Cypriot airliner crash - the accident and investigation
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Missed Signs
It is agreed that each individual item is easily missed by each individual but it is the combination of oversights that is unlikely. Add to this in the same sequence with the same system, a very experienced eng has to deviate from the usual practice and it becomes, I think, very unlikely.
Re the video, the accident aircraft did partially pressurise to a differential of just over 1 psi - the reconstruction flight stabilised at just over 1 psi with the same setting as the video test where the cabin stabilised at just over 1 psi diff with the OFV posn as recorded on NVM and as found at impact so it looks pretty reasonable and a side test has shown that the fluctuations are very noticeable even with it twice that far open.
Re the video, the accident aircraft did partially pressurise to a differential of just over 1 psi - the reconstruction flight stabilised at just over 1 psi with the same setting as the video test where the cabin stabilised at just over 1 psi diff with the OFV posn as recorded on NVM and as found at impact so it looks pretty reasonable and a side test has shown that the fluctuations are very noticeable even with it twice that far open.
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Update on Cyprus investigation and Tsolakis' report [from the Cyprus Mail online edition for today]:
Local Helios commission suspends hearings pending Tsolakis report
THE COMMISSION of Inquiry into the causes of the Helios air crash suspended its hearings yesterday ahead of the publication of the final report on the causes of the crash.
The announcement was made by Commission chair Panayiotis Kallis, noting that the first round of witnesses who were invited to testify was completed.
He also said that the Commission will continue with the second round of testimonies once it examines the report of the Greek Air Accident and Incidents Investigating Committee which is chaired by Akrivos Tsolakis. The report is expected to be made public this week.
Meanwhile, during yesterday’s proceedings, the Commission heard that the German captain who flew the Helios Boeing which crashed at the Grammatikos site near Athens on 14 August 2005 killing all 121 people on board, had problems in 2004 in implementing the aircraft’s Standard Operating Procedures (SOPs).
However, the he had adjusted by 2005 and implemented the company’s SOPs.
Pilot Marios Ioannou said that Hans Jeurgen Merten was a “good captain and knew the aircraft”.
However, Kallis who heads the independent commission presented a written note by the company’s British pilot Robert Lascelles which said that Ioannou was one of the co-pilots who did not want to fly with Merten, something which Ioannou rejected.
Replying to a question by Helios’s lawyer Demetris Araouzos, Ioannou said that SOPs differ from company to company and time is allowed for training the pilots who will work on contract in a company so they will become familiar with the procedures.
Sotiris Nicolaou, who worked as pilot at Helios from May 2004 until February 2006, said he had no communication problems with Merten and problems in keeping the SOPs stopped in 2005.
Co-pilot Stelios Mavrogenis, who also worked for Helios during the same period with Nicolaou, said Merten had problems in implementing the SOPs because he was working on contract but underlined he never felt unsafe while flying with him.
Asked what kind of problems Merten had, Mavrogenis cited an instance when Merten had exceeded the speeding limit as they were landing, pulled the air brakes, the use of which is not indicated below a certain altitude and as a result the plane started shaking.
Mavrogenis said he wrote to Helios about these problems and the chief pilot talked to Merten about the incident, noting that in 2005 the German captain had improved as far as the SOPs were concerned.
Co-pilot Lazaros Katsouromallis who works for Helios since 2004 said that he flew with the ill-fated plane on a number of occasions and never had any problem. He also said he had a good cooperation and communication with Merten.
On August 14 2005, an Helios Airways Boeing 737, on its way to Prague via Athens, crashed into the mountain side north of the Greek capital killing all 121 passengers and crew on board, most of them Cypriot holidaymakers.
Former member of the Supreme Court Panayiotis Kallis was sworn in on 24 May 2006 as the member of the independent Commission of Inquiry that will fully look into the causes of the air crash.
The Kallis Commission is expected to name those involved in the tragedy so that the Attorney General can bring criminal liability charges against them.
Copyright © Cyprus Mail 2006
Local Helios commission suspends hearings pending Tsolakis report
THE COMMISSION of Inquiry into the causes of the Helios air crash suspended its hearings yesterday ahead of the publication of the final report on the causes of the crash.
The announcement was made by Commission chair Panayiotis Kallis, noting that the first round of witnesses who were invited to testify was completed.
He also said that the Commission will continue with the second round of testimonies once it examines the report of the Greek Air Accident and Incidents Investigating Committee which is chaired by Akrivos Tsolakis. The report is expected to be made public this week.
Meanwhile, during yesterday’s proceedings, the Commission heard that the German captain who flew the Helios Boeing which crashed at the Grammatikos site near Athens on 14 August 2005 killing all 121 people on board, had problems in 2004 in implementing the aircraft’s Standard Operating Procedures (SOPs).
However, the he had adjusted by 2005 and implemented the company’s SOPs.
Pilot Marios Ioannou said that Hans Jeurgen Merten was a “good captain and knew the aircraft”.
However, Kallis who heads the independent commission presented a written note by the company’s British pilot Robert Lascelles which said that Ioannou was one of the co-pilots who did not want to fly with Merten, something which Ioannou rejected.
Replying to a question by Helios’s lawyer Demetris Araouzos, Ioannou said that SOPs differ from company to company and time is allowed for training the pilots who will work on contract in a company so they will become familiar with the procedures.
Sotiris Nicolaou, who worked as pilot at Helios from May 2004 until February 2006, said he had no communication problems with Merten and problems in keeping the SOPs stopped in 2005.
Co-pilot Stelios Mavrogenis, who also worked for Helios during the same period with Nicolaou, said Merten had problems in implementing the SOPs because he was working on contract but underlined he never felt unsafe while flying with him.
Asked what kind of problems Merten had, Mavrogenis cited an instance when Merten had exceeded the speeding limit as they were landing, pulled the air brakes, the use of which is not indicated below a certain altitude and as a result the plane started shaking.
Mavrogenis said he wrote to Helios about these problems and the chief pilot talked to Merten about the incident, noting that in 2005 the German captain had improved as far as the SOPs were concerned.
Co-pilot Lazaros Katsouromallis who works for Helios since 2004 said that he flew with the ill-fated plane on a number of occasions and never had any problem. He also said he had a good cooperation and communication with Merten.
On August 14 2005, an Helios Airways Boeing 737, on its way to Prague via Athens, crashed into the mountain side north of the Greek capital killing all 121 passengers and crew on board, most of them Cypriot holidaymakers.
Former member of the Supreme Court Panayiotis Kallis was sworn in on 24 May 2006 as the member of the independent Commission of Inquiry that will fully look into the causes of the air crash.
The Kallis Commission is expected to name those involved in the tragedy so that the Attorney General can bring criminal liability charges against them.
Copyright © Cyprus Mail 2006
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The Consequences of Kallis
The Commission of Inquiry, chaired by Panayiotis Kallis, has been suspended ahead of the publication of the Greek AAI & ASB Final Report that is expected to be made public this week. Once it has been examined by the Commission, the inquiry will continue, and I understand that this second phase will be based on the information contained in the Final Report.
The stated purpose of the Kallis Commission is to name those responsible for the tragedy so that the Attorney General can bring criminal liability charges against them.
The Kallis Inquiry has already introduced parts of the confidential Draft Report into the public domain and now the Final Report is to be used.
ICAO Annex 13, Aircraft Accident and Incident Investigation, states that the “sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.”
A clear warning is given that records made during an investigation include information given voluntarily by persons interviewed and that this information could be “utilised inappropriately for subsequent disciplinary, civil, administrative and criminal proceedings.”
The consequence of using the Final Report as a basis to establish criminal liability is that vital information may, in the future, not be openly disclosed to air saftey investigators, and the lack of access to such information could impede the investigation process and seriously affect flight safety worldwide.
A very dangerous precedent.
The stated purpose of the Kallis Commission is to name those responsible for the tragedy so that the Attorney General can bring criminal liability charges against them.
The Kallis Inquiry has already introduced parts of the confidential Draft Report into the public domain and now the Final Report is to be used.
ICAO Annex 13, Aircraft Accident and Incident Investigation, states that the “sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.”
A clear warning is given that records made during an investigation include information given voluntarily by persons interviewed and that this information could be “utilised inappropriately for subsequent disciplinary, civil, administrative and criminal proceedings.”
The consequence of using the Final Report as a basis to establish criminal liability is that vital information may, in the future, not be openly disclosed to air saftey investigators, and the lack of access to such information could impede the investigation process and seriously affect flight safety worldwide.
A very dangerous precedent.
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Article in the Phileleftheros
Hi,
This is my first post on this forum (so please excuse my mistakes), though I've been reading this thread, and the previous one, with interest ever since the accident happened. As there hasn't been a post for a couple of days, I thought I'd contribute something.
Today's Phileleftheros, the Greek-language Cypriot daily newspaper, has an article titled "There were eight causes in the Grammatikos tragedy" and subtitled "What the Tsolakis Report says." This was also reported on London Greek Radio this morning.
It says Tsolakis will deliver the Final Report in Greece and Cyprus on Tuesday. The Phileleftheros claims to reveal the eight causes in the article. Four of the mentioned causes were labelled "active" and the other four "latent." The "active" causes, according to the paper, were identified as the joint responsibility between the ground engineers and the flight crew for the outflow valve remaining in manual, the incorrect reaction to alarm signals, the procedures for the crew, and the communication between flight crew and cabin crew.
For the "latent" causes the newspaper says the blame lies on the Cyprus Department of Civil Aviation for "seriously insufficient monitoring" by , Helios for "shortages" (presumably of staff?), and what surprised me was that even Boeing was blamed, for "failing to take corrective measures" for problems it already knew about, as well as JAA, ICAO and EASA, which "knew but tolerated" the situation with serious problems in the Dept. of Civil Aviation and the aviation industry in Cyprus.
What I don't get is how the newspaper claims to know the causes identified in the report, when it says in the same paragraph that the report is not going to be published until Tuesday. It also suddens me to see that the article just talks about blame, instead of what can be done to avoid similar accidents. I hope the actual Report won't be as bad as this newspaper article makes it out to be.
This is my first post on this forum (so please excuse my mistakes), though I've been reading this thread, and the previous one, with interest ever since the accident happened. As there hasn't been a post for a couple of days, I thought I'd contribute something.
Today's Phileleftheros, the Greek-language Cypriot daily newspaper, has an article titled "There were eight causes in the Grammatikos tragedy" and subtitled "What the Tsolakis Report says." This was also reported on London Greek Radio this morning.
It says Tsolakis will deliver the Final Report in Greece and Cyprus on Tuesday. The Phileleftheros claims to reveal the eight causes in the article. Four of the mentioned causes were labelled "active" and the other four "latent." The "active" causes, according to the paper, were identified as the joint responsibility between the ground engineers and the flight crew for the outflow valve remaining in manual, the incorrect reaction to alarm signals, the procedures for the crew, and the communication between flight crew and cabin crew.
For the "latent" causes the newspaper says the blame lies on the Cyprus Department of Civil Aviation for "seriously insufficient monitoring" by , Helios for "shortages" (presumably of staff?), and what surprised me was that even Boeing was blamed, for "failing to take corrective measures" for problems it already knew about, as well as JAA, ICAO and EASA, which "knew but tolerated" the situation with serious problems in the Dept. of Civil Aviation and the aviation industry in Cyprus.
What I don't get is how the newspaper claims to know the causes identified in the report, when it says in the same paragraph that the report is not going to be published until Tuesday. It also suddens me to see that the article just talks about blame, instead of what can be done to avoid similar accidents. I hope the actual Report won't be as bad as this newspaper article makes it out to be.
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Translation correction
Yesterday I wrote:
> Four of the mentioned causes were labelled "active" and the other four "latent."
That was a poor translation. Of course, what I meant was "direct" and "indirect" causes.
> Four of the mentioned causes were labelled "active" and the other four "latent."
That was a poor translation. Of course, what I meant was "direct" and "indirect" causes.
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Final Report
Well we will all know by Wednesday morning. The various leaks about the content of the Final Report give credibility to an excellent quote I saw recently:
“I'm not sure that there is a Greek word for 'objective evidence' unless it's the same as 'my opinion'.”
“I'm not sure that there is a Greek word for 'objective evidence' unless it's the same as 'my opinion'.”
Pegase Driver
But to be fair , let's read the original report before asuming it is what we fear it will be.
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Confirmed: Report out tomorrow
http://news.ert.gr/en/10/21317.asp
[quote]
Chairman of the Hellenic Air Accident Investigation and Aviation Safety Board Akrivos Tsolakis is to hand Tuesday morning the finding on the crash of the Helios airliner, which crashed in the area of Grammatiko on 14 August 2005, over to Transport Minister Michael Liapis. The finding puts the crash down to human error, sources said. In particular, it primarily holds the pilot and the co-pilot responsible, for failing to shift the compression valve from the manually-operated mode to the automate one. They are also blamed for not realizing that it was the partial decompression that prompted the alarm to sound. The partial decompression raised oxygen levels inside the cockpit and the pilots lost their senses. Responsibilities are also attributed to the technicians who performed the last inspection prior to Helios airliner’s fatal flight, because they left the compression valve to the manually-operated mode.
[END QUOTE]
Sources: ΝΕΤ-ΝΕΤ 105.8
TR
----------------------------
ThinkRate! ThinkRate! Don't Think!
[quote]
Chairman of the Hellenic Air Accident Investigation and Aviation Safety Board Akrivos Tsolakis is to hand Tuesday morning the finding on the crash of the Helios airliner, which crashed in the area of Grammatiko on 14 August 2005, over to Transport Minister Michael Liapis. The finding puts the crash down to human error, sources said. In particular, it primarily holds the pilot and the co-pilot responsible, for failing to shift the compression valve from the manually-operated mode to the automate one. They are also blamed for not realizing that it was the partial decompression that prompted the alarm to sound. The partial decompression raised oxygen levels inside the cockpit and the pilots lost their senses. Responsibilities are also attributed to the technicians who performed the last inspection prior to Helios airliner’s fatal flight, because they left the compression valve to the manually-operated mode.
[END QUOTE]
Sources: ΝΕΤ-ΝΕΤ 105.8
TR
----------------------------
ThinkRate! ThinkRate! Don't Think!
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All this was more or less expected.
I wonder if he will give a definite reason why the Cabin crew didn't enter the cockpit sooner. I doubt it though. I don't think we'll ever know for sure.
I wonder if he will give a definite reason why the Cabin crew didn't enter the cockpit sooner. I doubt it though. I don't think we'll ever know for sure.
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Hyperoxia?
When I read the following in the previous post...
"The partial decompression raised oxygen levels inside the cockpit and the pilots lost their senses."
I thought that was a translation error. But when I looked at the original Greek text on the same website, it really did say "high blood oxygen level." Surely that's wrong??
"The partial decompression raised oxygen levels inside the cockpit and the pilots lost their senses."
I thought that was a translation error. But when I looked at the original Greek text on the same website, it really did say "high blood oxygen level." Surely that's wrong??
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..on the wires...
Report: Human error main cause of 2005 Helios air crash
Eds: LEADS to UPDATE with more from report, ADDS details; RESTORES background; ADDS byline
By PATRICK QUINN
Associated Press Writer
ATHENS, Greece (AP) – Investigators cited human error Tuesday as the main cause of the Helios Airways crash that killed all 121 passengers and crew near Athens last year, in the deadliest air disaster in the history of Cyprus and Greece.
The two pilots of the Cypriot 737-300 failed to competently operate controls regulating cabin pressure and misinterpreted a subsequent warning sign, which eventually led to the Aug. 14 crash of the jetliner on a hill north of the Greek capital, according to a report delivered to Greece’s transport minister.
Maintenance officials left pressure controls on an incorrect setting, the report said, and the aircraft’s manufacturer, Boeing, was cited for “ineffectiveness of measures taken in response to previous pressurization incidents in the particular type of aircraft.”
The report was prepared by Akrivos Tsolakis, head of Greece’s National Aviation Safety Board.
It also said that the direct causes of the crash were the crew’s failure to recognize that the plane’s pressurization switch was in the “manual position” before takeoff and not set to automatic – which would have allowed the cabin to pressurize by itself.
After takeoff, the plane failed to pressurize and the two pilots did not recognize “the warnings and the reasons for the activation of the warnings,” including one showing that the oxygen masks dropped.
That failure led to the “incapacitation of the flight crew due to hypoxia,” or lack of oxygen, and resulted in the plane being flown on autopilot for two hours until it ran out of fuel and crashed.
Maintenance officials in Cyprus were also indirectly blamed, along with Cypriot civil aviation authorities.
The report said latent causes included Helios’ “deficiencies in the organization, quality management, and safety culture and the regulatory authority’s “inadequate execution of its safety oversight responsibilities” over time.
The captain contacted Helio’s operations center after takeoff and as the aircraft climbed though 16,000 feet (4,879 meters), reporting that there were warnings going off in the cabin, according to the report.
“Several communications between the captain and the Operations Centre took place in the next eight minutes concerning the above problems and ended as the aircraft climbed through 28,900 feet (8,810 meters). Thereafter, there was no response to radio calls to the aircraft,” the report said.
During the climb, “the passenger oxygen masks deployed.”
The report did not say if any of the passengers had managed to put on the masks, but it found that at least one man without a mask was seen alive in the cockpit 14 minutes before the crash by the pilot of a Greek F-16 fighter jet that had been scrambled to intercept the airliner.
“The F-16 pilot tried to attract his attention without success,” the report found. The plane issued two Mayday signals when the first engine flamed out and crashed 13 minutes later after the second engine flamed out, it said
Earlier this year, Tsolakis said a flight attendant on the plane had wrestled with controls for at least 10 minutes before the crash, in a failed effort to regain control of the airliner.
Helios Airways Flight 522 had been traveling from Larnaca, Cyprus, to Prague, Czech Republic, with a scheduled stop in Athens.
The aircraft was shadowed by Greek fighter jets before it crashed at Grammatiko, some 40 kilometers (25 miles) north of Athens. All 115 passengers – all Greek Cypriots and Greeks – and six crew were killed in the crash.
Helios Airways, a budget Cypriot airline, was replaced earlier this year by a new carrier called ajet. 100831 oct 06GMT
Eds: LEADS to UPDATE with more from report, ADDS details; RESTORES background; ADDS byline
By PATRICK QUINN
Associated Press Writer
ATHENS, Greece (AP) – Investigators cited human error Tuesday as the main cause of the Helios Airways crash that killed all 121 passengers and crew near Athens last year, in the deadliest air disaster in the history of Cyprus and Greece.
The two pilots of the Cypriot 737-300 failed to competently operate controls regulating cabin pressure and misinterpreted a subsequent warning sign, which eventually led to the Aug. 14 crash of the jetliner on a hill north of the Greek capital, according to a report delivered to Greece’s transport minister.
Maintenance officials left pressure controls on an incorrect setting, the report said, and the aircraft’s manufacturer, Boeing, was cited for “ineffectiveness of measures taken in response to previous pressurization incidents in the particular type of aircraft.”
The report was prepared by Akrivos Tsolakis, head of Greece’s National Aviation Safety Board.
It also said that the direct causes of the crash were the crew’s failure to recognize that the plane’s pressurization switch was in the “manual position” before takeoff and not set to automatic – which would have allowed the cabin to pressurize by itself.
After takeoff, the plane failed to pressurize and the two pilots did not recognize “the warnings and the reasons for the activation of the warnings,” including one showing that the oxygen masks dropped.
That failure led to the “incapacitation of the flight crew due to hypoxia,” or lack of oxygen, and resulted in the plane being flown on autopilot for two hours until it ran out of fuel and crashed.
Maintenance officials in Cyprus were also indirectly blamed, along with Cypriot civil aviation authorities.
The report said latent causes included Helios’ “deficiencies in the organization, quality management, and safety culture and the regulatory authority’s “inadequate execution of its safety oversight responsibilities” over time.
The captain contacted Helio’s operations center after takeoff and as the aircraft climbed though 16,000 feet (4,879 meters), reporting that there were warnings going off in the cabin, according to the report.
“Several communications between the captain and the Operations Centre took place in the next eight minutes concerning the above problems and ended as the aircraft climbed through 28,900 feet (8,810 meters). Thereafter, there was no response to radio calls to the aircraft,” the report said.
During the climb, “the passenger oxygen masks deployed.”
The report did not say if any of the passengers had managed to put on the masks, but it found that at least one man without a mask was seen alive in the cockpit 14 minutes before the crash by the pilot of a Greek F-16 fighter jet that had been scrambled to intercept the airliner.
“The F-16 pilot tried to attract his attention without success,” the report found. The plane issued two Mayday signals when the first engine flamed out and crashed 13 minutes later after the second engine flamed out, it said
Earlier this year, Tsolakis said a flight attendant on the plane had wrestled with controls for at least 10 minutes before the crash, in a failed effort to regain control of the airliner.
Helios Airways Flight 522 had been traveling from Larnaca, Cyprus, to Prague, Czech Republic, with a scheduled stop in Athens.
The aircraft was shadowed by Greek fighter jets before it crashed at Grammatiko, some 40 kilometers (25 miles) north of Athens. All 115 passengers – all Greek Cypriots and Greeks – and six crew were killed in the crash.
Helios Airways, a budget Cypriot airline, was replaced earlier this year by a new carrier called ajet. 100831 oct 06GMT
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According to the Cyprus Mail [below], the report hasn't been handed over quite yet.
Helios report to be handed over today
THE LONG awaited report into last year’s Helios air crash will today be handed over to President Tassos Papadopoulos.
Following the conclusion of the Greek Air Accident Investigating Committee’s probe into the August 14 tragedy, which killed all 121 passengers and crew on board, committee chairman Akrivos Tsolakis will fly to Cyprus early this afternoon to hand over the final report, after first handing it over to Greece’s Transport Minister.
Tsolakis is expected to land at Larnaca airport at around 3.30pm, where he will meet with Communication and Works Minister Harris Thrassou at 4.30pm.
From there, the chief investigator will be driven to the Presidential Palace where he will present President Tassos Papadopoulos with copies of the document in English and Greek.
Cypriot Air Accident Investigating Committee Chairman Costas Orfanos is also expected to receive a copy of the report.
Speaking to the Cyprus News Agency yesterday, Thrassou said the report would be made public without delay and a copy would also be given to Panayiotis Kallis, the chairman of the independent Commission of Inquiry into the causes of the air crash, on Wednesday.
The minister said the report would clarify the cause of the accident and that anyone held responsible would be named during the Kallis inquiry.
The Kallis Commission is expected to name those responsible for the tragedy so that the Attorney-general can bring criminal liability charges against them.
It is believed the report will blame human error and oversights for the accident. The Civil Aviation Department has also been showed to have cut corners in its handling of the safety measures.
The Civil Aviation Department and ajet, formerly known as Helios, will also receive copies of the report this week.
Meanwhile, the independent Commission yesterday resumed its hearings, after suspending them last week ahead of the publication of the Tsolakis report.
During yesterday’s hearing, Michael Agisilaou, who worked as co-ordinator at the Aviation Safety Division, was recalled to testify, as was ajet co-pilot Andreas Aristedou.
The Commission will continue its hearings today at 11am. It will suspend the proceedings and continue with the second round of testimonies once it examines the Tsolakis report.
Copyright © Cyprus Mail 2006
Helios report to be handed over today
THE LONG awaited report into last year’s Helios air crash will today be handed over to President Tassos Papadopoulos.
Following the conclusion of the Greek Air Accident Investigating Committee’s probe into the August 14 tragedy, which killed all 121 passengers and crew on board, committee chairman Akrivos Tsolakis will fly to Cyprus early this afternoon to hand over the final report, after first handing it over to Greece’s Transport Minister.
Tsolakis is expected to land at Larnaca airport at around 3.30pm, where he will meet with Communication and Works Minister Harris Thrassou at 4.30pm.
From there, the chief investigator will be driven to the Presidential Palace where he will present President Tassos Papadopoulos with copies of the document in English and Greek.
Cypriot Air Accident Investigating Committee Chairman Costas Orfanos is also expected to receive a copy of the report.
Speaking to the Cyprus News Agency yesterday, Thrassou said the report would be made public without delay and a copy would also be given to Panayiotis Kallis, the chairman of the independent Commission of Inquiry into the causes of the air crash, on Wednesday.
The minister said the report would clarify the cause of the accident and that anyone held responsible would be named during the Kallis inquiry.
The Kallis Commission is expected to name those responsible for the tragedy so that the Attorney-general can bring criminal liability charges against them.
It is believed the report will blame human error and oversights for the accident. The Civil Aviation Department has also been showed to have cut corners in its handling of the safety measures.
The Civil Aviation Department and ajet, formerly known as Helios, will also receive copies of the report this week.
Meanwhile, the independent Commission yesterday resumed its hearings, after suspending them last week ahead of the publication of the Tsolakis report.
During yesterday’s hearing, Michael Agisilaou, who worked as co-ordinator at the Aviation Safety Division, was recalled to testify, as was ajet co-pilot Andreas Aristedou.
The Commission will continue its hearings today at 11am. It will suspend the proceedings and continue with the second round of testimonies once it examines the Tsolakis report.
Copyright © Cyprus Mail 2006
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There are two articles on the CNN International edition today, and from the second one, link below, I have extracted the following statement (which I am sure will be well debated on this forum):
"The report also found that the man in the cockpit had been in communication with other aircraft during the last 30 minutes of the flight."
http://edition.cnn.com/2005/WORLD/eu...day/index.html
"The report also found that the man in the cockpit had been in communication with other aircraft during the last 30 minutes of the flight."
http://edition.cnn.com/2005/WORLD/eu...day/index.html
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Where's the report?
According to Reuters, Tsolakis has already submitted the report to the Greek Ministry of Transport, and will hand it to the Cypriot authorities this afternoon. All the articles I've read so far in the press appear to be too brief and most of them inaccurate. Will we eventually be given a link to the actual report somewhere on the web?
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http://www.politis.com.cy/other/down...a_20061010.pdf
The link above is the report in brief both in greek and in English. It says at the end 'by the press office' but doesn't say of what.
The link above is the report in brief both in greek and in English. It says at the end 'by the press office' but doesn't say of what.
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This just received from the Ministry of Transport (in Greek, with Synopsis in English, which is posted below):
On 14 August 2005, a Boeing 737-300 aircraft, registration number 5B-DBY, operated by Helios Airways, departed Larnaca, Cyprus at 09:07 h for Prague, Czech Republic, via Athens, Hellas. The aircraft was cleared to climb to FL340 and to proceed direct to RDS VOR. As the aircraft climbed through 16 000 ft, the Captain contacted the company Operations Centre and reported a Take-off Configuration Warning and an Equipment Cooling system problem. Several communications between the Captain and the Operations Centre took place in the next eight minutes concerning the above problems and ended as the aircraft climbed through 28 900 ft. Thereafter, there was no response to radio calls to the aircraft. During the climb, at an aircraft altitude of 18 200 ft, the passenger oxygen masks deployed in the cabin. The aircraft leveled off at FL340 and continued on its programmed route.
At 10:21 h, the aircraft flew over the KEA VOR, then over the Athens International Airport, and subsequently entered the KEA VOR holding pattern at 10:38 h. At 11:24 h, during the sixth holding pattern, the Boeing 737 was intercepted by two F-16 aircraft of the Hellenic Air Force. One of the F-16 pilots observed the aircraft at close range and reported at 11:32 h that the Captain’s seat was vacant, the First Officer’s seat was occupied by someone who was slumped over the controls, the passenger oxygen masks were seen dangling and three motionless passengers were seen seated wearing oxygen masks in the cabin. No external damage or fire was noted and the aircraft was not responding to radio calls. At 11:49 h, he reported a person not wearing an oxygen mask entering the cockpit and occupying the Captain’s seat. The F-16 pilot tried to attract his attention without success. At 11:50 h, the left engine flamed out due to fuel depletion and the aircraft started descending. At 11:54 h, two MAYDAY messages were recorded on the CVR.
At 12:00 h, the right engine also flamed out at an altitude of approximately 7 100 ft. The aircraft continued descending rapidly and impacted hilly terrain at 12:03 h in the vicinity of Grammatiko village, Hellas, approximately 33 km northwest of the Athens International Airport. The 115 passengers and 6 crew members on board were fatally injured. The aircraft was destroyed.
The Air Accident Investigation and Aviation Safety Board (AAIASB) of the Hellenic Ministry of Transport & Communications investigated the accident following ICAO practices and determined that the accident resulted from direct and latent causes.
The direct causes were:
· · Non-recognition that the cabin pressurization mode selector was in the MAN (manual) position during the performance of the Preflight procedure, the Before Start checklist and the After Takeoff checklist.
· · Non-identification of the warnings and the reasons for the activation of the warnings (Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication, Master Caution).
· · Incapacitation of the flight crew due to hypoxia, resulting in the continuation of the flight via the flight management computer and the autopilot, depletion of the fuel and engine flameout, and the impact of the aircraft with the ground.
The latent causes were:
· · Operator’s deficiencies in the organization, quality management, and safety culture.
· · Regulatory Authority’s diachronic inadequate execution of its safety oversight responsibilities.
· · Inadequate application of Crew Resource Management principles.
· · Ineffectiveness of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft.
The AAIASB further concluded that the following factors could have contributed to the accident: omission of returning the cabin pressurization mode selector to the AUTO position after non-scheduled maintenance on the aircraft; lack of cabin crew procedures (at an international level) to address events involving loss of pressurization and continuation of the climb despite passenger oxygen masks deployment; and ineffectiveness of international aviation authorities to enforce implementation of actions plans resulting from deficiencies documented in audits.
In the months following the accident, the AAIASB made seven interim safety recommendations: five recommendations to the National Transportation Safety Board and to the manufacturer, four of which already resulted in the implementation of corrective actions, one recommendation to the Cyprus Air Accident and Incident Investigation Board and the airlines based in Cyprus, for which corrective action had already been taken, and one recommendation to the Hellenic Civil Aviation Authority (HCAA), which also resulted in the implementation of corrective action. In addition, the FAA in the United States issued an Airworthiness Directive (AD) which informed flight crews about upcoming, improved procedures for pre-flight setup of the cabin pressurization system, as well as improved procedures for interpreting and responding to the Cabin Altitude Warning Horn and to the Takeoff or Landing Configuration Warning Horn.
The report also identifies a number of additional safety deficiencies pertaining to: maintenance procedures; pilot training, normal and emergency procedures; organizational issues of the Operator; organizational issues related to safety oversight of maintenance and flight operations by Cyprus DCA, EASA/JAA and ICAO; issues related to the aircraft manufacturer’s documentation for maintenance and flight operations; and issues related to handling by the International Authorities of precursor incident information so as to implement preventive measures in a timely manner. As a consequence of the above, in its Final Report the AAIASB promulgated an additional eleven safety recommendations, addressed to the Republic of Cyprus, EASA, JAA and ICAO.
In accordance with ICAO Annex 13, paragraph 6.3, copies of the Draft Final Report were sent on 18 May 2006 to the States that participated in the investigation, inviting their comments. The comments sent to the AAIASB by the relevant Authorities in Cyprus, the United Kingdom and the United States were taken into account in the Final Report.
Note: All the above times are local.
On 14 August 2005, a Boeing 737-300 aircraft, registration number 5B-DBY, operated by Helios Airways, departed Larnaca, Cyprus at 09:07 h for Prague, Czech Republic, via Athens, Hellas. The aircraft was cleared to climb to FL340 and to proceed direct to RDS VOR. As the aircraft climbed through 16 000 ft, the Captain contacted the company Operations Centre and reported a Take-off Configuration Warning and an Equipment Cooling system problem. Several communications between the Captain and the Operations Centre took place in the next eight minutes concerning the above problems and ended as the aircraft climbed through 28 900 ft. Thereafter, there was no response to radio calls to the aircraft. During the climb, at an aircraft altitude of 18 200 ft, the passenger oxygen masks deployed in the cabin. The aircraft leveled off at FL340 and continued on its programmed route.
At 10:21 h, the aircraft flew over the KEA VOR, then over the Athens International Airport, and subsequently entered the KEA VOR holding pattern at 10:38 h. At 11:24 h, during the sixth holding pattern, the Boeing 737 was intercepted by two F-16 aircraft of the Hellenic Air Force. One of the F-16 pilots observed the aircraft at close range and reported at 11:32 h that the Captain’s seat was vacant, the First Officer’s seat was occupied by someone who was slumped over the controls, the passenger oxygen masks were seen dangling and three motionless passengers were seen seated wearing oxygen masks in the cabin. No external damage or fire was noted and the aircraft was not responding to radio calls. At 11:49 h, he reported a person not wearing an oxygen mask entering the cockpit and occupying the Captain’s seat. The F-16 pilot tried to attract his attention without success. At 11:50 h, the left engine flamed out due to fuel depletion and the aircraft started descending. At 11:54 h, two MAYDAY messages were recorded on the CVR.
At 12:00 h, the right engine also flamed out at an altitude of approximately 7 100 ft. The aircraft continued descending rapidly and impacted hilly terrain at 12:03 h in the vicinity of Grammatiko village, Hellas, approximately 33 km northwest of the Athens International Airport. The 115 passengers and 6 crew members on board were fatally injured. The aircraft was destroyed.
The Air Accident Investigation and Aviation Safety Board (AAIASB) of the Hellenic Ministry of Transport & Communications investigated the accident following ICAO practices and determined that the accident resulted from direct and latent causes.
The direct causes were:
· · Non-recognition that the cabin pressurization mode selector was in the MAN (manual) position during the performance of the Preflight procedure, the Before Start checklist and the After Takeoff checklist.
· · Non-identification of the warnings and the reasons for the activation of the warnings (Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication, Master Caution).
· · Incapacitation of the flight crew due to hypoxia, resulting in the continuation of the flight via the flight management computer and the autopilot, depletion of the fuel and engine flameout, and the impact of the aircraft with the ground.
The latent causes were:
· · Operator’s deficiencies in the organization, quality management, and safety culture.
· · Regulatory Authority’s diachronic inadequate execution of its safety oversight responsibilities.
· · Inadequate application of Crew Resource Management principles.
· · Ineffectiveness of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft.
The AAIASB further concluded that the following factors could have contributed to the accident: omission of returning the cabin pressurization mode selector to the AUTO position after non-scheduled maintenance on the aircraft; lack of cabin crew procedures (at an international level) to address events involving loss of pressurization and continuation of the climb despite passenger oxygen masks deployment; and ineffectiveness of international aviation authorities to enforce implementation of actions plans resulting from deficiencies documented in audits.
In the months following the accident, the AAIASB made seven interim safety recommendations: five recommendations to the National Transportation Safety Board and to the manufacturer, four of which already resulted in the implementation of corrective actions, one recommendation to the Cyprus Air Accident and Incident Investigation Board and the airlines based in Cyprus, for which corrective action had already been taken, and one recommendation to the Hellenic Civil Aviation Authority (HCAA), which also resulted in the implementation of corrective action. In addition, the FAA in the United States issued an Airworthiness Directive (AD) which informed flight crews about upcoming, improved procedures for pre-flight setup of the cabin pressurization system, as well as improved procedures for interpreting and responding to the Cabin Altitude Warning Horn and to the Takeoff or Landing Configuration Warning Horn.
The report also identifies a number of additional safety deficiencies pertaining to: maintenance procedures; pilot training, normal and emergency procedures; organizational issues of the Operator; organizational issues related to safety oversight of maintenance and flight operations by Cyprus DCA, EASA/JAA and ICAO; issues related to the aircraft manufacturer’s documentation for maintenance and flight operations; and issues related to handling by the International Authorities of precursor incident information so as to implement preventive measures in a timely manner. As a consequence of the above, in its Final Report the AAIASB promulgated an additional eleven safety recommendations, addressed to the Republic of Cyprus, EASA, JAA and ICAO.
In accordance with ICAO Annex 13, paragraph 6.3, copies of the Draft Final Report were sent on 18 May 2006 to the States that participated in the investigation, inviting their comments. The comments sent to the AAIASB by the relevant Authorities in Cyprus, the United Kingdom and the United States were taken into account in the Final Report.
Note: All the above times are local.
Join Date: Jul 2005
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...and here's a link to a story in The Times (they seem to have an aviation day today...)
http://www.timesonline.co.uk/article...396691,00.html
http://www.timesonline.co.uk/article...396691,00.html
Join Date: Dec 2001
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...and here's a link to a story in The Times (they seem to have an aviation day today...)
http://www.timesonline.co.uk/article...396691,00.html
http://www.timesonline.co.uk/article...396691,00.html
The company said today that it had not yet seen the final report into the accident but was "deeply dismayed" that more emphasis had not been placed on the actions of the ground engineers who had moved the cabin pressure control from its normal position.