzare causes. I applaud them. It was years of hard graft and eventually they found the tiniest grain of truth. Real Silent Witness stuff, but usually mechanical, not human failure.
The process needs to change, as does the incessant removal of the pilot from the flying loop, otherwise we'll become earth astronauts on a computer controlled trajectory with TCAS as the final safety net. Afterall, the only thing missing is automatic taxy & takeoff, and taxy after landing. For 20 years, from 400' up to landing, it has been able to pre-program it. However, I suspect the ball will roll much further in its present direction before someone puts their foot on it and looks around to pause and makes a back-pass.
As our friends in ATC and engineering are commenting, it is not isolated to the sharp end. Our world is part of a chain of many links. I wonder if they are all evolving in a coordinated manner? I wonder if isolated technocrats & accountants are too inward looking at their own territory? It is not impossible to imagine an incident being created by one link working out of sinc with another down the chain and catching the latter by surprise. However, I'm sure blame would be attached to the final culprit. It's an extremely complex area for discussion, and as always 10 experts will have 10 opinions. Who decides?

RAT 5 -

I think it is fairly well appreciated that a devious sim instructor could conjure up any number of failures that could result in a pilot losing his/her S.A. - but there is a very real trap in that doing so introduces the possibility of negative training. I too have had the pleasure of a failue of the air/ground system in a 73-3 sim - the fundamental shortfall of this scenario being the complete absense in your bowels (and ears) that something is VERY wrong with the pressurisation system. In the Helios situation - a typical (but unpressurised) 737 with typical ROC - these visceral clues SHOULD be ringing alarm bells independently of anything Mr Boeing has fitted. They certainly have with me - in stark contrast to what happens in the sim. An experienced pilot might say this is a perfect example of where one has to follow ones gut instinct.

Nevertheless, you raise many very valid points. There are a number of issues here not confined to the aviation industry, and we must work not to let them make our business less safe (like negative sim training). Most pertinently, because the powers and responsibilities of the Commander of an aircraft essentially have their roots in old maritime law, they were not written with the concept of a gratuitously litigious society and law profession in mind. In other words, as you have alluded to, we (and our employers) are far too ripe a target for the avaricious and/or political not to have a pop at. We either need to modify these old laws so that we do not bear responsibility absolute for everything that happens on our flights, or we need to have a bullet-proof get-out-of-jail-free clause that admits the possibility of "honest" human falibility on the flight deck and decriminalises it. The later, of course, still does not negate the possibility of civil lawsuit, hence we really should be carrying professional insurance, like many in the medical profession.

There are parallels here with AF447 inasmuch as design philosphy with Airbus worked towards decreasing the motor-skill levels required to fly the aeroplane, thereby (theoretically) decreasing the likelyhood of mis-handling leading to an accident. But, in accordance with the law of diminishing returns, the human use-it-or-lose-it skill trait in itself introduces a risk that must be carefully balanced. Broadly, AF447 came unstuck because of this and, paradoxically, one other important element of flight safety - a decision of judgement. I cannot see how a manufacturer can design a system that is perfectly fool-proof, 100% safe, and able to accomodate every possible scenario and variable that international passenger air transport involves. There will always be judgement calls to be made and systems that need setting and monitoring, and at least some of that stuff can only be done in-situ .

W.R.T. your other observations, I wholeheartedly agree - the processes of accident investigation, and of judicial process, must be kept very separate. This is clearly not happening in many (most) countries at present and I can't see it changing in a hurry. I suggest whilst we as a profession try to get our laws re-written, we reflect upon what it entails to be a skilled pilot, and what value we place on experience.

gradual/slow depress
 

I can say from personal experience (in my AF days I did 2 times climb in a baro-chamber to 5000 m at an average rate of 1000f/min) that gradual depress is not even close to a calamity. But the effect of hypoxia is! One can't even imagine the gibberish one puts down on his notepad under the dictation of the people conducting the exercise from the outside!
The Helios 522 crew were in a high workload scenario immediately after t/o. This, of course should have not in itself alone sprung the trap on them, but with the slow onset of hypoxia we could never be so sure!
The prosecution in Larnaca is so sure (remember - prosecution claims the pilots were inadequately trained and wrongfully selected for the job) that they are using as evidence a test flight conducted on an Olympic B737 that didn't even have the same pressurization system.
It had the analogue one...
Nevertheless the Hon Judge allowed above piece of evidence...
:mad:

I'm just an SLF but tonight, my wife's washing machine didn't spin the clothes after rinsing them.

Last time the machine didn't do what it was supposed to, I pulled out the filter and found a coin in it after removal of which the machine worked perfectly.

Tonight, I pulled out the filter but found a coin jammed in the hose. I spent about 20 minutes trying to prise it loose but even after I'd got it out, the machine didn't seem to want to spin.

5 minutes later, my wife realised the spin speed dial was set to zero - she reckoned she'd accidentally nudged it from its usual setting while cleaning the machine last night ...

Two points arise from this tedious little tale -

1. Pretty daft of Hoover to design a washing machine with a spin speed setting of zero BUT ...

2. Don't get tunnel vision-ed on the "usual solution" - scan the instrument panel (which Hoover WMs have as well as Boeings!) to see if something's out of place.

Midland63:

I really like that analogy!

You are right in every word .

Nic

midland 63,

Their first clue was the intermitent horn at 10,000 ft cabin altitude. Hypoxia didn't set in until several minutes later so if they knew their systems at all they should have realized the warning in flight is cabin altitude, not take off warning. It happened to me one day and I figured it out in a few seconds, as we are trained to do, so it was a non event. Blaming Boeing for using the same warning on the ground and in the air seems lame. They should have performed standard procedures to easily handle the situation.

Kind of like going from manual to auto on the presssurization panel. Going from zero to a higher setting on the dryer. Just think a bit.

RAT 5,


I am an SLF with a bad cold so you and all the others please feel free to ignore me.


May I argue that the Turkish crew, the KLM in Teneriffe crew, and the Callie crew as well as the captain of Helios all share a common dedication to hierarchy. In the first three cases the FO dared not to talk back or argue to their respective captain and in the Helios case the captain did the talking with his company's maintenance dept instead of letting his FO to discuss the matter in their native tongue. I think this is clearly stated on the report.

No regarding the specific issue most of us would agree that the crew did mis-interpret the warning after having various times failed to set correctly the pressurization controller. PAX on that flight did pay to have a crew correctly trained to operate the flight. Instead they died because the crew failed on this role. Why should the relatives of the crew don't seek a settlement against the airline for failing to meet a basic obligation?

Rwy in Sight