Cypriot airliner crash - the accident and investigation
Pegase Driver
At 11:49 h, he reported a person not wearing an oxygen mask entering the cockpit and occupying the Captain’s seat.
something does not add up here.
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Slumped over the controls
Hi, I'm just a piece of SLF but have been following this story with interest.
Every report I read refers to the F/O being "slumped over the controls" - what does this mean? Are "the controls" the control column? If someone "slumped" on the c/c might that not have disengaged the A/P (a la Everglades L1011)?
Sorry for ignorance displayed here - look forward to being corrected (and reading the full report on this accident).
Thanks, Neil
Every report I read refers to the F/O being "slumped over the controls" - what does this mean? Are "the controls" the control column? If someone "slumped" on the c/c might that not have disengaged the A/P (a la Everglades L1011)?
Sorry for ignorance displayed here - look forward to being corrected (and reading the full report on this accident).
Thanks, Neil
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ATC Watcher
Hand held oxygen set?
Not in the airline business, but I've seen the sets in stowages ready to be grabbed - a bottle with a mask screwed directly on to the regulator - would only be against the face when you needed to breathe.
Sven
Hand held oxygen set?
Not in the airline business, but I've seen the sets in stowages ready to be grabbed - a bottle with a mask screwed directly on to the regulator - would only be against the face when you needed to breathe.
Sven
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The summary of the report in both english (scroll down) and greek from Greece's Ministry of Transport
http://www.yme.gr/pressdetail.php?se...12d7e8f3ca6fb4
http://www.yme.gr/pressdetail.php?se...12d7e8f3ca6fb4
SYNOPSIS IN ENGLISH
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:
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:
- Operators deficiencies in the organization, quality management, and safety culture.
- Regulatory Authority 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.
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How long does it take?
Amazing! A full copy of the original report (alas in Greek) can already be found and is currently being circulated around various aviation-related discussion groups in Greece:
Copy of Report in Greek
TR
---------------------------------
ThinkRate! ThinkRate! Don't Think!
Copy of Report in Greek
TR
---------------------------------
ThinkRate! ThinkRate! Don't Think!
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What I would like to see is the full 250 page report, including FDR and CVR data, all in English, of course. The size of the report was mentioned in a blurb today in Kathimerini.
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Maybe I'm missing something (although I've done my best to read the various threads in Prune on this topic), but one line from the report interests me:
"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".
I am aware in the past that other manifestations of the same problem were helped by cabin crew going to the cockpit to advise that masks had dropped and what was going on - these incidents happened before 9/11 and cockpit security doors. Are the Greeks suggesting that SOPs need to be updated as a result of increased cockpit security, or am I misreading?
Regarding the specific Helios incident, has the report or anybody else come up with a satisfactory explanation for the large amount of time it took for the cabin crew to get into the cockpit? I realise it's subsidiary to the failure of pilots to find the problem using SOPs, but surely in terms of preventing reoccurrences, it's an important point?
"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".
I am aware in the past that other manifestations of the same problem were helped by cabin crew going to the cockpit to advise that masks had dropped and what was going on - these incidents happened before 9/11 and cockpit security doors. Are the Greeks suggesting that SOPs need to be updated as a result of increased cockpit security, or am I misreading?
Regarding the specific Helios incident, has the report or anybody else come up with a satisfactory explanation for the large amount of time it took for the cabin crew to get into the cockpit? I realise it's subsidiary to the failure of pilots to find the problem using SOPs, but surely in terms of preventing reoccurrences, it's an important point?
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just out of interest
Quote:
"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"
Does the checklist item "cabin pressurization mode selector to AUTOMATIC" appear in the ALL THREE procedures/checklists??? If so, is it fair to say that the crew missed SIX clues about this switch being in the wrong position (three checklists plus the Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication and the Master Caution signal???)
"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"
Does the checklist item "cabin pressurization mode selector to AUTOMATIC" appear in the ALL THREE procedures/checklists??? If so, is it fair to say that the crew missed SIX clues about this switch being in the wrong position (three checklists plus the Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication and the Master Caution signal???)
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Maybe I'm missing something (although I've done my best to read the various threads in Prune on this topic), but one line from the report interests me:
"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".
"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".
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Does the checklist item "cabin pressurization mode selector to AUTOMATIC" appear in the ALL THREE procedures/checklists??? If so, is it fair to say that the crew missed SIX clues about this switch being in the wrong position (three checklists plus the Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication and the Master Caution signal???)
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Amazing! A full copy of the original report (alas in Greek) can already be found and is currently being circulated around various aviation-related discussion groups in Greece:
Copy of Report in Greek
Copy of Report in Greek
http://download.yousendit.com/9EC42D2E175FECCB
[Military reported seeing a person entering the cockpit and occupying the captain's seat]
I don't understand this either. Assuming they had somehow avoided the effects of hypoxia e.g. had been breathing oxygen in the cabin shortly before - is it sensible to assume that whoever was seen to occupy the captain's seat wasn't flight crew? I base this assumption on the report that there was no comms from the a/c for some time before the military intercepted or up until the crash..
I don't understand this either. Assuming they had somehow avoided the effects of hypoxia e.g. had been breathing oxygen in the cabin shortly before - is it sensible to assume that whoever was seen to occupy the captain's seat wasn't flight crew? I base this assumption on the report that there was no comms from the a/c for some time before the military intercepted or up until the crash..
Last edited by Blues&twos; 11th Oct 2006 at 20:42. Reason: Fingers playing me up.
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Blues I know its a long thread, but the answer's in there.
A flight attendant with some 737 sim experience somehow remained conscious and tried to sort the situation out once the door unlocked, sadly and notr unsurprisingly he failed. His mayday calls were recorded on the CVR but not received by other stations.
A flight attendant with some 737 sim experience somehow remained conscious and tried to sort the situation out once the door unlocked, sadly and notr unsurprisingly he failed. His mayday calls were recorded on the CVR but not received by other stations.
Per Ardua ad Astraeus
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Worth downloading the report. It is long and I have not read it fully.
The issue of why the c/crew did not APPEAR to enter the cockpit for around 2 hr 28 mins 'puzzles' the enquiry team - and me. How they - probably 2 - retained consciousness also is a mystery.
Hopefully all c/crew now know that if a rapid descent does not start when cabin masks drop, ask questions.
A truly sad event.
The issue of why the c/crew did not APPEAR to enter the cockpit for around 2 hr 28 mins 'puzzles' the enquiry team - and me. How they - probably 2 - retained consciousness also is a mystery.
Hopefully all c/crew now know that if a rapid descent does not start when cabin masks drop, ask questions.
A truly sad event.
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not @FL340
[Military reported seeing a person entering the cockpit and occupying the captain's seat]
I do not think that the aircraft was @FL340 at this time
[At 11:24 h, during the sixth holding pattern, the Boeing 737 was intercepted]
I have still to see holding patterna @FL340
. . .
cheers
I do not think that the aircraft was @FL340 at this time
[At 11:24 h, during the sixth holding pattern, the Boeing 737 was intercepted]
I have still to see holding patterna @FL340
. . . cheers
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Interesting.
The FO's slightly poor training record is there in some detail. One of the causes is cited as CRM. There is this:
There were numerous remarks in the last five years by training and check
pilots on file for the First Officer referring to checklist discipline and
procedural (SOP) difficulties.
But absolutely nothing at all on the captain and his extraordinary record(s) at previous airlines.
Need to read some more
The FO's slightly poor training record is there in some detail. One of the causes is cited as CRM. There is this:
There were numerous remarks in the last five years by training and check
pilots on file for the First Officer referring to checklist discipline and
procedural (SOP) difficulties.
But absolutely nothing at all on the captain and his extraordinary record(s) at previous airlines.
Need to read some more
1. three of the four portable oxygen bottles found had their valves in an open position.
2. as approximately 1 psi over external ambient was provided by the balance between inflow and outflow, the cabin altitude is estimated to have stabilized about 24000 feet pressure altitude--which gives substantially longer useful consciousness (heavily dependent on the individual) than 34000.
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So where is the report?
Lots of newspapers have been printing edited findings from the report for several days. So presumably they have had access to it.
I've searched the web and I can't find any published report for it.
Anyone know where the official report can be accessed?
GB
I've searched the web and I can't find any published report for it.
Anyone know where the official report can be accessed?
GB