Helios Crash

[bizdev]

Anyone know who the five are (roles)?:ugh:

[fox_trot_oscar]

what's your source bizdev?

[Cyclone733]

A quick google search gives the story, but it looks like the names are not yet in the public domain. Can't be a pleasant time for anyone with links to the accident.

Trend News : Cypriot prosecutors to charge five over 2005 Helios air crash (http://news.trendaz.com/index.shtml?show=news&newsid=1337275&lang=EN)

http://www.cyprus-mail.com/news/main.php?id=42300&cat_id=1

[nessim]

local Cyprus newspapers say that after attorney general announcements, its gonna take at least two months till charges turn against specific persons.

[Evanelpus]

I smell journalist here!!

[bizdev]

You must have a cold then:).

I used to work with one of the individuals involved in this incident and rate him as one of the very best in the business. I therefore have an interest in who they are gunning for. If one of the accused turns out to be the individual that I know then we really are in a sorry state!

[cessna24]

bizdev,
ditto what you said.
Its got to be a crap link

[levantes]

It's true, official, and no journo trash!
The fact is that the autorney general is bringing charges to these individuals!
It is a whole different story if they will be convicted or not!
Personally I wasn't expecting charges to be brought forward as I think is difficult to make a case of this incident!
Nevertheless it's happening and I'll be interested to see how it will evolve!

[PAXboy]

I don't suppose there's a chance that politicians are trying to show that they are doing something? Must be an election due.

As someone said to all politicians: Don't just do something - Stand There.

[kotakota]

Just as long as the poor relatives of the deceased are not going to be fleeced by the 'ambulance-chasers ' and lose their homes ( as well as their loved ones ) to pay these leaches .
Earlier talk of suing Boeing was irresponsible - you do not take on an American powerhouse ( and , by default , the White House ) unless you have unlimited funds .
I take it the Cypriot tax-payers are going to pay for this 'trial' ?

[CYatUK]

Yes, however I don't think anyone will complain as the Cypriot public opinion is in favour of the procedure and most people think/expect that someone will (unfortunately) be convicted.

[yowie]

So who wears it, the last one that aligned the hole?:ouch:

[oversteer]

Where do you draw the line of blame - the pilots ignoring the cabin altitude warning, the designer of the aircraft for using the same system as takeoff config warning, the maintenance who set the outflow valves manually.. like all things a number of errors occur which separately would not have caused an issue.. I do not understand why any individual persons could get blamed for this incident.

[TheShadow]

LINK ONE (http://www.timesonline.co.uk/tol/news/uk/article565157.ece)

link TWO (http://www.timesonline.co.uk/tol/news/uk/article565157.ece?token=null&offset=12&page=2)

[kotakota]

This is all so incredibly sad . The accident so traumatised the entire country , not sure it will ever go away , even if they do prosecute somebody .
All I know is , that if the crew had finally woken up to what the problem was , initiated an emergency descent etc and landed safely , then they would have been held entirely responsible for the event . Performing any checklist wrongly is going to be punished by an inquiry . If the cockpit preparation had been performed correctly , that aircraft would probably still be flying to this day .
Obviously , the crew cannot be disciplined having paid the ultimate price , so it seems that someone else must be held responsible.
I have had dealings with Lasham engineering since it was DanAirs engineering base , subsequently also with Astraeus , and have never had any doubts whatsoever.
As a Captain , whenever I have entered a flight deck and discovered that the aircraft has just left the hangar , I have made sure that the cockpit prep is very thorough indeed. This has even been at some of the worlds major airlines
whose engineering I trust completely - their job is NOT to set up the flight deck for me and my crew , they may have been under commercial pressure to get the aircraft released and back in service , some switches do get missed , packs are off to allow work underneath the aircraft etc . If I have found a switch not in the preflight position I have never made a song and dance about it , it is my responsibility to ensure that it is correct before take-off.
Having heard from various ex-Helios cabin crew about how they were abused by the public in supermarkets etc , while they were still grieving themselves over the loss of colleagues and friends , then I fully expect others will get it in the neck . If this finally brought the episode to a close , I might concur somewhat , but I suspect the mud-slinging will never stop.

[ExSp33db1rd]

As a Captain , whenever I have entered a flight deck and discovered that the aircraft has just left the hangar , I have made sure that the cockpit prep is very thorough indeed.


Sadly, the most dangerous aircraft to fly is one that has just come off maintenance - and I'm truly not knocking engineers, but we're all human and mistakes and omissions can occur in the best regulated facilities.

Y'e canna be toooo carrreful - I was once taught.

[oversteer]

Is checking the Pressurisation Mode Selector = AUTO not a manufacturer specified "Preparation" checklist item for this aircraft?

[A and C]

The maintenance staff are not trained to "set up" the aircraft for flight and so CAN NOT be responsable for the switch positions of an aircraft that is offerd for service.

The sujestion that the maintenance staff are responsable for this accccident is not sustanable, after all the logical conclusion of this would be demanding the maintenance guy to set the FMC and all the navigation radios.

The bottom line is that the fault for the flight deck not being set up properly lies with the crew, just as not knowing what the warning horn was telling them and not stopping the climb when they got the warning.

( I offer this opinion as a 73NG rated person)

[Right Engine]

A + C,

The maintenance staff are not trained to "set up" the aircraft for flight and so CAN NOT be responsable (sic) for the switch positions of an aircraft that is offerd (sic) for service.

If the Helios Operations Manual (engineering) did not include a work schedule that included returning the offending 'lever' to ON then I grant you, Helios are more culpable than the engineer that made the mistake but to claim maintenance staff are not responsible, is off the mark. They were part of the chain of error. The engineer in this instance has lived to carry some of that guilt but the crew haven't.

Engineers are not grease monkeys. They are responsible professionals who work to strict regimes that should include returning aircraft to service in a condition that is safe, functional and consistent. This is not about setting altimeters or programming FMC's is it?

[Litebulbs]

Does such a thing as an Operations Manual Engineering exist?

[Litebulbs]

The FAA have released a new AD 2008-23-07 calling for a revision of the AFM.


SUMMARY: We are adopting a new airworthiness directive (AD) for all Boeing Model 737 airplanes. This AD requires revising the airplane flight manual to include a new flightcrew briefing that must be done before the first flight of the day and following any change in flightcrew members, and to advise the flightcrew of this additional briefing.

This AD results from continuing reports that flightcrews have failed to recognize and react properly to the cabin altitude warning horn. We are issuing this AD to prevent failure of the flightcrew to recognize and react properly to a valid cabin altitude warning horn, which could result in incapacitation of the flightcrew due to hypoxia (lack of oxygen in body) and consequent loss of airplane control.

[IFixPlanes]

Does such a thing as an Operations Manual Engineering exist?
No. All steps are described in the AMM (Aircraft Maintenance Manual).

IIRC the maintenance did a leak check on one of the aft doors.
Every switching is mentioned in the AMM.
Here you see a quote out of the actual "Cabin Pressure Leak Test" Task:

05-51-91-702-001
...
D. Prepare for the Cabin Pressure Leakage Test
...
(9) (a) Move the pressurization mode selector on the forward overhead panel to MAN.
...

...
F. Put the Airplane Back to its Usual Condition
(1) Do a check of the Pitot Static system for leaks and correct operation if it is necessary
(2) Open the equipment cooling flow control valve.
(3) If the equipment cooling fans were selected from NORMAL to ALTERNATE, the switches must be returned to the NORMAL position.
(4) Move the pressurization mode selector on the forward overhead panel to AUTO.


But the point F(4) did not exist in the AMM revision valid at august 2005.
This sentence appears in the revision januar 2006. :}

[Engineer]

If the AMM did not state that the control should be returned to the Auto then the engineers have nothing to fear and the responsibility surely lies at Boeings door.

Maybe if the cockpit check had been more thorough the situation may have been averted but hind sight is a wonderful pill that cures all ailments

[fireflybob]

One aspect of the Helos accident which interests me is whether either of the flight crew had had hypoxia training. During my commercial pilot training (back in 1969) we were all taken to the nearby Navy base and put in the chamber and taken up to 35,000 ft or so and then asked to do simple tasks after the oxygen was turned off. (We had previously covered all the various physiological aspects in the classroom). It was really impressed on us how vital it was to get onto oxygen should there be a pressurisation failure and the dangers of not doing so. But the actual experience of hypoxia in that chamber is something I have never forgotten.

As a professional pilot I have asked some of the new entrant pilots whether they have had hypoxia training and have been very surprised that this was not included in the syllabus for their commercial training. I would have thought that all commercial pilots who may be involved in operating pressurised a/c ought to have had practical training concerning hypoxia.

[green granite]

If the AMM did not state that the control should be returned to the Auto then the engineers have nothing to fearThat surely depends upon how much trust you place in that country's judicial system to produce a verdict based on the law and not on emotion.

[AMEandPPL]

I would have thought that all commercial pilots who may be involved in operating pressurised a/c ought to have had practical training concerning hypoxia

I'd like enthusiastically to second that ! I have also had the good luck actually to experience depressurisation followed by hypoxia, but in a controlled environment for training purposes. 1986, when AMTC was located at North Luffenham !

The really frightening thing is that you get ZERO warning or prior awareness when you are drifting into potentially fatal hypoxia. I'd agree that a much increased awareness even of the possibility should be an essential part of the initial and recurrent training of all crews operating pressurised aircraft.

It's worth noting that this is one of the few areas which cannot be realistically practised in simulators, which, however sophisticated they may be, never leave the ground !

[FlyingOfficerKite]

It would be good to have at least one experience of hypoxia at some stage during training - cost and logistics no doubt being the determining factor in this case.

Although a good number of pilots have no doubt seen the videos of aircrew in a chamber, it cannot bring home the reality as AMEandPPL states - and he should know!

I know that when I did my initial type rating on the B737 it was impressed on us that we should check the position of the oxygen selector on the first flight of a duty as a part of the 'rainbow' check - and over the years I always did this check thoroughly - and found on at least one occasion that the selector was OFF.

It's so sad when such a simple check results in a tragedy - but what about the other indications along the way during the course of the flight?! It's hard to believe that ALL the warnings and indications were missed during standard operations - but they obviously were.

FOK :)

[tcas1]

My humble opinion is that this is a combination of boeings' incomplete AMM and the crews inability to realise what the problem was when the cabin altitude warning sounded. Nevertheless responsibility lies with the management of Helios who although received 5 reports from F/O's about the certain Captain, continued to employ him. Apparently the reports dissapeared by magic although the F/O's involved gave the info to the police during their testimony.
Finally as a proffessional pilot myself and as some of you have commented, i take it as my responsibility to prepare my a/c prior a flight and make sure all is ok. We must learn as pilots to learn from ours and other peoples mistakes and take responsibility for them.
As for the inquiry i hope justice is awarded.
Fly safe.

[itsresidualmate]

I've been called out to departing aircraft a fair few times with 'faults' only to discover a bus-tie switch or fire loop detector switch in the wrong position, enough so that when I'm called to a snag I do a switch check first. These are invariably switches that are always left in their default positions. I suppose if you're checking the same switches every day you become blind to ones that 'never move'. I've been caught out myself on ground runs.

If I'm working a u/s aircraft my thoughts are directed at fixing the fault, not leaving the flight deck switching in a ready to fly state. If I'm working a snag when the crew 'own' the plane, I'll always ask them to move a switch rather than do it myself.

Pre-flight checks just aren't part of an engineer's remit. Harsh as it may be, I'm afraid the buck stops with the flight crew on this one.
Perhaps the problem IS that switches are always left in a flight ready position?!

[itsresidualmate]

....meant to add that Boeings cabin alt warning looks a bit shabby, doesn't do much to help the crew when one warning has multiple meanings.

[Joetom]

Ever seen this before.

During cruise, defect xxx, QRH actioned. (pilot report)

Defect xxx tested as per MM, test ok, xxx now servicable. (eng entry)

Next pilots may find switches out of normal positions ?

Whos job is it to reverse QRH actions ?

[itsresidualmate]

If Engineering has worked the defect then certified the aircraft as serviceable, responsibility to move switches to the ready for flight position lies with the next crew taking the aircraft. We will make switch selections required for our tests and should leave them in the normal position or where the Aircraft Maintenance Manual states. This may or may not be where the Ops manual requires them to be for flight which is why pre-flight checks are so important.
The only people that know where pilots want switches placed are pilots. We work to the AMM not a Flt Ops Manual.

[IFixPlanes]

....meant to add that Boeings cabin alt warning looks a bit shabby, doesn't do much to help the crew when one warning has multiple meanings.The crew should know if they are in air or not. :zzz:
On gound = T/O config warning
In air = cabin altitude warning

[GS John]

My view, engineers / previous flight crew should try and leave the aircraft in the correct configuration, on-coming crew is responsible for checking it is.

[D O Guerrero]

Ifixplanes - I think it would be fair to say that under conditions of potential hypoxia, it is probably not a good idea to have a warning horn that has 2 meanings. As far as I can see it can only lead to a strong potential for confusion in a period where judgement is possibly impaired. So much so that Boeing have modified the warning horn to also trigger a light which indicates whether it is sounding for takeoff config or cabin pressurisation. An admission, surely, that there is a problem with the design of this system? Not only that, but the config warning can sound in flight, for example retarding the thrust levers to less than 68% N1 with flaps out and gear not down will trigger it. So its not quite as clear cut as you seem to think (Edit: this sentence is garbage - I was thinking of the steady warning horn, but the rest of this paragraph is accurate!).
Furthermore, regardless of the position of the pack switches/pressurisation mode selectors, I find it quite amazing that they were not reset as part of the normal procedures or caught in the normal checklist sequence. I don't know the Helios SOPs but at my outfit the auto mode selector should have been checked at least 3 times by the time 10,000' is reached, the pack switches having been reset as part of the after start sequence and checked in the A/S checks. So perhaps someone could explain where the maintenance personnel fit into the story here? I can't see how they could be blamed?

[Flight Detent]

Hey DOG...

The initial part of your post is rubbish...

The second part I agree with entirely...

Howzat...Cheers...FD

[IFixPlanes]

I think it would be fair to say that under conditions of potential hypoxia, it is probably not a good idea to have a warning horn that has 2 meanings. ...A few minutes at 10.000ft Potential hypoxia is unlikely.
Again: in air it must be "cabin altitude warning". There is no other meaning.
If there is a fault in the AIR/GRD you can easyly find out a incorrectly T/O Config Warning by retarding the throttle (the Helios Crew did this...)

...but the config warning can sound in flight, for example retarding the thrust levers to less than 68% N1 with flaps out and gear not down will trigger it. ...I hope you know the difference between a "intermittent horn" and a "continuous horn" :E

The second part I agree too ...

[flynowpaylater]

Are their any question marks surrounding the CRM on this flight?

Sorry if I am repeating anything on the previous thread.

[framer]

I can understand missing it pre-flight and taking off, but for the life of me I can't imagine not noticing the climbing cabin. I have taken off in a 737 with the packs off and I had felt it, looked up and identified the problem, and made a decision not to say anything about it until 500ft, all before the gear was up. It was that obvious. I didn't have a cold or restricted sinuses either.
Hopefully that doesn't come across as 'look how great I am', ( I was the idiot who got distracted and left packs off), the point I'm trying to make is that it is incredible that they didn't notice the cabin climbing. Any thoughts on that? Was it some sort of low climb rate with a hold down or something?

[IFixPlanes]

Please read the accident report. (http://www.cyprus.gov.cy/moi/pio/pio.nsf/all/F15FBD7320037284C2257204002B6243/$file/FINAL%20REPORT%205B-DBY.pdf)

[D O Guerrero]

Ifixplanes...
Oh yeah.. you're right. Sorry I was upstairs and the lack of oxygen was getting to me... I was indeed confusing the steady and intermittent warning horns.
Nevertheless I think I made a point by mistake, which is that it is a potentially confusing setup. The fact does remain though that someone somewhere thinks the system is such to warrant the fitting of the Takeoff Config/Cabin Alt annunciators on both the left and right forward panels on new 737s. That bit was not rubbish.

[IFixPlanes]

...The fact does remain though that someone somewhere thinks the system is such to warrant the fitting of the Takeoff Config/Cabin Alt annunciators on both the left and right forward panels on new 737s. ...I do not understand what you want to say with this sentence. :uhoh: Maybe because english is not my native language...

[D O Guerrero]

All I'm saying is that Boeing are now fitting these lights to clarify the meaning of the warning horn when it goes off. I'm not sure of the schedule or if they are being retro-fitted, but they are certainly now standard on 737NG currently coming off the production line.
The point I am making is that the fact they are being fitted now, must mean that there is an acknowledged problem with the warning horn and its interpretation. Sorry If I'm wording it badly...

[Heathrow Flyer]

From the report:

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.

[mono]

Actually you CAN get a take-off warning in the air. It occurs if the ground spoiler interlock valve is still open with the a/c in the air and flaps up.

I don't know at what height the a/c would be clean but I would have thought it would be a far bit before 10000ft (cabin px at which the cab alt horn sounds)

For me the give away as to the reason for the horn, is the point at which the horn first sounded. 10000ft is not high enough to couse hypoxia and reasoned thought should have deduced the cause. However. The fact that so many holes in the cheese lined up staggers me.

Incorrect sw pos after maintenance
Incorrect pre-flight checks (surely the elevation must be set on the controller and this is right next to the auto/man switch), after t.o checks, etc.
Poor (appalling) CRM
Cabin crew not aware of emergency access code to cockpit (or scared to use it?)

There were at least 5 layers where it all lined up.

I also have worked with one of the engineers involved and if he is one of those to be prosecuted then that will be a sad state of affairs. We need to learn from this and prosecution will drive untold nails into the no blame culture coffin.

[Litebulbs]

At the time of the incident, the switch was not in the incorrect position after maintenance. The maintenance manual has now been changed to reflect where the switch should be after maintenance.

[IFixPlanes]

At the time of the incident, the switch was not in the incorrect position after maintenance. The maintenance manual has now been changed to reflect where the switch should be after maintenance.
Was mentioned before (http://www.pprune.org/rumours-news/349774-five-people-charged-over-2005-helios-crash-post4523457.html#post4523457[/url]) :ok:

[Litebulbs]

Yeah, sorry for not quoting you as that is where I got it from.

[Northbeach]

IFixPlanes, thank you for posting the link to this accident report. Its an informative “read”. There were several imbedded surprises as there usually are. I depart today on a 3 day 737 trip, looks like I have my layover reading material.

[orangelitebulbtech]

I have worked with one of the engineers in question..... he is one of the most experienced, knowledgable engineers ive ever worked with... it will be a sad day if he is charged in relation to this accident.

Regardless of where the switch was left after maintenance... it should still have been picked up by the crew.

[Clandestino]

So if i got it right, there's no red "EXCESSIVE CABIN ALT" light on 737 to go with warning horn? You get the horn blasting and cabin altimeter with funny reading and that's it?!?

[BOAC]

Actually you CAN get a take-off warning in the air. It occurs if the ground spoiler interlock valve is still open with the a/c in the air and flaps up. - taking us a bit off thread, but can you amplify that please? The 'message' sent down from above was along the lines of Ifixplanes' post "Again: in air it must be "cabin altitude warning". There is no other meaning." and we have been told there is no other possibility.

[Joetom]

Lots of talk about the position of the press switch.

1/ Is the switch position recorded on any device ?

If the answer is no, then we do not know who placed the switch to the position it was found in after the event or when it was placed in this position.

Another point to remember, some pilots do check A/B or 1/2 normal systems for indicated defects plus an operation check of the Man Mode/Stby Mode before flight.

Have even seen some very keen pilots using Man Mode to drive OFV out of normal position and then check A/B can control OFV, a pro-active check may be, but that system can become very very important if problems ocour in flight, plus with smoke, pilots need to have good skills using those little buttons with poss poor view.

Thoughts with all involved.

[D O Guerrero]

Clandestino....
There wasn't. There is now (on new aircraft).

[mono]

BOAC,

Sorry actually a type error!

The classic indeed can only have an intermittent horn in the air for a cabin altitude excedance.

The NG however, can have the intermittent horn on in the air for either a cabin alt exceedance OR a fault with the ground spoiler system.

The opening statement from the MM 31-53-00 page 2 reads

The takeoff warning function gives an aural warning sound if the airplane is in an unsafe condition during takoff or if the ground spoiler interlock valve remains open after takeoff

The conditions for in air warning; are ground spoiler interlock valve open and leading edge flaps and slats not extended.

Sorry for the thread creep.

[BOAC]

I'll take your word for it, but the message that came 'loud and clear' from Boeing was that the intermittent horn in the air could 'only be pressurisation', so that is interesting. However, our drill remains the same - we ASSUME loss of cabin pressure and act accordingly until we prove otherwise. No mention of this 'interlock' in any of our owners' handbooks or our MEL. I guess a failure of the A/G switching in general could produce a warning too when the flaps are retracted.

[Capot]

prosecution will drive untold nails into the no blame culture coffin. There is no such thing as a "no blame" culture, or rather there is not supposed to be in aviation.

There IS a "just" culture, and if not there should be, which seeks to analyse and search out the root cause of why an error occured, rather than simply blaming the nearest mechanic in sight. The MEDA approach, in fact, in one form or another, where maintenance is concerned.

But if the root cause turns out to be that someone royally screwed up, through culpable negligence, or knowingly ignoring instructions, procedures etc, he or she will get blamed, partially or wholly, and perhaps punished, and rightly so.

It is pretty obvious to me that this cannot be said of any engineer, at least, in the Helios case, but I'm a zillion miles from that loop and only know what I've read.

[barnflee]

After reading this thread (and the report) I can't help thinking if this will finally be the case where the role of 'Accountable Manager' is put under the spotlight.

None of the replies in this post consider management oversight / responsibility or the contribution of a sound and constantly applied Quality Management System may have had in preventing this incident happening in the first place.

The report should help those who ask the question 'what is the cost of quality'......... more importantly the report (and unfortunately the incident) in my view identify the cost of not having quality.

I hope the bean counters and ladder climbers of the world take note and that the court fully understand the deffinition of 'Accountable Manager' and do the right thing.... if it has the teeth that is.

[Lancman]

5 to be charged with manslaughter for Helios crash including 2 Britons. See

Cyprus Mail Internet Edition (http://www.cyprus-mail.com/news/) 24th Dec.

[LNAV VNAV -]

Cypriot newspaper 'Politis' says today that 4 people have been charged with manslaughter over the Helios accident.


Andreas Drakos, Chief Executice
Demetris Pantazis General Manager
George Kikidis Operations Manager
Ianko Stoimenov, Chief Pilot

[AMEandPPL]

Pity, that link seems to be more about the Cyprus weather !
Rain and snow, but lot more needed to ease the drought


Also, in another thread started today, it says only 4 to be charged.

[forget]

Click on 'news', it's there. :hmm:

Also, in another thread started today, it says only 4 to be charged.

It doesn't say that at all. It says 4 charged.

[AMEandPPL]

It doesn't say that at all

Apologies for my poor punctuation. Perhaps it should have been :

Also, in another thread started today, it says only: "4 to be charged"

[TheShadow]

Five face manslaughter charges over Helios crash
By Elias Hazou

FIVE people face charges of manslaughter and of reckless and wanton endangerment that caused the death of 121 people aboard a Cypriot commercial airliner more than three years ago.

The suspects are all former members of now-defunct Helios Airways, operators of the doomed jet.

“The charges concern two of the gravest offenses in criminal law,” deputy Attorney-general Akis Papasavvas told reporters yesterday after revealing that the bill of indictment had been filed with the Nicosia district court.

“The charges are manslaughter, and causing death through a reckless, careless and dangerous act.”

Papasavvas declined to name the suspects, saying it would be “unethical” to do so before the charge sheets were actually served.

This should be done over the next few days, he said.

“Be patient. All we can say at this point is that both charges apply to all five suspects,” he told the Mail later in the day.

Reports say the charge sheet is massive, and that it contains hundreds of separate indictments levelled against the five.

Under Cyprus law, a person found guilty of reckless endangerment leading to death faces a sentence of up to four years in jail; the maximum sentence for manslaughter is life imprisonment.

Papasavvas said the suspects had until February 26 (3pm) to appear before court and answer the charges – effectively to enter a plea.

“The ball is now in the court of the justice system,” said Papasavvas.

The deputy AG declined also to say whether any of the suspects posed a flight risk.

“Hypothetically speaking – and I stress that – if this were the case, there are ways around it, such as through issuing a European arrest warrant. Again, this is hypothetical, in response to your question,” said Papasavvas.

It has been three-and-a-half years since a Boeing 737 operated by Helios Airways smashed into a ravine 40km outside Athens, killing all 121 people on board. The subsequent accident probe blamed pilot error primarily, but also cited as latent, or underlying, reasons the organisational shortcomings within the airline as well as Civil Aviation.

A similar judicial investigation is underway in Greece – the site of the accident – where earlier this year an Athens prosecutor charged six people with manslaughter. Reports at the time said the suspects were two Britons, one Bulgarian national and three Cypriots.

Yesterday’s news was greeted with measured satisfaction by the friends and families of the air crash victims.

“We have waited three-and-a-half years for blame to be apportioned… but at least it’s a positive step forward,” said Nicolas Yiasoumi, a spokesman for the bereaved relatives.

“At long last, someone is facing the dock. But for us, going before a court is not enough. When the court punishes the guilty, that will be justice. We believe that 121 people were murdered in the air,” he added.

The relatives have meanwhile filed a class-action suit against the government – specifically the Department of Civil Aviation – for negligence that led to the air disaster. They claim that the DCA was turning a blind eye to airlines’ loose enforcement of regulations, and that in general the department cut corners when it came to flight safety.

Neither the criminal nor the civil trials are expected to end any time soon and, if the Cypriot justice system is anything to go by, the cases could drag on for years.

What is reckless endangerment?

A person commits the crime of reckless endangerment if he or she recklessly engages in conduct which creates a substantial risk of serious physical injury to another person. “Reckless” conduct is conduct that exhibits a culpable disregard of foreseeable consequences to others from the act or omission involved. The accused need not intentionally cause a resulting harm or know that his conduct is substantially certain to cause that result. The ultimate question is whether, under all the circumstances, the accused’s conduct was of that heedless nature that made it actually or imminently dangerous to the rights or safety of others.



Copyright © Cyprus Mail 2008
from this link (http://www.cyprus-mail.com/news/main.php?id=43215&cat_id=1)

[airsnoop]

The Hellenic language paper Politis gives the names of the five:
Andreas Drakou
Demetris Pantazis
George Kikkedes
Ianko Stomenov
and the fifth is the company itself - Helios Airways.

[gdionas]

As reported by the national TV stations RIK1 and MEGA during their tonight's news at 8:
1. Andreas DRAKOU, executive chairman of board of directors of Helios.
2. Alpha Jet Aviation Ltd previous Helios Airways Ltd, Limassol.
3. Dimitri PANTAZI, accountable manager of Helios, Nicosia.
4. Giorgos KIKIDIS, flight operations mgr, Devon.
5. Lanko STOIMENOV, chief pilot of Helios, Larnaca.

[airsnoop]

A recent FAA AD urged Boeing yet again to do something about the Cabin Altitude Warning which is still being misidentified by flight crews - also see the comment in Flight International 18 - 24 Nov.
The UK CAA did audit the airline under contract and were satisfied that Helios Airways was in compliance JAROPS at the time of the accident and recommended continuance of the AOC. The AAI&ASB Report Findings identified no shortcomings with the Aircraft or crew.
Regulators don't come much better than UK CAA and if they say it was OK, that's fine by me:D

[IFixPlanes]

@airsnoop
I did mot find a recent FAA AD which urged Boeing to do something about the Cabin Altitude Warning. :confused:
Can you give me the number?

[airsnoop]

2008-23-07 effective 25 November 2008 and refers to Boeing 737 all series.

[IFixPlanes]

On which page? :uhoh:
AD 2008-23-07 (http://www.airweb.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/0/9da618efecdae41c862574fd0050510b/$FILE/2008-23-07.pdf)

[Old King Coal]

You can see the AD here --> Boeing Model 737 Airplanes (http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgAD.nsf/0/9DA618EFECDAE41C862574FD0050510B?OpenDocument)

[spannersatKL]

A note in the AFM...that'll fix the issue......not! What next a placard?
Bite the bullet and change the warning!!!!

[airsnoop]

Boeing has already done the work and taken the simple but effective expedient of adding a Cabin Altitude caution, but for some reason I don't understand, it has not been yet implimented.
The most telling part of the AD is:
"Unsafe Condition
(d) This AD results from continuing reports that flightcrews have failed to recognize and react properly to the cabin altitude warning horn. We are issuing this AD to prevent failure of the flightcrew to recognize and react to a valid cabin altitude warning horn, which could result in incapacitation of the flightcrew due to hypoxia (lack of oxygen in body) and consequent loss of
airplane control."
Writing a procedure should only be a temporary fix for a design weakness, so let's stop procrastinating and get the light in before it happens again.
After 50 years in the business as a driver airframes and 25 of those as an accident investigator, can I appeal to the Greeks and the Cypriots, and now the Spanish, to drop the blamefest and let the professionals get on with the business of Air Safety.
Can I also appeal to organisations such as ICAO-ISASI-FSF to stand up and be counted, your silence is deafening!
That's it, I'll wind my neck in - to all in "the business" have a happy and safe 2009:ok:

[OTHELOS]

The five people involved are the company's post holders and these are:


Andreas Drakos- Helios Manager Director (and owner)
Dimitris Pantazis - Accountable Manager
George Kikidis - Flight Operations Manager
Ianko Stoimerov- Chief Pilot
The Board of Directors of Helios Company.They are not charged only for the accident occurred on the 14/08/05 but for the operation of the company since the takeover from the previous owners.

[Rananim]

The report cites company malaise in its list of indirect causes.Very hard to prove.Only thing I can come up with would be:
a)a failure to disseminate the data from the Aer Lingus/Ryanair incidents prior 522 which seemed to prove that flight crew can be confused by Boeings intermittent horn.In particular,the importance of direct intervention from the cabin when a climb is continued with masks deployed.If this information had been disseminated and the lessons learnt incorporated into CRM classes then the FA's of 522 would have had a precedent on which to base their actions.
b)Possible(ie.rumored only)failure to prevent the 2 flight crew members from operating together when there was reasonable justification to do so.

Both (a) and (b) are the repsonsibility of the CP.Does it make him responsible for the crash?No.Was failure to do (a) or(b) reckless endangerment?No.

The report says it quite clearly;this was flight-crew error.They paid for it with their lives.We should leave it at that.

[IFixPlanes]

Airsnoop, i am still searching the sentence in your mentioned AD where FAA urged Boeing to do something about the Cabin Altitude Warning. :zzz:

[captplaystation]

Rananim
your point b) above. . . . . .I must have missed something here. What was the issue with the two flight crew members operating together ?
Were one or other known/believed/rumoured/accused (or all 4 )to be "a little light" on ability.
If that was the case there are probably grounds for prosecuting every accountable manager of every airline in existence.
Don't tell me any of us have worked for a company where there wasn't at least 1 person in both the LH & RH seat who was generally acknowledged to be less than the sharpest tool in the box.
I would like to see someone find a realistic justifiable solution to that problem, I sure don't have one.

[B737NG]

Does that contribute to prevent it from reoccurence anywhere else?

What was the main cause of the fatal loss.... Where could someone cut the Chain of events and prevent it ? More important then naming the individuals here. Focus more on Facts and less on Roumors, even in PPRUNE.

Fly safe and land happy

NG

[EatMyShorts!]

But that's why these persons get so much money: they are responsible, they can be hold accountable for what happens in their company or on their fleet.

[captplaystation]

B737NG,
Don't shoot the messenger, he is only confirming the fact. The rights and wrongs (and of course any reasonable person will probably agree with you that this decision is manifestly wrong) are discussed at length on another thread here if you care to read it. Pity the original poster hadn't just posted it on there.

Mods, any chance to move this to the end of the already existing thread to avoid doubling up ?

[Devils Advocate]

So lets review this...

Imagine that I'm recruited by XYZ airlines with the following:
ATPL.
Type rating.
Medical.
Verifiable history of prior experience (log book & references).

I then go on to pass the LPC / OPC in the sim(s), and also pass all ground-school courses & line-training, as required & defined in the company Operations Manual.

Nb. The co-pilots I fly with are, likewise, similarly qualified, albeit with maybe less overall experience.

By the time I'm flying the line, all the required training, experience & recency items have been ticked. The requirements of the Ops Manual have been fully complied with (this being a manual which is certified / approved / overseen by the local CAA; as is the whole operation).

One day I take-off, have a technical problem with the aeroplane and, for whatever reason, it appears that I don't correctly diagnose the problem (it happens!), following which all on-board die.

Given that all due diligence (by the management & the local CAA) was achieved for my (& my FO's) recruitment, training & subsequent oversight... whom is now responsible for me crashing?

The local Management?
The local CAA?
The local Engineers?
The aircraft manufacturer?
The training providers?
All the above?
None of the above?
Well, who?

:E

[SPA83]

AIRCRAFT ACCIDENT REPORT


3.1.6 EASA, JAA and ICAO
1. Despite several EASA, JAA and ICAO audit and follow up audit findings
performed on Cyprus DCA, there was no enforcement of implementation of
action plans in order to meet its international obligations in the shortest
possible time.
3.2.2 Latent causes
1. The Operator’s deficiencies in organization, quality management and safety
culture, documented diachronically as findings in numerous audits.
2. The Regulatory Authority’s diachronic inadequate execution of its oversight
responsibilities to ensure the safety of operations of the airlines under its
supervision and its inadequate responses to findings of deficiencies
documented in numerous audits. /.../

[captplaystation]

Talk about "out of the frying pan, into the fire" :eek:

[Southernboy]

And what about the regulators, who spectacularly failed to regulate this complete shower?

[Frangible]

You mean our own dear CAA? Nada. They claimed not to be responsible because they made recommendations which were not carried out by the Department of Civil Aviation in the Transport Ministry (which had hired them because they had zero aviation regulation expertise themselves).

Ridiculous situation: CAA finds crap airline to be crap and reports upwards. Cyprus authorities refuse to do anything at all (we don't know why but the airline owners were pretty well connected locally). But in the face of official inaction the CAA inspectors could, contractually, do nothing, even though they knew that British citizens were risking their lives daily on the airline.

Most curious was how the inspectors recorded a raft of serious violations right up to the time Helios was due to get it AOC (it needed a variation so as to be able to operate another 737). Suddenly, all the problems disappeared and Helios got a clean bill of health followed by its AOC. Within weeks the inspectors were reporting more serious violations and the cycle of critical report followed by DCA inaction resumed.

In sum, IMO, it is not only a case of regulators failing to spot what was going wrong, but of allowing an airline to begin operations which should never have flown. The rumour mill says that CAA acknowledges it "dropped the ball" on Helios. Not very inspiring.

[Paphian]

Cyprus Mail Tuesday 24 FebruaryHelios trial set to open old wounds
By Elias Hazou
But will justice actually be served?

A HIGH-PROFILE trial opens in Nicosia on Thursday, when the five parties accused in the Helios case are due to appear in court to enter a plea on charges of manslaughter and reckless endangerment leading to the deaths of 121 people.

The state prosecution’s case essentially rests on their ability to prove that the two aviators – Captain Hans-Jurgen Merten and co-pilot Pambos Charalambous – were incompetent and that, consequently, it is the airline’s fault for employing them and allowing them to fly.

It has been more than four years since a Boeing 737-300 jet operated by Helios Airways out of Larnaca smashed into hilly terrain 40km outside Athens after running out of fuel. All 121 people on board were killed, making this the worst aviation disaster in Cypriot history.

The precise indictments are known only to the parties concerned: the state prosecution and Helios’ defence team. It is known, however, that the two chief charges, which apply to all five of the accused, are manslaughter and “causing death through a reckless, careless and dangerous act.”

The five accused are: Andreas Drakos, chief executive officer of Helios; Demetris Pantazis, general manager; Giorgos Kikidis, operations manager; Ianko Stoimenov, chief pilot; and Helios Airways as a legal entity.

But legal circles are already pointing out that the prosecution’s approach is flimsy at best. Under Cyprus law, manslaughter is defined as “causing death through an illegal act” – begging the question of what constitutes an illegal act where flying planes is concerned.

There’s also a great deal of speculation that manslaughter may have been thrown in as a peace pill because, unlike negligence, this offence must be tried in a criminal court.

Since the burden of proof is on the prosecution, all the defence needs to do is demonstrate that the two pilots were in fact competent.

It’s a process that’s sure to turn ugly for the relatives of the deceased airmen. The prosecution will argue that Captain Captain Hans-Jurgen Merten had “difficulties in communicating” and that his co-pilot Pambos Charalambous was not proficient in carrying out pre-flight and take-off checklists. Moreover, Merten is said to have missed an alarm systems test two months before the crash.

But the now-defunct airline dismisses the negligence charge and insists that both pilots were fit to fly.

Helios acknowledges that Pambos Charalambous was found to “experience difficulties coping under pressure,” but says it did take corrective action in this regard, by rejecting Charalambous’ application for promotion to the rank of captain.

“The airline feels it is not to blame for anything. We maintain that the accident was down to a manufacturing fault on the specific model of plane,” said Christos Neocleous, a lawyer for Helios.

The fact-finding probe had primarily blamed the two pilots, but also cited the shortcomings within the airline as well as Civil Aviation as latent, or underlying, reasons for the crash.

The report by Air Accident Investigator Akrivos Tsolakis found that the airflow valve was set at a 14-degree angle from the manual position, allowing for partial pressurisation. For this type of Boeing, it should have been set on auto before takeoff.

According to the report, on the night before the accident, ground crew had reset the switch to manual, but on the fateful day the pilots apparently omitted to conduct the pre-flight checks.

The problem was compounded in the air, when the pilots misread an alarm for a takeoff configuration glitch, because the sound emitted for that is identical to the one for a decompression problem.

Helios say the problem with the alarms – which has been documented by several other airlines – is the manufacturer’s fault. They point out also that, in the wake of the Cypriot accident, the United States’ Federal Aviation Administration has instructed Boeing to take corrective steps.

Having mistaken the alarm for a false takeoff configuration warning – which could not be the case, as the plane was already airborne – the aviators were troubleshooting in the wrong direction, while all the time the plane steadily depressurised, leading to the onset of hypoxia.

The investigation in Cyprus has taken quite a different path from that in Greece (the actual site of the accident), where a preliminary judicial investigation found five people were liable to manslaughter charges. They have not been officially indicted.

According to reports, three of the five persons are the same as in Cyprus: Pantazis, Kikidis and Stoimenov. Under EU law, they cannot be charged or tried on the same offence in two different EU countries. The other two persons are Helios’ chief operating officer Bryan Field and engineer Alan Irwin.

Irwin was the last engineer to inspect the aircraft on the night before the flight. According to the charge sheet filed with an Athens court, the pressurisation checks conducted by Irwin were “imperfect, unorthodox and non-compliant with the relevant maintenance manual…”

Elsewhere, the same document states that the engineer “…in a completely irresponsible manner did not follow the proper [control] procedures, but rather improvised.” It goes on to say that the entries recorded in the maintenance logbook were “vague, incomplete and contradictory.”

Though the trial in Cyprus is scheduled for Thursday, it is more than likely that the District Court will adjourn to examine the file in order to decide whether the case should be referred directly to a criminal court.

Nicolas Yiasoumi, a spokesman for the victims’ relatives, told the Mail that come Thursday, the families and friends of the deceased would be at court.

“We are concerned [with the trial]… but let’s wait and see,” he said.


Copyright © Cyprus Mail 2009

[dontdoit]

Bio on one of the accused here:

Job's description - Arik wings of Nigeria - (http://www.arikair.com/arikair/racine_site/content_news.asp?cms_page=40)

[FrequentSLF]

I do wonder why the bashing team is avoiding this thread....nobody has yet made a comment about this thread to be of interest...20 over posts bashing a guy that posts something related to lightning...
I do not believe that the court case is the ultimate solution...why some many people died...a very avoidable accident...we need to find the root causes...

[Rotorhead412]

'will justice be served?'

What kind of a statement is that? seriously.....

No matter what the final outcome of the findings, unless the reason any a/c goes down is because of unlawful interference... then why try 'get revenge/ justice' on the pilots...?

Everyone makes mistakes, its in all training syllabus', crm course etc... Its inevitable!! Hence the reason for all the new training coming into play to cut out as much as possible!

The pilots obviously tried their best to keep the plane airborne and land it safely, whether it was a mechanical failure, or a human error etc... It wasn't intentional, therefore 'justice' should not be served... Any pilot put in a position where no engines were operative of no flaps, whatever it may be, will do there best to get the plane down safely... and absolutley NO ONE can say anything otherwise, unless they themselves were in that same position as the pilots...

Anyone can say, o of course, yea, keep her steady rate of descent, land on a nice hard patch o land.... but doing it is a different thing... there is only a few people on this earth how could possibly say they've been there done that...!

So find out the cause of the accident(s), and try to ensure it doesn't happen again, but don't jump on the pilot(s) back and start blaming them for doing a bad job... Get a life!

[FrequentSLF]

Anyone can say, o of course, yea, keep her steady rate of descent, land on a nice hard patch o land.... but doing it is a different thing... there is only a few people on this earth how could possibly say they've been there done that...!

So find out the cause of the accident(s), and try to ensure it doesn't happen again, but don't jump on the pilot(s) back and start blaming them for doing a bad job... Get a life!

You absolutely right.
Each and every single job has its own challenges and difficulties. You (and I) are trained in order to perform to our best. Albeit my job is not piloting, I always assume I am doing my best, as well as I am confident you do.
The big question mark is...are we confident that our colleagues (mine and yours) are always up to the task? Have we taken all the counter measures to minimize the effect of mistakes? Your statement implies that everything was done by the book... I am strongly against criminalization of accidents, but we should have an open mind and accept that mistakes/errors can be made, and learn from it in order to break the chain of events...

[Safety Concerns]

Wake up people.
We need to find the root cause

We know the root cause, it was well documented in the accident report. Trouble is the industry and many posters here are not being honest.

The root cause was self regulation and corruption in the regulatory system. Is it confined to Cyprus no.

Will it happen again, already has.....Spanair.

Treat the cause and you remove the illness.

It really is that simple without 550 pages of rubbish

[Rananim]

I dont like to see this dragged through the courts.They wont get anywhere with the charges as there was no "illegal" act.Both pilots were not only qualified but experienced.
-Captain's communication skills?If the Captain had come straight from Interflug to Helios,then perhaps.But he had worked in several western airlines prior to Helios so I dont see any mileage in that one.
-First Officer's alleged incompetence;the Company rejected him for command.They didnt act rashly by promoting him purely on seniority number.
He was kept in the right seat.

Only possible areas of contention:
i)those listed in the report
ii)no specific challenge/response item for pressurization controller(now changed)
iii)no visual warning to supplement the aural warning for decompression(Cabin ALT red light on main instrument panel now retro-fitted)
iv)no dissemination of data from previous similar incidents(seen most recently in the Spanair case as well)..these incident reports spoke of the crew being "confused" by the horn and one involved entry into flight-deck by a FA to report mask-drop.If properly disseminated to all 737 operators,corrective training would have prevented the Helios tragedy.Perhaps,at the time,there was a belief amongst other 737 operators that their crews couldnt possibly confuse the meaning of the intermittent horn,that it was such a rudimentary error,it wasnt even worth noting...perhaps.Prior to Helios,the only decompression scenario trained in the sim on a regular basis was the rapid one at 350.Very few operators,if any,trained the more insidious scenario as well.
v)The rumored mis-match of Mertens and Paralambous..it was alleged that they didnt get along.If the records prove that in addition to this they were both "weak",then they clearly shouldnt have operated together.

IMHO,(iv) is strongest bone of contention.Others are weak and hard to substantiate.On the face of it,Boeing's cabin decompression warning system is unambiguous.Legally,it would be a tough nut to crack.

[Flight Detent]

Guys...
My bottom line here is 'Everybody must take responsibility for their actions'

If the last step of the maintenance manual procedure says 'Outflow switch to Auto', then the maintenance person has to take some responsibility that that action was not completed.

If (as it is) the FOs preflight procedure says 'Outflow valve must be selected to Auto', then the FO has to take some responsibility that that action was not completed.

If (as it is) the NNC for Cabin Altitude Warning was not completed, as it wasn't, then the Captain must take responsibility for not initiating that NNC.

If both the pilots didn't recognize the relevance of the aural warning, then the airline training/checkout people, as well as the pilots themselves, must take some responsibility for that.

If the Captain didn't recognize the aural warning (as he seems not to have), he should have followed common sense procedure and initiated a complete flight deck instrument check, that's every indication they can see!
(That would have found the cabin altitude/diff pressure indication actually showing what was happening + the outflow switch out of place!)
This can also be initiated by the FO, if that indication/auto switch had teeth, it would have bitten him, it is so close to his face, should he had just looked at it!

For my money, they were not competent to operate that airplane, given the evidence aired so far!

Cheers...FD...:uhoh:

[rubik101]

Rotorhead, you say that:

The pilots obviously tried their best to keep the plane airborne and land it safely, whether it was a mechanical failure, or a human error etc... It wasn't intentional, therefore 'justice' should not be served... Any pilot put in a position where no engines were operative of no flaps, whatever it may be, will do there best to get the plane down safely... and absolutely NO ONE can say anything otherwise, unless they themselves were in that same position as the pilots...

The point is, they weren't; Through a combination of all or any of the following; ignorance, lack of understanding, inaction, omission, errors on their part and of the Tech the night before, they were either comatose or dead and had absolutely no control of the outcome of the flight once they had passed out.

They, and the rest of the victims, died because of an inadequate and badly run system, from the regulators, to the management, to the trainers who signed off apparently sub-standard pilots and to the pilots themselves who were deluded enough to think they knew how to fly.

Flying is more than smooth PAs and greasy landings. It is a thorough knowledge of all the associated elements and they evidently had no idea what was wrong at the time, in spite of the warning horn blasting away for several minutes.

Why shoul we not apportion blame in this instance?

[kotakota]

[I][/Prior to Helios,the only decompression scenario trained in the sim on a regular basis was the rapid one at 350.Very few operators,if any,trained the more insidious scenario as well.

True , the insidious case is very rarely practiced , but I had a case about 4 years ago in a 300 series . The aircraft was permanently operated between UK and Iceland at FL 280 Northbound and FL 290 Southbound (Schedule times and MNPS issues , single FMC operation). One day we crossed into Scottish FIR and decided to climb to 330 to try and avoid turbulence . While climbing , the Cabin Alt Warning sounded . Both pilots on 'O2 , Comms established ' seconds later. No ambiguity there.

( After much trial and error , it was found to be a cracked Heat Exchanger . If at 290 , the cabin was climbing to just short of 10,000' at a rate on the Pressurisation ROC indicator of under 50' per minute - virtually undistinguishable to the naked eye , and definitely undetectable to a healthy ear either ). Only noticed after the Cabin Alt Warning set things off. For info , cabin pressure was never anywhere near 14,000' , and never uncontrollable. In the cabin - a complete non-event.)
FYI switching pack to HIGH forces cabin to descend.
Safe flying
KK

[Rotorhead412]

Rubik say 'Why shoul we not apportion blame in this instance?'

BECAUSE ITS ALREADY HAPPENED, THE PILOTS ARE NOT AROUND TO TAKE 'THE BLAME', AND ITS NOT GOING TO CHANGE A DAMN THING, NOR BRING ANYONE BACK.

They should find out the cause of the accident, and highlight it to all pilots worldwide to ensure it doesnt happen again, thats the only thing that need be taken from such incident!

[CR-ASC]

A few years ago I posted on Flight International my concern regarding this case.
Absolutelly no impact with the situation:ugh:
Crews are not trained to deal with hypoxia symptoms.
Unlike military crews that are trained in a hypobaric chamber to
know and understand their OWN symptoms.
Civilian crews are left with a few chapters in the Human Performance and Limitations, a lot of wording, but zero training.
Of course something like CRM spread like fire all over the world, it is cheap, anybody can became a crm facilitator and outrageous amounts of money can be charged with a minimum investment.
Or the MCC training that in my point of view is a bit a duplication of training, as any Type Rating multi crew adresses it, but of course a lot of simulators are used and students charged for it, sometimes, again huge amounts of money.
I have been a TRI and do not see the benefits of a couple of extra sim sessions versus a full MCC course.
On the contrary an hypobaric chamber involves a huge investment and a huge liability if something goes wrong during practice.
Thousands of crews are flying in pressurized airplanes without any PRACTICAL training regarding hypoxia.
Just wonder whom many lives will be lost until regulators find this type of training essential like CRM or MCC.

[rubik101]

Rotorhead, they have already decided the cause of the crash was due to the crew's mishandling of the warning.
Now we are discussing the rights and wrongs of bringing those responsible to a court to ascertain if any criminal or negligence charges should apply.
I see nothing wrong with that.
People get put in prison for dangerous driving, why shouldn't guilty pilots, if they are found to be negligent, also be punished for causing death by negligence or dangerous flying?
I admit that they are not here to receive any punishment but that is not the point.
Blame needs to be apportioned if we are to learn anything from such an incident.
The guilty should pay for the consequences of their negligence, or not?

[BYALPHAINDIA]

That aircraft should NEVER have been in the air with it's fault/s.

Just the same as a car on the road with no MOT!!

Full Stop!!

[passengera]

Rotorhead412 (http://www.pprune.org/members/231789-rotorhead412)

Join Date: Mar 2008
Location: A land not far from here.
Posts: 53




The pilots obviously tried their best to keep the airplane airborne..


No they did not. They FAILED to wear oxygen masks when low cabin pressure signal went beeping, they FAILED to react appropriatelly by descending to safe height, they generally FAILED in many simple procedures that do not require some special training... And, the chief captain did not understand ENGLISH.

[Markos480]

I was under the impression that the aircraft didnt have any proir issues (save of cource for the pressure switch possibly being left in the MAN instead of AUTO possition )

[turbocharged]

If people did their research they would find that, in the 12 months prior to the Helios accident, other aircraft got airborne with the system in MAN and the crew did not spot it. Other crews failed to diagnose systems problems related to pressurization. Other crews misdiagnosed the warning horn. Other crews failed to don their masks. It happens every year and will continue to happen. Helios is no more than an extreme example of a not uncommon event.

Hindsight is a wonderful thing and the court action is just a social system wanting to find a scapegoat to explain an irrational tragedy. I blame God. If she hadn't invented gravity aircraft wouldn't crash.

[barnflee]

Funny how nobody seems to be mentioning the word 'Accountability' as in Accountable Manager - there is reference in the report regarding poor quality oversight, and there lies the root of the problem, regulatory oversight (or lack of) and self-regulation (of a poor standard). So why isn't the regulator in the dock?

[royalterrace]

turbocharged

Spot on. This has happened 100's if not 1000's of times over the years and has been dealt with properly by many embarassed crews. Only once , to my knowledge , was the outcome this disasterous.

Despite many chances to break the chain (maintenance and pilot checklists) this mistake is still being repeated. Where it really went off the rails in this case , was the crews failure to identify the problem. In my opinion the shared warning horn has the potential to confuse a crew as it seems it did in this case.

We are probably lucky this has'nt ended up this way more often than it has.

[Safety Concerns]

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 fact is Helios was operating well below european standards just like many still are today.
The fact is the regulators should be holding their heads in shame for being totally incompetent or unwilling to deal with the failings of Helios and other still flying airlines.
The fact is money talks and safety comes second.

Yet we still have pilots and engineers who knowingly assist such companies by not being prepared to say NO.

You reap what you sow

[Bridge Builder]

All -
Our Cypriot friends had excellent advice from the CAA on airline regulatory oversight prior to Helios. Sadly, they chose to ignore much of it.

Problem as I see it: The main airline in Cyprus, Cyprus Airways, has always been a very good airline from a safety point of view. (The airline was created by BEA and is run operationally like BA). Possibly because of this, the Cyprus Department of Civil Aviation took a pretty laid back attitude to airline safety. (Conversely, their attitude to aviation safety from a non airline perspective - aerodrome, air navigation etc., was pretty much ok. Indeed, let us not forget that the one of the worst mid-air disasters of all time occurred in Swiss controled airspace, not in ‘poor’ Cyprus).

Don’t forget that apart from CY, all the other aircraft flying in and out of the place were regulated by their home regulators. The vast majority of these aircraft were British, so they were policed by the CAA. No problems there. You also had Air France, Lufthansa, Olympic, Austrian, KLM etc. etc. - again all very well regulated by their home regulators. So the Cypriots smoked lots of cigarettes and continued not to worry.

Don’t forget that Hellas (NOT Helios - which confused people) and Cypriana were gov / CY controlled and operated to the same high standards of CY. Helios was the FIRST Cypriot deregulated airline.

So then....deregulation occurs. Now deregulation is fine PROVIDING you have very good regulatory oversight. When Helios popped up this firm regulatory oversight didn’t exist on the island. Moreover, many people flew on Helios / Flash Air thinking that European oversight would guarantee their safety. Most people thought that if an airline that wasn’t up to scratch it simply couldn’t operate in Europe. (Me included. And I work in the industry.) We all now know better, of course.

I know the little island very very well. This was an accident waiting to happen. There’s no point paying for and getting world class advice on airline regulation - as the Cypriots got from the CAA - and then ignoring it. Sadly, that’s what occurred. And without prejudicing the trial that’s about to occur, most commentators would agree that Helios did not run a tight ship (to put it diplomaticaly).

Again, I emphasise - this happens in rich and poor countries, Just look at the Swiss aviation safety record as a comparison. That does not excuse the lack of regulatory oversight of Helios. But there was very much ‘Don’t worry - airlines know what they are doing’ approach to things’.

[barnflee]

SC - I'm right with you on this point

'The fact is it is a disgrace that the accident report cites regulatory failings and no one single regulator is being charged'

and to add insult to injury UK CAA if your listening - you knew there were serious concens not only with Helios but also with thier oversight yet you saw fit to allow them to operate int UK airspace.

Whats the problem Oh don't tell me politics - of course they always coe before saftey!

[Bridge Builder]

Question:

1. Are there any European Union based airlines on the blacklist?

2. If the answer is 'no' is it conceivable that an EU airline could be placed on the list, as it would in effect be the same as EASA admitting that they are failing to regulate a particular airline? Moreover, wouldn't the EU member state which hosts said airline get very cross and throw its toys out of the pram?

(My definition of European Union: EU 27, plus Norway, Iceland, Lithcenstein, and Switzerland).

[Safety Concerns]

1. NO
2. NO and YES hence the governmental visit to ensure that they didn't get put on the list

politics before safety.....ahem

[Bridge Builder]

Thanks Safety Concerns. And interestingly the list is cannily called the,

‘List of airlines banned within the EU’.

So, by definition, an airline such as Helios (Cyprus) could not be banned as Helios is / was already within the EU. It would therefore be a contradiction in terms.

You have to hand it to our friends in Brussels and Baden-Württemberg!

[barnflee]

What's the point of a regulator (any regulator) that has no teeth, a regulator that puts politics first before safety, a regulator that was aware of and voiced concerns about this particular operator but did nothing to prevent an incident of this nature happening in the first place. If they prevented them flying into the UK that may have sent them a message to shape up and sort themselves out, but oh no... just write the report and walk away but do nothing.

And where does ICAO stand here I wonder... are they taking an interest in this case? As there are no 'regulators' in the dock probably not as this too will make a mockery of their USAOP.

[Bridge Builder]

Agreed.

And please don't get me started on ICAO! ICAO missed the TCAS 'warning from God', the JAL 747 / DC10 near miss in 2001.

ICAO twiddled its thumbs until the totally avoidable and tragic fiasco that was Uberlingen.

[barnflee]

How many fatal incidents could have been prevented if the regulators had stuck thier heels in and demanded change instead of caving in to political pressure or the industry jumping up and down saying 'it'll cost too much'.

Regulators should regulate regardless of money or politics - thier primary concern should be safety and prevention of injury / loss of life.

Instead we have an industry regulated by pussy cats - paper tigers who write reports wash thier hands and walk away.

Yes we may have individuals who may share some responsibility in this particular incident in the dock - but there is one who isn't, they just walk away calling themselves regulators... how perverse.

[Bridge Builder]

Since the Manchester air disaster in 1985, regulation got better and better. The chap who is head of the AAIB has said - and I agree - that the reason everyone survived the Toronto A340 crash was due to the lessons learnt way back then in how we design and configure aircraft.

However, in the past few years there has been pressure to dilute standards. EASA is being battered around by different interests to lower its standards to the lowest common denominator. That may well mean that high standards that exist in, for example, the UK, are dragged down. This is not an anti-European rant. I am all in favour of the EU. But harmonisation should be about harmonising to the highest possible common denominator, not the lowest. EASA is in real danger than its going for the lowest.

What’s more is that EASA has these crazy nationality quotas in how its staff is made up. That may be fine for the European Central Bank, but in EASA you want people from the countries who do safety best in the high up positions, so they can then share their best practise with the whole organisation and the whole of Europe. They need to scrap nationality quotas and hire senior staff based on their knowledge and experience. If they don’t they’ll be just like ICAO.

[John47]

Helios accused plead not guilty
By Elias Hazou
(archive article - Friday, September 18, 2009)

THE HELIOS trial yesterday adjourned to late November after the five defendants pleaded not guilty to the charges of manslaughter and of causing the death of 119 people through a reckless act.

The defendants are: Andreas Drakos, chairman of the board of Helios; Demetris Pantazis, chief executive officer; Ianko Stoimenov, (former) chief pilot; Giorgos Kikidis, operations manager; and Helios Airways as a legal entity.

Each faces a total of 238 counts, consisting of the 119 victims aboard the ill-fated plane (minus the two pilots) times the two charges.

The trial resumes November 27 at the Nicosia criminal court. The new date is the result of a deal struck between the defence and the prosecution in court yesterday.

Drakos, Pantazis, Stoimenov and Kikidis remain free on bail.

The defendants stood poker-faced in the courtroom as the charges were read out, making no eye contact with Helios relatives seated inside.

The case of the prosecution (the Attorney-general’s office) hinges on demonstrating that the company and its officers are liable for employing, and continuing to employ “inadequate and unfit” pilots, as state prosecutor Eleana Zachariades said in court yesterday.

But legal circles are already voicing doubt over the prosecution’s approach, which they see as flimsy at best. Under Cyprus law, manslaughter is defined as “causing death through an illegal act” – begging the question of what an illegal act in this case would constitute. Could operating or flying an aircraft be considered an illegal act, for example?

In short, the Attorney-general’s office’s angle is that the accident was caused by mistakes/omissions made by Captain Hans-Jurgen Merten and his co-pilot Pambos Charalambous, that they were unfit to fly, and that therefore it is the airline’s fault for allowing them to do so.

There is also the matter that the two pilots were fully licensed.

Among relatives of the Helios victims resentment over delays in starting the trial (it has been four years since the accident) has now been mixed with criticism of the prosecution’s handling of the case. Many are not at all happy with how things are going.

A trial is also set to get underway in Greece (the location of the accident), with reports recently of possible legal barriers and jurisdiction complications in the case of an individual being set to appear before trial in two different countries for the same case.

The Greek indictment also features Pandazis, Kikidis and Stoimenov, as well as chief mechanic Allan Irwin, who has not been charged in Cyprus.

It is said the trial in Cyprus could be threatened should Greece not co-operate in handing over evidence germane to the case. Latest reports, however, say a deal has been struck between the two countries.

“Justice? What justice? They’re going to lay all the blame on the pilots…it’s so obvious,” said Elena Georgiou, who lost her brother, his fiancée Christiana and six other friends on the doomed flight.

And she wondered why it took the Attorney-general’s office “four whole years to ask for the evidence in Greece, when they knew all along that this would come up.”

On the morning of August 14, 2005, a Boeing 737-300 jet operated by Helios Airways out of Larnaca smashed into hilly terrain 40km outside Athens after running out of fuel. All 121 people on board were killed, making this the worst aviation disaster in Cypriot history.

A subsequent fact-finding probe on the accident primarily blamed the two pilots, but also cited shortcomings within the airline as well as Cyprus’ Civil Aviation as latent, or underlying, reasons for the crash.

The crash report found that the airflow valve was set at a 14-degree angle from the manual position, allowing for partial pressurisation. For this type of Boeing, it should have been set on auto before takeoff.

According to the report, on the night before the accident, airline engineers left the switch on manual, but on the fateful day the pilots apparently omitted to conduct the pre-flight checks.

Cyprus Mail Internet Edition (http://www.cyprus-mail.com/news/)

[no more nite flights]

The F/O flew with me in the UK prior to joining Helios.I knew him well and his operating standard under pressure in the Flight Deck. Anyone want any more info,please P :sad:M me.

[GlueBall]

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. :{

This type of voice generated cabin altitude warning system was included in the Lockheed L1011 TriStar which I had flown many moons ago. :ooh:

[tailstrikecharles]

why not have drop down masks like the pax? even in addition to the masks already there?

Few things are as unambiguous as a yellow mask popping down in the face.

A horn which sounds just like a horn for something else is kind of hard when you are no doubt starting to suffer from hypoxia :(

[zekeigo]

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…. That’s what they say… Oh Dear… :ugh:

[cwatters]

Isn't this really about who's insurance company ultimately pays?

[AnthonyGA]

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.

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.

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….

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.

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.

[rottenray]

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.

Doubt it's something a line pilot flying a passenger frame expects.

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?

[sharksandwich]

Safety Concerns lays out the facts. I doubt any of this is disputed (in this forum):


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 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.

[tailstrikecharles]

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.

Why not throw them a crossword puzzle while you're at it?

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.

[AnthonyGA]

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?

The cabin altitude alarm would have sounded at 10,000 feet. Unless they had some unusual preexisting medical issues, they would not be suffering from hypoxia at that altitude. Indeed, the altitude for the alarm is chosen so that it is triggered before hypoxia is likely to be a problem.

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.

[p51guy]

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.

[tailstrikecharles]

:( 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...

[AnthonyGA]

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.

Perhaps the designers were trying to economize on audible annunciations. The greater the number of different sounds, the harder it is to make them distinctive, and the harder it is to remember what they all mean. You're not likely to get a cabin altitude warning on the runway, and you're not likely to get a take-off warning at 10,000 feet, so I can see why the same sound might be used for both. A pilot would logically say to himself, "hmm, passing through 10,000 feet, can't be a take-off warning," and would quickly realize that it's something else—which appears to be what you did. Cabin altitude is likely a rare warning so you might have to look something up … but that's what pilots are supposed to do. As long as they follow procedures, they'll isolate the problem and fix it.

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?

[ThinkRate]

Link to the 38 minute interception video by the two HAF F16 (callsigns Perseus 400 & 401).

Gnews f16 - Video (http://www.metacafe.com/watch/4426412/gnews_f16/)

Shocking and disturbing beyond belief :sad:

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.
_______________________________________

:sad:
TR

[jcjeant]

Hi,

Link to the 38 minute interception video by the two HAF F16 (callsigns Perseus 400 & 401).This video was removed ! :)

Found it in cache :)
Gnews f16 - Video (http://209.85.135.132/search?q=cache:QuubBiL-PK8J:www.metacafe.com/watch/4426412/gnews_f16/+%22www.metacafe.com/watch/4426412/gnews%22&cd=1&hl=fr&ct=clnk&gl=be)

[cheekychappie]

the link has been pulled, but the cvr summary is still shocking

[Bobman84]

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).

[ThinkRate]

Uploaded again here:
RapidShare: 1-CLICK Web hosting - Easy Filehosting (http://rapidshare.com/files/380349294/1.part2.rar.html)
RapidShare: 1-CLICK Web hosting - Easy Filehosting (http://rapidshare.com/files/380350005/1.part1.rar.html)

According to the source (?? ???????????? ?????? ??? F16 ??? Helios (http://www.gnews.gr/Reportage/f16Helios)) 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".
f16_dialogoi (http://translate.googleusercontent.com/translate_c?hl=el&ie=UTF-8&sl=el&tl=en&u=http://www.gnews.gr/Reportage/file/f16_dialogoi%3Fm%3Ddownload&prev=_t&rurl=translate.google.com&twu=1&usg=ALkJrhjtu4wmARMIrlPWJRNttA9aKiLPJQ) f16_dialogoi2 (http://translate.googleusercontent.com/translate_c?hl=el&ie=UTF-8&sl=el&tl=en&u=http://www.gnews.gr/Reportage/file/f16_dialogoi2%3Fm%3Ddownload&prev=_t&rurl=translate.google.com&twu=1&usg=ALkJrhhaga4Axm3DlQeBH87nR6xt1KD7rQ)
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:sad:

[swish266]

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
:mad:

[fokker1000]

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?

[BOAC]

Do. It is worth digging out the original thread and you will see what happened.

[jcjeant]

Hi,
swish266 (http://www.pprune.org/members/65887-swish266)
Pilots from all over the world - the next victim on the bench could BE YOUMethink .. 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.

[Centaurus]

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.

[Denti]

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.

[ThinkRate]

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

[MU3001A]

Not familiar with the 737, but am I to understand there is no cabin altitude master warning caption or EICAS message complimenting the aural warning? If not, then while the Helios crew didn't exactly cover themselves in glory, I would consider inadequate design of the pressurization system by the manufacturer to have been a significant contributing factor here. Similar in consequence to the inadequately designed AT retard function which contributed to bringing down THY 1951 at Schiphol.

[Idle Thrust]

At my former mob we checked the pressurization every ten thousand feet going up and going down.

[BOAC]

Better late than never! The after take-offs is the best place to start.

[Idle Thrust]

Right on BOAC! My point was that 10K checks would have caught the Helios error. Rather like a "back-up" which is the heart of safe transport ops.

[Denti]

Of course BOAC is right, the after take off is the place to do it. However to have additional checks doesn't hurt, even now that Boeing fittet those two additional warning lights per side that tell you if it is either the config warning or altitude warning horn you are right now listening to.

[BOAC]

Denti and Idle, what I said was The after take-offs is the best place to start. - not the only place! 10, yes, 20 yes, 30, yes, 40 yes and then in the cruise. Descent is also a good idea but less vital.

[PJ2]

BOAC, others;

You mean to say that such a check is actually not SOP or at least part of the kit everywhere? It seems second nature - did it from Day One and for 35 years thereafter - it is absolutely fundamental airmanship because failure of the system can kill, (clearly) and we check and re-check anything that can kill, like speed, like altitude, like clearances for same, like terrain, like wing contamination, like the runway we're about to use - all that, ....don't we?....

[criss]

Question is, can we put everything to checklists? As someone mentioned, pilots should be able to think, not only to follow checklists. And even if we add it, something will still be left out.

Centaurus mentioned how many crews fail to check this instruments during after take-off checks while at simulator checks. Shouldn't this be a moment to strenghten their understanding of the system, its philosophy, traps, how it works, and what should be checked. Good training would mean getting crews to understand what's going on, not just adding things to checklists for people to blindly follow them.

[protectthehornet]

some pilots are good....some are lucky...few are both....but when your luck runs out...you better be good...so start working hard at being a good pilot.

the 10,000' check is a darn good one. sensitive ears are important too!

I once had a cabin pressure problem, due to a electrical failure...my first warning was my ears hurting!

[PJ2]

criss;

Exactly.

A while back on another thread, the notion of "Killer Items" came up - it was after the Spanair MD82 accident at Madrid where a complex series of mis-steps and minor failures led to the deaths of over 150 passengers and crew.

There aren't many events/items that will kill right away but they exist on every flight. Some of them are,

- slats-flaps set,
- stab trim correctly set,
- speeds correctly calculated/set,
- correct/clear runway,
- spoilers retracted
- controls free, (should be obvious but I have seen data to the contrary),

The way we ran it was: pressurization - checked and announced every 10k in the climb and descent; a Cruise Check covers speeds, altimeters, pressurization, fuel and then a geographical check of all controls/indicators is done.

and there may be other type-specific killer items to check).

Those are checklist items to be emphasized for sure, but in truth the killer items should be automatic - should be habit, and also emphasized during training as an airmanship thing as well as adherence to SOPs. By the time one is flying airliners one shouldn't need "training" to check such items, but if we take a look at the industry's history over the past, say, three years, one or two of the basics were clearly missing in the six or seven stall/loss-of-control fatal accidents which have occurred. Why?

[criss]

By the time one is flying airliners one shouldn't need "training" to check such items

For some this time comes pretty early. And from other posts there emerges an image of crews that tend to just go through the motions, like "XXX Checklist pls" "BLABLABLA" "CHECKED" "BLABLABLA" "SET" "CHECKLIST COMPLETE". Added items could have saved this crew and a few others, but I'd assume that it's rather philosophy of training that's important (know, sounds kinda pompous).

[PJ2]

criss;

"Comes pretty early...", Yeah, we see that more and more as the smaller carriers continue to pay less but need more - (I don't want to go there, it's been done to death already). Re your comment re 'checked'...blablabla...'checked', etc, in my view quite frankly, only the visceral, primary realization and then active acknowledgement that one's next takeoff or approach and landing could be one's last, and that one has at that moment, the 30 seconds that one may wish one had in the next minute. The Comair crew comes to mind in this example.

Blunt though it may be, it is that kind of thinking, perhaps viewed as morbid by others who don't fly airplanes, that keeps everyone alive during those fw moments of high risk exposure.

"Blablabla" is apparently what happened at Madrid - the F/O called the slats/flaps but clearly never looked at the lever or the guage otherwise they would have been out.

There is a video of this same operator of an MD82 taxiing and lining up with the slats/flaps retracted but where the crew extends them just as they line up for takeoff - clearly forgotten but remembered or warned by the TOWS.

I am of the view that, on top of/in addition to, checklists, one must BE a pilot all the time. That involves and includes knowing and being cognizant of and ensuring that the Killer Items are checked and set correctly.

We all know that the challenge for all crews doing many legs per day sometimes in atrocious hours and weather systems, to engage the checklist process and not just recite it. It is a challenge because everything is so ordinary and normal and routine all the time.

But...it's only about six items per flight and takes less than that 30 seconds - certainly, it isn't the employer putting that much pressure on any crew that they have to get out, line up and get away.

PJ2

[HAWK21M]

Exactly.....Add the Cabin Depressurization Audio & the Pressure felt on the ears.

[BOAC]

You mean to say that such a check is actually not SOP - others have referred to the post by Centaurus which highlights the 'attitude' to 'checks' (aka airmanship) delivered by manufacturers which can rapidly become the 'norm'.

I always made sure the thing was pressurising normally after take-off and it was only post-Helios that I noticed very few F/Os were aware of what the panel should show and were not really checking it. Always better to 'notice' at 3000' than at 10,000'+ - and it is very easy to see there if it is wrong..

At 10, the BA 'SOP' 'check' was 'FEIPL' - fuel, engines, icing, PRESURISATION and inboard lights (Off). Out of interest the first action of most F/Os was lights (which are the least important of the lot! I insisted always that the 'P' came first, as a finite time passes on the first items and often these 'checks' were interrupted by ATC etc and could sail gently towards mask drop in a light jet, when it would be a mad and uncomfortable scramble.to level off.

[Kiltie]

Slight thread drift but this is pertinent to many 737 operators in recent months / years "returning" to the basic Boeing manufacturer's SOPs and checklists as is the trend these days with the supposed fear of litigious exposure.

In my opinion many of the lessons learned from decades of airlines' millions of hours flown, operating experience & accident report reviews have been dumped, opening up a lot of Swiss cheese holes again.

For instance, latterly my previous employer removed the Captain's challenge of "Set Flaps" (provoking the PM who was setting the flap to not be led in to a trap of the usual setting of 5 but to think about the setting they had briefed during the performance review some minutes before) and returned to Boeing's method of "Set Flaps 5/10/15". This was defended only by that tiresome cliche "standard Boeing."

I recall BAe's manufacturer's checklists were painfully long winded during busy stages of flight which my then employer made a good job of adjusting to make more practical, sadly my Boeing experience has been quite the reverse in that the manufacturer's checklist is sparse in comparison to that of the airline's.

It seems to be popular to berate airline's own checklists and praise the manufacturer, but I've seen a lot of good stuff dropped because of it. I'd be interested to hear others' opinions on this.

[Centaurus]

I would consider inadequate design of the pressurization system by the manufacturer to have been a significant contributing factor here. Similar in consequence to the inadequately designed AT retard function which contributed to bringing down THY 1951 at Schipho

It must be so frustrating and difficult for any aircraft manufacturer to be forced to try and cover every possible eventuality that incompetent pilots get themselves into. The Turkish Airlines accident is a classic example where the crew apparently just watched in disbelief at what was occuring in front of their noses - and did nothing...

The Helios accident is another case in point. After this accident, Boeing had little choice but to once more grit their teeth and try to cover their arse by acting on the Accident Board recommendation that a specific checklist of the position of the engine bleed switches, the pack switches and the Isolation switch should be made - even though for many years the original checklist items were considered sufficient to be understood by competent pilots.

Despite that, my private view was that the after takeoff checklist should always have been subject to the usual challenge by one pilot and answered by the other. Yet there was no mention by the investigators of the Helios accident of that flaw (my words) in that specific checklist policy favoured by Boeing since the very first 737 flew.

No doubt, former flight engineers could make the point that if an F/E had been carried as a member of the operating crew, the Helios event would most likely have never happened. They may well be right. But that doesn't necessarily mean Boeing should redesign the flight deck to include an engineer in future Boeing aircraft designs.

Plugging perceived loop-holes is never-ending because there will always be slack incompetent pilots on airline flight decks who will find a way of stuffing up somewhere. Maybe not today or tomorrow - but one dark night...

[BOAC]

Centaurus - in defence of 'competent' pilots, the design flaw by Boeing which had the same warning noise for both TOCW and cabin altitude caused a lot of confusion and should have been sorted out years ago.

[jcjeant]

Hi,

Plugging perceived loop-holes is never-ending because there will always be slack incompetent pilots on airline flight decks who will find a way of stuffing up somewhere. Maybe not today or tomorrow - but one dark night...

A common mistake that people make when trying to make something completely foolproof is to underestimate the ingenuity of complete fools...

[PLovett]

the design flaw by Boeing which had the same warning noise for both TOCW and cabin altitude caused a lot of confusion and should have been sorted out years ago

Surely a competent crew is going to recognise that the TOCW means something else at 10,000'? It beggars belief that the Helios crew were able to spend so much time pursuing the wrong question but perhaps hypoxia was already affecting their though processes.

[Idle Thrust]

A common mistake that people make when trying to make something completely foolproof is to underestimate the ingenuity of complete fools...

A great line JC

[BOAC]

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'.

[fokker1000]

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.

[b737800capt06]

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:

[BOAC]

Well it is easy to blame dead pilots for the accident - 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"

[SLFguy]

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

Quality.

[KiloMikePapa]

For b737800capt06:

Having a bad day, are we?

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

[green granite]

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

[A37575]

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

[lomapaseo]

A37575

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

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

[kotakota]

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 ................

[abc1]

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!

[BOAC]

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.

[MU3001A]

Centaurus: The Turkish Airlines accident is a classic example where the crew apparently just watched in disbelief at what was occuring in front of their noses - and did nothing...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.

[cats_five]

<snip>
F*ck the self loading freight who have no idea.:mad:

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

[swish266]

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.

[yaw_damper]

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!

[assymetric]

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

[Frangible]

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.

[Ex Cargo Clown]

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" ?

[quaxyisysu]

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.

[MU3001A]

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.

[Weary]

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.

[Smudger]

Weary

Hear hear

(That means "I agree" for all you youngsters

[swish266]

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:

[Denti]

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.

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.

[RAT 5]

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.

[ATC Watcher]

RAT5 : 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.

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.

[MU3001A]

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.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.

[RAT 5]

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.

[Flight Detent]

I agree entirely with this view...

Cheers...FD...:)

[swish266]

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.

[ATC Watcher]

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.

[RAT 5]

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?

[Weary]

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.

[swish266]

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:

[Midland63]

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.

[Admiral346]

Midland63:

I really like that analogy!

You are right in every word .

Nic

[p51guy]

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.

[p51guy]

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.

[Rwy in Sight]

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

[BOAC]

P51 - may I assume you have read the archive thread on this accident and the report - in particular page 121?

Hoping you have, in which case, with particular reference to p121, in your 737 flying (line and sim), how many times have you heard:-

1) The Config Warning Horn?
2) The Cabin Altitude Warning Horn?

[LNAV VNAV -]

The below is from a Cypriot newspaper today and basically says that three managers / manager pilots and an engineer have been found guilty for manslaughter and will be given jail sentences of about 10 years.

Interestingly it says that the First Officer was 'weak in executing procedures' and 'the accused should not let him fly the aircraft' !!! It also says something similar for the captain. :confused:



A GREEK court yesterday sentenced three executives and an engineer from defunct Helios airline to 10 years in jail – pending an appeal – for the 2005 crash, which killed all 121 passengers and crew on board.
The four, Helios’ managing director Demetris Pantazis, flight operations manager Giorgos Kikkides, Bulgarian chief pilot Ianko Stoimenov and chief British engineer Alan Irwin, were found guilty of negligent manslaughter, a misdemeanor.
The court rejected a proposal that would have allowed the defendants to buy their way out of jail. Under Greek law, people convicted of certain crimes can convert jail sentences into fines.
The defence said it appealed the verdict.
The defendants were not present yesterday but they posted a €10,000 bail each to remain free until the appeal is heard.
The trial in Greece – the site of the crash -- began in December 2011, shortly after a three-judge criminal court in Cyprus had acquitted – by majority decision -- all five defendants charged in connection with the charge.
Apart from Pantazis, Kikkides, and Stoimenov, Cypriot authorities had also charged Helios executive chairman Andreas Drakos and Helios as a legal entity with manslaughter. But they had not charged Irwin.
The Attorney-general has appealed the Criminal Court’s decision.
“It is good that there are some guilty parties here, because in Cyprus no one was found guilty,” said Sophia Charalambous, wife of the ill-fated flight’s co-pilot Pambos Charalambous, 51.
The charge sheet in Cyprus said the two pilots were unfit to fly the aircraft and that Helios knew or should have known about this.
“This did not appear (in the Greek court). For us it was good because our own was not to blame,” Charalambous said in Athens, referring to her husband. .
Charalambous suggested political interests had played a role in the decision of the Cypriot court.
“We do not think it is right to put the responsibility on two dead men,” she said.
Eleni Alexandri, the mother of one victim, appeared somewhat satisfied but said that the trial (in Greece) should have been held at a criminal court and not a magistrate’s court, which cannot impose more than 10 years.
“They know very well that all these people are guilty and it is a shame that the trial took place at a magistrate’s court,” Alexandri said.
Lawyers representing the relatives in Athens said it was a fair and correct decision, affording the bereaved some degree of satisfaction for the first time in some seven years.
“Nothing can reverse their loss, given that human life cannot be measured in money, neither can it be covered by court decisions,” said attorney Apostolos Pantos.
The defence said it would fight the verdict, which they considered “wrong”.
It was not clear yesterday if the Greek court’s decision would have any bearing on the appeal procedure here, which is set to kick off in Nicosia next month.
“If the Supreme Court rejects the Attorney-general’s appeal, then Cyprus’ decision will become irrevocable, thus various issues will come up,” with the main one being whether the Greek court’s decision could be enforced, said Constantinos Mavroides, a lawyer for the relatives.
“But that is something that we will deal with in the course of things.”
The August 14 crash of flight ZU522 was the deadliest aviation disaster in Greece and Cyprus. The Boeing 737-300 slammed into a hillside at Grammatikos, near Athens, killing all 115 passengers and six crew.
In an October 2006 report on the crash, Greek investigators cited human error as the main cause of the crash, saying the pilots had left cabin pressure controls at an incorrect setting.
Passengers and crew were starved of oxygen due to problems in the cabin pressurisation, while the aircraft subsequently crashed into the hill after running out of fuel.
The report also cited Boeing for “ineffectiveness of measures”, since the same alarm was used for two different problems, resulting in the pilots misinterpreting the information.
A 2006 independent inquiry into the crash found that although the pilots were directly responsible for the crash, the airline as well as civil aviation officers were criminally liable.
The full findings of the inquiry, carried out by former judge Panayiotis Kallis, were only made public in December last year.
The 170-page report had been placed under the care of the Cabinet, the body that appointed the panel, and kept from the public eye since.
The panel was appointed back in 2006 to investigate both the underlying and immediate causes of the crash.

More stories (http://news.google.com/news/story?hl=en&gl=uk&q=helios&um=1&ie=UTF-8&ncl=dCCAQEEcsFHhLZMjjngyH0GdbNmRM&ei=mHOST7ClH4X28gP56fHNDA&sa=X&oi=news_result&ct=more-results&resnum=2&ved=0CDQQqgIwAQ)

[ECAM_Actions]

Interesting - neither pilot fit to fly the aircraft?? Was a transcript of the CVR released? If so, where can it be found?

[Out Of Trim]

Was a transcript of the CVR released?

Not sure there would be much to hear; seeing as the crew and passengers were all unconscious for much of the flight! :confused:

[waveskimmer]

This may be of interest,my apologies if it has been posted before in relation to this thread."http://www.youtube.com/v/fC0aAY6oIjM?version=3&feature=player_detailpage"><param

[ECAM_Actions]

@Out Of Trim: I appreciate your point, but it was a serious question, as it would be interesting to listen to (uhh... read) how the flight preceding the excess cabin altitude was conducted (e.g. was it disorganized, organized chaos, or a textbook case of proper CRM?), particularly during the ground portion where the pressurization would be set up/checked.

[Lancman]

A copy of the report can be read at http://homepages.pathfinder.gr/aas/Helios522.zip. (http://homepages.pathfinder.gr/aas/Helios522.zip) u

[BOAC]

ECAM - read the thread?

[EK Profesional]

Isn't only the last 30mins saved?

Recording only begins at 1st engine start, no?

[LNAV VNAV -]

I think the main issue here is whether a manager can legally assume that if the pilots have their licenses and have done their sim checks/ CRM courses/ technical questionaires and all the other staff professional pilots have to do these days, they are 'suitable' to operate an aircraft.

These pilots had some bad comments in sim checks apparently (who hasn't ?) and some unfavourable reports from their colleagues. But they had completed all the required tests succesfully in the end, i.e., no-one was flying without all the licences and signatures as far as I know.

So after the accident someone can say that they shouldn't be flying because they didn't handle a problem well and the result was an accident. But how was one to know or decide before the accident? How many bad comments can declare a pilot 'unsuitable' if he passes the test in the end?!! :confused:

[Denti]

EK-Professional, nowadays two hour recordings are the norm and with the right tools the investigators are often able to unearth even more. Should be in the report which version they had, 30 min or two hours.

[Rananim]

The charge sheet in Cyprus said the two pilots were unfit to fly the aircraft and that Helios knew or should have known about this

Confusing the meaning of the intermittent horn did occur before Helios.Several times.On paper, its a surprisingly simple and basic error for a flight crew to make.But it happened.The precedents mean the crew can not be characterized as "unfit".Pilot error is pilot error.And they have already paid the ultimate price.We should leave it at that.I studied the case and saw no real indication of company malaise.It was a one-off.A freak accident.

[Al Murdoch]

A freak accident!? Are you mad?
The phrase "freak accident" implies that it happened by chance, out of the control of the people involved. Is that really what you are suggesting?

[tbaylx]

Leaving the controller in manual during your pre flight checks then not checking pressurization at all during the climb and misinterpreting the cabin horn for the take off config while already in flight hardly seems like a one off "freak accident" to me.
Too many crashes over the last few years caused by complete lack of airmanship and ability, this would be one of them imho.

[captplaystation]

Engineer did his job, maintenance manual at the time did not specify returning the control to Auto. "Nice to know/ please do", No more than that, I am sure he wished he had, he does not deserve a jail sentence for this.
Capt, if I remember from a previous company, was not regarded as "ace of the base", but he passed all mandatory checks, as , I assume, did the FO. The guy who employed/approved their employment ? does he deserve a jail sentence ? I think not.
Finally, we can all have a "dull" moment, or a "dull" day, I have, early in my career, f*cked up a bleeds-off TO, we felt it in our ears, these guys didn't. We retreived the situation, they didn't. . . .am I smarter than them ? nope, I was lucky, I didn't "****-up" so badly to be found out/cause the masks to drop, but I did (royally) screw up. . .not proud, hands up Mea Culpa :(


There but for the grace of God etc.

Boeing (finally) acknowledged their "imperfections", I also, acknowledged mine, hopefully the Helios accident was public enough that it will never happen again.

Met the PIC, nice guy.

[Halfbaked_Boy]

I know very little about this case, but I would like to add -

Is ruining four peoples' lives really justified in this instance?

[blackhand]

The mechanic was found guilty of failing to reset a pressure valve, causing both crew and passengers to pass out from lack of oxygen.
This is food for thought for any technician that has ever worked on an aircraft.

[TRIM-RUN2]

Greetings All. I was registered here as TRIM-RUN but have not logged in in a long time.I have also changes my email address so can not recover my password, apologies to the moderators.

When I was a young engineer many years ago I had the pleasure and privilege of working with Alan Irwin. I was a fresh kid with my first type rating on my ticket nervous as hell about my first day on the job in a new company and country. Alan could see this and took me under his arm and brought the best out of me just like he had done with many guys before me and no doubt after me. His understanding of aircraft systems is second to none and there is no snag he can't rectify. Anyone who knows him will agree with me.

I am sick to my stomach with todays news and really can't believe it. I hope he is not in Greece but knowing him he probably is.

Personally I would warn any young guys or girls from ever getting into aircraft maintenance, you spend your life including nights and weekends pushing tin around the pan and chasing snags just to get shafted for doing your best.

Now I sell aircraft spare parts and make more a year than I did in fifteen years swinging spanners put together and thats the truth. anyone want an A+P and Part66 ticket ? screw it I will burn them instead.

Keep the faith mate.

[captplaystation]

He "failed" to reset a switch to the normal position. It was not mentioned in the maintenance schedule he should do so, he didn't, the pilots didn't check/notice. . . . . ultimately? pilots fault . . .spoken as a pilot. (nice if he had done so, but, who flies the damn thing/breathes (or not) if it is wrongly set?)

[Alexander de Meerkat]

The legal proceedings here are all a bit 'third world', as is the way with many legal actions in Greece. Rather than conduct a sensible investigation to ensure it does not happen again, the route of many third world nations is to go for litigation and 'heads on poles' - you must always have a scapegoat after all. I am reminded of a similar approach to the biz jet colliding with the 737 over Brazil as another similar example of mishandling accident investigations.

As others have stated, if a pilot has passed his checks even after remedial training then he is 'fit to fly'. We can never go down the route of canning a pilot because he failed a check in order to pre-empt a crash. Clearly if there is a pattern and the individual shows no signs of responding to training, then that is a different matter. There is always a balance here and there is no evidence that I have seen to tell me that these pilots were not competent to fly the aircraft. There is no doubt they made mistakes on the day (have we not all done that?), but that is very different to saying they were intrinsically incompetent.

[chickendrummer]

The investigation itself appears to be to a 1st world-country standard. The litigation side of things is a little different.

When are management finally liable for cutting costs in every area (apart from their own bonus schemes etc)? This may well rattle their cage and be a wake up call for every other goose out there that thinks they can keep cutting costs on training and safety, get away with it and claim to have increased efficiency.

The line has to be drawn somewhere and responsibilities must be accepted by those running the system. There is so much we can do when the system lets us down... I guess we could always leave..Perhaps.

[TOON737]

Well said Trim Run I have known And worked with Alan some 20 years and is one of the most knowledgable engineers I have meat
The Greek authorities have insufficient evidence to convict the engineer however
There has to be a scape goat for the the friends and families of the victims
This is nothing but a kangaroo court and I think time the UK CAA and the AAIB we're involved.

[RADIO1]

alan irwin ia a first class engineer who’s knowledge of aircraft is second to none. The report on the helios crash shows he did his job correctly and iaw the amm as always. It would seem he is being blamed for being there and not for any failures. this growing trend of justices systems in many different countries to persecute hard working proffesionals just to try and prove that something has been done will lead to a lowing of safty standards due to the reluctance of all aviation personnel to speak out on any safty issue before or after an incident due to fear of self incrimination.

[NG_Kaptain]

Has any of you received an aircraft from maintenance and always found all switches in the correct position? Don't we preflight the aircraft to ensure serviceably, check switch positions and function check items? When I accept an aircraft I assume some switches that should be either off or on are incorrectly set and it's my job is to make sure they are correct. Insane to charge the engineer for this.

[Rananim]

It was a "freak" accident because so many holes in the cheese had to line up that day;

door report---switch left in manual after maintenance action---FO misses switch setting in pre-flight scan---Captain misses the same---horn at ten thousand cabin confuses not one but BOTH pilots-Equip cooling problem that is due to lack of pressurization SIDETRACKS both pilots from the real issue---Master Caution oxygen drop annunciation is missed due masking---Plane is light and quickly climbs to its cleared level 340---Captain is EAST German native and accent is strong---FO has just failed captain upgrade and is feeling resentful---they DONT like each other---Helios FA's and flt deck didnt brief together---who knew the code???--FA's remain sitting while plane climbs and climbs---would you sit in your seat while the plane continues to climb?

Who would believe such a scenario?It sounds like science fiction.Precedents of this type of accident (insidious failure to pressurize) have happened but there was always something that broke the chain eg,one flight crew member recognizes what is going on OR FA's making their way to the flight deck regardless of SOP.

If you factor in the old design of the B737 (one horn for 2 different problems) and the fact that failure to pressurize in a climb is insidious and could be a nasty trap,theres no doubt in my mind that this was a "one off" crash and that the flight crew were responsible.Were they unfit?No,pilots have taken off without flaps and stalled.Pilots stalled a 737 on final because they werent monitoring airspeed.Mistakes are part of human nature.

If the two pilots did not get on and were both viewed as weak under pressure,then I would have some measure of agreement in the accusation that they should not have flown together as a crew.But hindsight is 20/20.

[WenWe]

In the light of the judgement, I (as an engineer) would have to think long & hard about working either on a Greek registered aircraft or one located there.

10 years for leaving a switch in a certain position & a European arrest warrant meaning you'll probably have to try & get help from your Greek jail cell......

This has shades of the carbon monoxide case, where resort reps were held responsible for a hotel's poor boiler installation.

[SPA83]

Many holes in the cheese, indeed...


Akrivos Tsolakis final report :

Latent causes
1. The Operator’s deficiencies in organization, quality management and safety culture, documented diachronically as findings in numerous audits.
2. The Regulatory Authority’s diachronic inadequate execution of its oversight responsibilities to ensure the safety of operations of the airlines under its supervision and its inadequate responses to findings of deficiencies documented in numerous audits.
/…/

[bearkeeper]

Like Trim Run and TOON737, I have known Alan Irwin for a long time - almost 20 years - and can honestly say he is one of the most professional and diligent engineers that I have had the pleasure to work with.

His knowledge and experience on the B737 (and other aircraft types) is beyond reproach and, I can only reiterate other comments made here, that he is being made a scapegoat for, what is basically, 3rd world politics.

Fight them with as much as you've got Al and prove that you are innocent in this affair. It will mean fighting at a high level but you can do it and hit these :mad: where it hurts. There must be many LAE's questioning their job right now and the only way to stop this nonsense is to prove that following AMM procedures is not an offence - my best wishes are with you in this fight!

[BugSpeed]

Hi All,

This case is particularly pertinent to me and I have taught it a couple of times at work.

The fault in question was reported as "loud knocking noise heard from the aft (starboard) service door during flt" in the cabin defect log. That was transposed into the tech-log as "aft service door requires full inspection". Without getting into the nitty-gritty, the latter is a very different comment. Crew are advised to write symptoms into the log in order for the engineers to work out the cure.

This lead the engrs to carry out the incorrect task, however, the CAUSE of the pressurisation failure should have been picked up by THE FLIGHT CREW. The engineering checks do not require them to put the a/c back to a "standard flight" condition. As a consequence we (pilots) are generally pretty aware of switch positions post maintenance.

I did my training with Andreas Prodromou who was the number 4 steward and he had swapped onto the trip to be with his girlfriend who was the number 3. Andreas had a job starting with Astraeus at the end of the summer season apparently. He would have known what he was looking at when he finally got into the flight deck: we did our MCC on the 737 at Oxford.

The skipper was an incompitent autocrat who thought CRM was a hinderance.

Helios paid lip service to CRM with little formal training.

Jet2 refused to renew the skipper's contract and he ended up at Helios.

Another mate of mine flew with the skipper and when he heard who it was showed no surprise.

This accident could have been avoided had the captain (notice use of lower case "c"):

a) not had 12 jobs in 12 years. It is questionable whether-or-not the captain had covered all the a/c systems within a 3 year period as a result.
b) believed in CRM
c) levelled off when the "gear" horn sounded (the horn was in fact the cabin press warning).

The Hellenic investigators comment in the report:

"...There was such a lack of evidence of CRM that it was considered a major contributrary cause to the accident..."

Sadly, in my humble opinion, whilst there were failings with the Helios management hierarchy and it is right and proper that punative measures are taken, this accident would PROBABLY have been avoided with any other captain.

I strongly agree with all comments reference Engineers and pilots checking switches but think it is EXCEEDINGLY unfair to punish the engineers. This was solely, after the engineering checks, a flight crew related error.

My summary to the courses usually runs along the following lines:

Captains: write SYMPTOMS not the cure into the tech-log.

Cabin Crew: if the masks drop and you still carry on climbing, do what you can to get onto the flight deck

Cause: One switch was in the wrong place and it should have been picked up about 6 times before FL100.

CRM: As per the Hellenic board, "...there was such a lack of evidence of CRM that it was considered to be a major contributrary cause of the accident..."

[airsnoop]

A few facts;

the CVR was 30 minutes so the last 30 minutes was recorded

it was ASSUMED the engineer left the PMS in MAN because it was found "past MAN" having been severely damaged in the impact and he was the last person who admitted touching it

there is evidence that he did return it to AUTO

there is evidence that it was in AUTO at impact but was moved by the impact

both bleeds were OFF before impact

both audio switches were to MASK


Alan Irwins comments to the investigation were "lost" then "found" but were not considered because they had not been "adopted" by UK AAIB.

The message - be careful what you say to investigators, you can never be certain it won't be used against you

You want me to go on or do you accept someone was stitched up!

[airsnoop]

TOON737 - Alan Irwin is a first class engineer and did nothing wrong.
To answer your last remark, he did appeal to the UK AAIB for help when the Greeks "lost" his submission that showed he could not have left the PMS in MAN - unfortunately they declined to help him clear this up.
They had not appointed an accredited representative because "there was no UK involvement - Safety oversight by UK CAA/JAR 145 Maintenance organisation ATC Lasham/pilots checked out by UK TREs/Alan was a UK LAe/ etc etc - so could not participate in the investigation even though entitled.

Appears to come under the heading of all too difficult and the excuse was not getting involved in criminal proceedings - if Alan is right it is an air safety concern as the investigation has missed the real cause of this accident.

[Evanelpus]

The Greek authorities have insufficient evidence to convict the engineer however

For insufficient, substitute NONE.

If the MM didn't specify that the switch should have been returned to a set position after maintenance, what can he be charged with?

Seems to me as though the Greeks have their scapegoats in a line.

[Joetom]

This is a very interesting thread.

Very sad for all involved.

I have not read the details for a long time, but a few points that come to mind.

1. Press switch/knob not the clearest/ind/de-tents.

2. Press mode light/ind cluster as above, waiting to happen.

3. Boeing made previous hi-lights of the above. "Beware"

4. MM checks of this system did not state switch positions after checks.

From memory, some layover/nightstop aircraft would have the outflow valve closed for various reasons, I think method was often by putting selector to Man, run closed, pull aircraft power and then select mode to Auto, next power up all back to normal, no problems.

Thinking about item 2 above, did we not see a good example of this indicator type on a LH 747 at NBO (1975ish ???) that was poss external lighting issues, but even a filament or two failures may not be of help, again thinking back, I recall Green was Auto and Blue was Man ????

Lets hope some lessons are learnt and save others in the future.

I also find it hard to understand how the Engineer is finding himself in this position, what do they say about the law ??????

My last thought for the day, on turnaround/transit aircraft, check panels well, nightstop/layover aircraft check panels well, after maint performed check panels well, after cockpit cleaning check panels well. Don't use Autoscan, use Manscan and keep it interesting(rev scan using other hand works for me)

Cheers all.....

[quickturnaround]

Does any one here have the original verdict by the Greek Judge, or is it not available on internet? I am really very curious to his/her motivation and the underlaying reasoning to convict these 4 seen the availability of proof in this case.
An other matter is offcourse the use of non-punitive information being transformed in punitive, a very very scary development and as such I presume a serious threat to flight safety as such. Forgive me if I am wrong, but I still did not see any evidence of gross negliance or willful misconduct in this matter by the 4 involved.

[BigFrank]

Post #27 inter alia

i) Interesting to compare this judicial decision with similar proceedings in Kingdom of Spain re Spanair accident at Madrid ?

ii) Very interesting to compare and to contrast this decision with likely outcome (no criminal proceeedings; natch?) for the yet-to-be-resolved investigation into the Cork accident, involving as it does a myriad of state supervisory and private organisations and companies [not to mention "ticket sellers"] registered in:

Kingdom of Spain
The United Kingdom
Republic of Ireland
(Banana Republic?) of Isle of Man
[plus overall "control" by the EU]

not to mention original manufacture in the US of A ?

How many "3rd world standard" procedure will that one reveal, I ask

[airsnoop]

Just to amplify a point made by Wenwe; the aircraft was neither Greek registered nor located there. It was a Cypriot registered aircraft based and operated from Larnaca.

This could happen to any of you who manage or work on any aircraft that operates into Greece from UK.

Greece was the State of Occurrence in ICAO speak and the State that conducted the investigation and the State whose legal system allows prosecution on evidence that would not apparently be acceptable in a UK ciminal court.

[quickturnaround]

Airsnoop, very true! Remember the unfortunate Swissair DC8 crew at Hellenikon many years ago!

[captplaystation]

Yep, and decades later the Jepp still said "use minimum reverse consistent with safety". . . . that will be detent 3 then :D for the safety of my freedom.

[marvo999]

I think its worth pointing out this extract from ICAO Annex 13:


5.4.1 Recommendation.— Any judicial or administrative
proceedings to apportion blame or liability should be
separate from any investigation conducted under the
provisions of this Annex.

We all need to think how we would react now if asked to 'co-operate' in an Air Accident Investigation when a European Court can take information from an Accident Investigation Report, which is not intended to apportion blame to an acceptable level to that of a criminal investigation, and use it as evidence of criminal guilt. Imagine what a Jury or non technical Judge could make from and Accident Investigation that was being used by the Prosecution and quoted from in order to apportion blame. Next then, think of the ease in which people can be extradited from the UK to another European State. Can I suggest we all lobby the BALPA and ALAE/Prospect Reps, maybe a joint BALPA/ALAE campaign might be the way forward?

[marvo999]

Perhaps a question we should all be asking our Employers is whether the Company has us covered for Criminal Prosecution Insurance?

Many Airlines would not have this sort of cover to protect its Employees from and at around about an average of one million euros required to defend a person involved in a fatal Transport Aircraft crash its way beyond peoples personal means. Lets also not forget we are not just talking about Pilots and Engineers here but everyone involved in an Airline Operation, Managers, Trainers etc etc

[WenWe]

Airsnoop, I know it wasn't Greek registered.

Unless I stop working for my (or probably any other UK) employer, I'm open to the same system should the unthinkabe happen.

The only thing I can control is not working on Greek aircraft.

[boris]

BigFrank,

Sice when was the Isle of Man a "Banana Republic"?

[airsnoop]

Time was when the UK AAIB would have become involved in the investigation and would have protected the UK interest but it appears to be no longer the case.

[Idle Reverse]

Just a quick line to add my support to Alan. He was our lead ground engineer when we were operating the old BAC1-11s and B737-200s at European Air Charter. What a good time we all had with EAC . . . lovely bunch of people and Alan was a super ground engineer. Very efficient, very skilled and totally reliable from a pilot's point of view. We wish you well, Alan.

By the way, TOON737, are you our old Geordie mate from EAC days ?

Regards to all ex EAC people.

[Slasher]

It was a "freak" accident because so many holes in the cheese had to line up that day;

"Freak accident" and its sister cliche of convenience "isolated
incident" are only heard in politics where the involvement of
politicians was the sole cause of the event (ie they cannot pin
it on anyone else), not in real life. And definitely not in aviation

Almost all aviation prangs are full of lined-up cheese holes eg
SQ006 under the same false rationale could also be classed a
"freak accident", as could Lima, Helios, etc.

[ABBOT]

Just a comment, if procedures taught by Boeing flight training are used, then the switch positions on the overhead are set/verified by the first officer, during the pre taxi check the pressurisation panel items are challenge/responded by the first officer whilst being monitored by the captain.

This procedure is based on areas or responsibility, at no point does the land. Asked engineer have any responsibility to position/verify/challenge/respond to the the status of the switches on the pressurisation panel, or indeed any other panel on the flight deck.

The incident was not the responsibility of the engineer, it was a consequence of poorly executed procedure and appalling CRM by the flight crew. Sadly, with regard to one of the crew members, this was, a known fact. Tragically when it was discovered no one had the b***s to bring the situation to a close.

[aeromech3]

After completing their O/N checks, Engineers are often expected to close the outflow valves for security and inclement weather reasons, especially for overnight parking.
Therefore, in my experience, it is not uncommon for Flight crew to find the control in manual; they are responsible to set up the pressurization panel.
Well wishes to Alan.

[Prober]

I hope that the aviation profession does not turn its back upon this ludicrous plan to crucify the engineer. This is not just some isolated weirdo decision emanating from an equally weirdo foreign judiciary. Not only is it blatantly wrong but it is also a wake-up call for those around the world (and closer to home!) who would espouse a continental style of justice.
I have many thousands of hours in Seat 0A in Boeings. Never, ever, have I heard it even faintly suggested that switch positions should be set by the engineers. In fact, one expects almost quite the opposite – without casting any aspersions whatsoever upon the engineers – but (especially) when an aircraft arrives from the hangar one actually expects the switches to be in anything but the correct position. If you cannot be bothered to check your switches, you should not be allowed on the airport, let alone on an aircraft.
Is it too much to expect that responsible aviation companies might show sufficient contempt for this turn of events to call a boycott of the country concerned?
Prober:ugh:

[EK Profesional]

Sure it wasn't mandated by the AMM procedure, but isn't it good maintenance practice to put switches and systems configured back to the way they are found?

[blackhand]

EK Profesional(sic)
Sure you are?