Cypriot airliner crash - the accident and investigation
Can anyone provide an alternate for the report in English?
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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
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From today's Cyprus Mail online:
Helios disputes Tsolakis findings
By Elias Hazou
ITS back to the wall, ajet, formerly known as Helios, is disputing the report into last August’s air disaster, questioning the reliability of chief investigator Akrivos Tsolakis.
Though not naming names, the fact-finding report established human error – primarily by the captain and his co-pilot – as the primary cause of the calamity, but it also noted several latent – or underlying – causes, such as the inadequate workings at Civil Aviation.
Hounded by the media ever since arriving on the island to hand over the report, Tsolakis caused controversy when he said that Helios Airways did not exist as an entity.
He was responding to a question as to why his report did not make any safety recommendations to the airline.
“We cannot deal with ghosts,” Tsolakis offered.
“Let us not try to delve into grey areas…our report flies only in clear skies.”
Helios changed its name a few months after the crash, provoking a general perception that the airline was attempting to avoid its responsibilities towards the victims’ families.
But Helios’ lawyers were yesterday up in arms over the comment, arguing that Tsolakis was contradicting himself.
They say it does not make sense for Tsolakis to mention the airline under the latent causes of the accident while at the same time not make any safety recommendations to Helios.
“It would be far more professional of Mr Tsolakis to admit that Helios is not at fault in the first place, rather than insult people’s intelligence,” challenged lawyer Demetris Araouzos.
Christos Neocleous, another Helios lawyer, added: “The company does exist, though under a different name. It makes no difference – this does not mean the airline will shirk its responsibilities.”
But the airline went a step further, casting doubts over the accuracy of the fact-finding report. According to the probe, on the night before the doomed flight airline engineers left the depressurisation switch on manual. The pilots failed to notice this and to reset the switch to auto; as a result, the plane did not pressurise properly, leading to a lack of oxygen supply in the cabin – the primary cause of the accident.
The final report features evidence of this – pictures of the scarred decompression panel.
But Helios insisted it had conducted extensive tests showing that it was “next to impossible” for a commercial jet to take off with the decompression switch on manual.
Yet Boeing pilot Costas Pitsilides told the Mail yesterday that this was not necessarily the case.
He said a plane could take off on manual, depending on the position of the airflow valve.
Assuming the valve was partly open, that would allow for some pressurisation at low altitudes.
“In my view, this is the most likely scenario: ground crew left it in manual, but the pilots should have carried out a checklist of the components. This is standard procedure. Evidently, they did not, and one thing led to another.”
The situation was compounded in the air because, on Boeing 737s, the sounds emitted for faulty pressurisation are identical to those for a glitch in the positioning of the flaps.
In his report, Tsolakis recommended to Boeing to take corrective steps to resolve this issue.
Yesterday, the Greek aviation expert said the manufacturers had already acted on his recommendations.
There are approximately 2,500 Boeing 737s in service today.
“I think that [based on these recommendations] an accident under similar circumstances shall never occur again worldwide,” Tsolakis told state radio yesterday.
Meanwhile Helios hinted it might altogether walk out of the committee of inquiry tasked with apportioning liability for the crash.
Based on its conclusions, the Attorney-general will next decide on whether to prosecute.
Araouzos suggested the company was not getting a fair trial.
“Why does the committee not call on Tsolakis to testify before it, so that he might back his claims?”
The company has filed a motion with the Supreme Court to have the hearings cancelled because, as it says, the committee’s proceedings are “flawed”.
The report itself contains some chilling details. In one passage it reads:
“The accident was not survivable for any of the aircraft occupants. The remains of the victims were removed from the wreckage area by fire fighters of the Fire Corps Special Rescue Forces. Most of the victims were found strapped in their seats. The seats had broken out of their rails in the aircraft floor during the impact sequence.”
The 121 passengers of flight ZU522 evidently did not realise what was happening, gradually slipping into hypoxia, a condition characterised by light-headedness, a feeling of euphoria and loss of cognitive performance.
From the mobile phones recovered from the crash site, “no data related to the accident flight were obtained”.
Tsolakis has therefore recommended to EASA and JAA (Joint Aviation Authorities) that henceforth flight crew and cabin crew undergo hypoxia training:
The report also appears to put to rest speculation that co-pilot Pambos Charalambous was unfit to fly:
“On the basis of the data that were given to us, such as the height of the flight, the fact of the existing heart function (pump function) upon crashing, and the fact that there is a similar pathologo-anatomical image both in the ‘suffering’ heart (myocardium) of the co-pilot, and in the ‘healthy heart’ of the pilot, we estimate that the brain hypoxia was the dominant and determinant cause that incapacitated the flying crew, with the findings of the heart being the matter of course and epiphenomenona [symptom] of the prolonged hypoxia.”
Further, from Tsolakis’ findings it can be inferred that the department of Civil Aviation – accused of cutting corners when it came to safety – was poorly organised and staffed:
“The structure of the DCA [Civil Aviation] to support safety oversight is inadequate to support current and future operations;
“The Systems supporting the technical programmes are not fully implemented in the areas of safety and security;
“At the time of this Diagnostic, there was no evidence that confirmed the existence of any Risk Management process within the DCA.”
Last month, it emerged that ajet and the civil aviation department in Cyprus were in trouble with the European Commission and EASA for not complying with EU air safety standards. It was even said the airline risked being placed on the EU’s blacklist – effectively banning it from operating inside EU airspace.
However, latest reports quoted EU officials as saying that ajet had not been blacklisted.
Copyright © Cyprus Mail 2006
Helios disputes Tsolakis findings
By Elias Hazou
ITS back to the wall, ajet, formerly known as Helios, is disputing the report into last August’s air disaster, questioning the reliability of chief investigator Akrivos Tsolakis.
Though not naming names, the fact-finding report established human error – primarily by the captain and his co-pilot – as the primary cause of the calamity, but it also noted several latent – or underlying – causes, such as the inadequate workings at Civil Aviation.
Hounded by the media ever since arriving on the island to hand over the report, Tsolakis caused controversy when he said that Helios Airways did not exist as an entity.
He was responding to a question as to why his report did not make any safety recommendations to the airline.
“We cannot deal with ghosts,” Tsolakis offered.
“Let us not try to delve into grey areas…our report flies only in clear skies.”
Helios changed its name a few months after the crash, provoking a general perception that the airline was attempting to avoid its responsibilities towards the victims’ families.
But Helios’ lawyers were yesterday up in arms over the comment, arguing that Tsolakis was contradicting himself.
They say it does not make sense for Tsolakis to mention the airline under the latent causes of the accident while at the same time not make any safety recommendations to Helios.
“It would be far more professional of Mr Tsolakis to admit that Helios is not at fault in the first place, rather than insult people’s intelligence,” challenged lawyer Demetris Araouzos.
Christos Neocleous, another Helios lawyer, added: “The company does exist, though under a different name. It makes no difference – this does not mean the airline will shirk its responsibilities.”
But the airline went a step further, casting doubts over the accuracy of the fact-finding report. According to the probe, on the night before the doomed flight airline engineers left the depressurisation switch on manual. The pilots failed to notice this and to reset the switch to auto; as a result, the plane did not pressurise properly, leading to a lack of oxygen supply in the cabin – the primary cause of the accident.
The final report features evidence of this – pictures of the scarred decompression panel.
But Helios insisted it had conducted extensive tests showing that it was “next to impossible” for a commercial jet to take off with the decompression switch on manual.
Yet Boeing pilot Costas Pitsilides told the Mail yesterday that this was not necessarily the case.
He said a plane could take off on manual, depending on the position of the airflow valve.
Assuming the valve was partly open, that would allow for some pressurisation at low altitudes.
“In my view, this is the most likely scenario: ground crew left it in manual, but the pilots should have carried out a checklist of the components. This is standard procedure. Evidently, they did not, and one thing led to another.”
The situation was compounded in the air because, on Boeing 737s, the sounds emitted for faulty pressurisation are identical to those for a glitch in the positioning of the flaps.
In his report, Tsolakis recommended to Boeing to take corrective steps to resolve this issue.
Yesterday, the Greek aviation expert said the manufacturers had already acted on his recommendations.
There are approximately 2,500 Boeing 737s in service today.
“I think that [based on these recommendations] an accident under similar circumstances shall never occur again worldwide,” Tsolakis told state radio yesterday.
Meanwhile Helios hinted it might altogether walk out of the committee of inquiry tasked with apportioning liability for the crash.
Based on its conclusions, the Attorney-general will next decide on whether to prosecute.
Araouzos suggested the company was not getting a fair trial.
“Why does the committee not call on Tsolakis to testify before it, so that he might back his claims?”
The company has filed a motion with the Supreme Court to have the hearings cancelled because, as it says, the committee’s proceedings are “flawed”.
The report itself contains some chilling details. In one passage it reads:
“The accident was not survivable for any of the aircraft occupants. The remains of the victims were removed from the wreckage area by fire fighters of the Fire Corps Special Rescue Forces. Most of the victims were found strapped in their seats. The seats had broken out of their rails in the aircraft floor during the impact sequence.”
The 121 passengers of flight ZU522 evidently did not realise what was happening, gradually slipping into hypoxia, a condition characterised by light-headedness, a feeling of euphoria and loss of cognitive performance.
From the mobile phones recovered from the crash site, “no data related to the accident flight were obtained”.
Tsolakis has therefore recommended to EASA and JAA (Joint Aviation Authorities) that henceforth flight crew and cabin crew undergo hypoxia training:
The report also appears to put to rest speculation that co-pilot Pambos Charalambous was unfit to fly:
“On the basis of the data that were given to us, such as the height of the flight, the fact of the existing heart function (pump function) upon crashing, and the fact that there is a similar pathologo-anatomical image both in the ‘suffering’ heart (myocardium) of the co-pilot, and in the ‘healthy heart’ of the pilot, we estimate that the brain hypoxia was the dominant and determinant cause that incapacitated the flying crew, with the findings of the heart being the matter of course and epiphenomenona [symptom] of the prolonged hypoxia.”
Further, from Tsolakis’ findings it can be inferred that the department of Civil Aviation – accused of cutting corners when it came to safety – was poorly organised and staffed:
“The structure of the DCA [Civil Aviation] to support safety oversight is inadequate to support current and future operations;
“The Systems supporting the technical programmes are not fully implemented in the areas of safety and security;
“At the time of this Diagnostic, there was no evidence that confirmed the existence of any Risk Management process within the DCA.”
Last month, it emerged that ajet and the civil aviation department in Cyprus were in trouble with the European Commission and EASA for not complying with EU air safety standards. It was even said the airline risked being placed on the EU’s blacklist – effectively banning it from operating inside EU airspace.
However, latest reports quoted EU officials as saying that ajet had not been blacklisted.
Copyright © Cyprus Mail 2006
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http://www.moi.gov.cy/moi/pio/pio.nsf/all/0E014F5B6043799CC22572040027B427/$file/ΤΕΛΙΚΟ%20ΠΟΡΙΣΜΑ%205B-DBY.pdf
Check this link. Go to page 63. It's in greek but there is a photo of the actual panel. Also check the previous page. A photo of the air conditioning panel. Are the pack switches off or are they just bent like that??
Check this link. Go to page 63. It's in greek but there is a photo of the actual panel. Also check the previous page. A photo of the air conditioning panel. Are the pack switches off or are they just bent like that??
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One interesting thing that comes out in the report is that whoever entered the cockpit actually used the code to do so. I always thought that it was when the engine failed that the door opened.
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http://www.moi.gov.cy/moi/pio/pio.nsf/all/0E014F5B6043799CC22572040027B427/$file/ΤΕΛΙΚΟ%20ΠΟΡΙΣΜΑ%205B-DBY.pdf
Check this link. Go to page 63. It's in greek but there is a photo of the actual panel. Also check the previous page. A photo of the air conditioning panel. Are the pack switches off or are they just bent like that??
Check this link. Go to page 63. It's in greek but there is a photo of the actual panel. Also check the previous page. A photo of the air conditioning panel. Are the pack switches off or are they just bent like that??
Magenta marks are investigator references as to how the panel was found.
I always thought that it was when the engine failed that the door opened.
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Interesting "Sky Wings" last night covering this story. Sky channel 542 for anybody interested. All their programs are on a loop so it should be on again soon.Quite amazing to see a new program on this channel, most of their stuff has been around for years.
I notice that on page 50 of the report, the air conditioning panel photo appears to show engine bleeds OFF and APU bleed ON – normal config for a bleeds off take-off. This should have been reconfigured to bleeds on after the take-off phase or MSA at the latest. Also notice that the text below the photo states:
“The left engine bleed toggle switch (BLEED 1) was found in the OFF position. The right engine bleed toggle switch (BLEED 2) was visually found in the OFF position. The APU toggle switch was found in the OFF Position.”
This configuration, if not a typo, would give no bleed air source whatsoever and no possible way of pressurising the aircraft.
It is of course possible that the crew reconfigured the panel this way during their troubleshooting. Once under the effect of hypoxia anybody could make mistakes.
“The left engine bleed toggle switch (BLEED 1) was found in the OFF position. The right engine bleed toggle switch (BLEED 2) was visually found in the OFF position. The APU toggle switch was found in the OFF Position.”
This configuration, if not a typo, would give no bleed air source whatsoever and no possible way of pressurising the aircraft.
It is of course possible that the crew reconfigured the panel this way during their troubleshooting. Once under the effect of hypoxia anybody could make mistakes.
Last edited by CaptainSandL; 13th Oct 2006 at 10:58. Reason: Formatting
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Now that the official report is out, it looks like everyone will be going after Boeing in civil suits and that no criminal proceedings are at all likely, according to the first of two articles appearing on today's Cyprus Mail Internet edition:
‘Don’t expect Helios prosecutions’
By Jean Christou
LAWYERS on both sides of the Helios debate yesterday agreed it would be difficult for the police to establish criminal responsibility for the crash.
Savvas Mamantopoulos, lawyer for some of the relatives of the 121 victims, said he was not hopeful and that he expected the outcome would leave the relatives “upset and bitter”.
Mamantopoulos was responding to statements made earlier by George Papaioannou, a lawyer for civil aviation workers, who told Radio Proto relatives were being appeased by the authorities because of their need to feel someone would be punished for their grief.
Papaioannou, a specialist in criminal law, told the Cyprus Mail yesterday that now that Air Accident Investigator Akrivos Tsolakis’ report had said human error by the captain and copilot were directly responsible for the crash, it would be difficult to prove criminal responsibility.
Deficiencies at Helios and the Civil Aviations Authority, while “latent causes” of the crash, did not contribute directly to the accident, Tsolakis` report concluded.
“In accordance with the report of Mr Tsolakis, it seems that the air crash is due to human error and that’s why all the other matters about the loopholes in the civil aviation department or about Helios and so on are irrelevant to the cause of the air crash,” Papaioannou said.
“The relatives are not being told the truth. It seems the impression being given to the relatives is that the crash is due to loopholes in the civil aviation or due to the problems with the particular aircraft. This, I believe, is not true, because I saw the report and it seems it’s a human error. If this is true, I cannot anticipate any serious criminal liability.”
Papaioannou said he believed the only recourse for the relatives was through the civil courts. “In view of the findings of this report, I don’t anticipate it will be easy for the Attorney-general to file serious criminal indictments against anyone.
“Criminal proceedings against whom? No one survived this air crash,” he said.
“According to the report, responsibility lies with the captain and copilot and not anyone on the ground,” Papaioannou said.
“Politicians, and I’m sorry to say this, always want to say what people like to hear. Unfortunately, they are not ready to tell the truth and that’s my personal opinion.”
Relatives’ lawyer Mamantopoulos said his clients wanted criminal cases to be filed.
But, he added, “in my opinion, it’s going to be very difficult to establish a criminal case against any persons, due to the fact the line between negligence and criminal responsibility is very close.
“All the politicians are going to keep saying they will try to bring all the responsible persons to justice, but it’s going to be very hard to prove.”
Mamantopoulos said there was a big difference between criminal negligence, and “human error” negligence or severe negligence.
“Criminal justice is an entirely different thing and I think the relatives are going to be very bitter and upset.
“Of course, if the police find out it was a criminal negligence… but I’m not very hopeful.”
Mamantopoulos is one of the lawyers involved in the case that some relatives are bringing against Boeing over the issue of the plane’s alarm, which it appears confused the Helios crew.
The same aural warning is used on Boeing 737s to signify two different situations; takeoff configuration and cabin altitude.
Mamantopoulos said that instead of playing the blame game in Cyprus and looking for scapegoats not directly responsible for the crash, “we have to concentrate on the responsibility of the manufacturing company Boeing because it was a product liability,” he said. “This is the basis of our case.”
In his report, Tsolakis cited the captain and copilot’s failure to identify the warnings as a direct factor in the crash.
He also listed as a latent cause, the “ineffectiveness and inadequacy of measures taken by the manufacturer in response to previous pressurisation incidents in the particular type of aircraft, both with regard to modifications to aircraft systems as well as to guidance to the crews.”
The use of the same aural warning to signify two different situations was not consistent with good Human Factors principles, the report said.
It also said that 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.
Tsolakis said 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 incidents and accidents.
On June 22, 2006, the US Federal Aviation Authority (FAA) issued an airworthiness directive applicable to all Boeing 737s, which became effective on July 7 the same year, nearly a year after the Helios crash.
This required revisions to the Airplane Flight Manual (AFM) within 60 days to advise the flight crew of improved procedures for pre-flight setup of the cabin pressurisation system, as well as improved procedures for interpreting and responding to the cabin altitude/configuration warning horn.
-----------------------------------------------------
Yellow card for ajet
By Jean Christou
THE EUROPEAN Commission yesterday placed ajet, formerly known as Helios, under heavy scrutiny and said it was limiting its flights within the EU.
It was the first time a European airline had faced such restrictions. The Commission said if the airline did not improve its safety standards, it could yet find itself blacklisted, according to reports from Brussels.
The Commission put two African airlines on its blacklist during its latest review, and gave ‘yellow cards’ to ajet, Russia's Pulkovo Aviation and Pakistan International Airways.
Although the Commission did not consider that the three airlines required an immediate ban due to safety concerns, more intense scrutiny and restrictions were called for.
There were no immediate details as to the extent of the restrictions on ajet flights.
Transport Commissioner Jacques Barrot, who announced the move at a news conference in Brussels, said the yellow card meant that EU authorities would place the airlines under much heavier scrutiny and would limit the number of flights they may land in the EU.
“We have announced measures to restrict the number of flights [from these airlines],” said Barrot. “We will keep a close eye on the carriers and there will be checks on the spot” to ensure safety measures are being adhered to.
Barrot's spokesman Michele Cercone confirmed that if the airlines given a "yellow card" yestrday did not improve their safety measures according to Commissions standards, they could find themselves blacklisted from landing anywhere within the EU
Last month, ajet was barred from landing in fog, after authorities deemed it could not guarantee safety in such conditions.
Reports at the time suggested that EASA, the European Aviation Safety Agency, had arrived at the same conclusion during an inspection last May. According to the reports, the airline lacked the adequate equipment, pilot training and experience to prove it could operate its jets in fog.
Copyright © Cyprus Mail 2006
‘Don’t expect Helios prosecutions’
By Jean Christou
LAWYERS on both sides of the Helios debate yesterday agreed it would be difficult for the police to establish criminal responsibility for the crash.
Savvas Mamantopoulos, lawyer for some of the relatives of the 121 victims, said he was not hopeful and that he expected the outcome would leave the relatives “upset and bitter”.
Mamantopoulos was responding to statements made earlier by George Papaioannou, a lawyer for civil aviation workers, who told Radio Proto relatives were being appeased by the authorities because of their need to feel someone would be punished for their grief.
Papaioannou, a specialist in criminal law, told the Cyprus Mail yesterday that now that Air Accident Investigator Akrivos Tsolakis’ report had said human error by the captain and copilot were directly responsible for the crash, it would be difficult to prove criminal responsibility.
Deficiencies at Helios and the Civil Aviations Authority, while “latent causes” of the crash, did not contribute directly to the accident, Tsolakis` report concluded.
“In accordance with the report of Mr Tsolakis, it seems that the air crash is due to human error and that’s why all the other matters about the loopholes in the civil aviation department or about Helios and so on are irrelevant to the cause of the air crash,” Papaioannou said.
“The relatives are not being told the truth. It seems the impression being given to the relatives is that the crash is due to loopholes in the civil aviation or due to the problems with the particular aircraft. This, I believe, is not true, because I saw the report and it seems it’s a human error. If this is true, I cannot anticipate any serious criminal liability.”
Papaioannou said he believed the only recourse for the relatives was through the civil courts. “In view of the findings of this report, I don’t anticipate it will be easy for the Attorney-general to file serious criminal indictments against anyone.
“Criminal proceedings against whom? No one survived this air crash,” he said.
“According to the report, responsibility lies with the captain and copilot and not anyone on the ground,” Papaioannou said.
“Politicians, and I’m sorry to say this, always want to say what people like to hear. Unfortunately, they are not ready to tell the truth and that’s my personal opinion.”
Relatives’ lawyer Mamantopoulos said his clients wanted criminal cases to be filed.
But, he added, “in my opinion, it’s going to be very difficult to establish a criminal case against any persons, due to the fact the line between negligence and criminal responsibility is very close.
“All the politicians are going to keep saying they will try to bring all the responsible persons to justice, but it’s going to be very hard to prove.”
Mamantopoulos said there was a big difference between criminal negligence, and “human error” negligence or severe negligence.
“Criminal justice is an entirely different thing and I think the relatives are going to be very bitter and upset.
“Of course, if the police find out it was a criminal negligence… but I’m not very hopeful.”
Mamantopoulos is one of the lawyers involved in the case that some relatives are bringing against Boeing over the issue of the plane’s alarm, which it appears confused the Helios crew.
The same aural warning is used on Boeing 737s to signify two different situations; takeoff configuration and cabin altitude.
Mamantopoulos said that instead of playing the blame game in Cyprus and looking for scapegoats not directly responsible for the crash, “we have to concentrate on the responsibility of the manufacturing company Boeing because it was a product liability,” he said. “This is the basis of our case.”
In his report, Tsolakis cited the captain and copilot’s failure to identify the warnings as a direct factor in the crash.
He also listed as a latent cause, the “ineffectiveness and inadequacy of measures taken by the manufacturer in response to previous pressurisation incidents in the particular type of aircraft, both with regard to modifications to aircraft systems as well as to guidance to the crews.”
The use of the same aural warning to signify two different situations was not consistent with good Human Factors principles, the report said.
It also said that 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.
Tsolakis said 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 incidents and accidents.
On June 22, 2006, the US Federal Aviation Authority (FAA) issued an airworthiness directive applicable to all Boeing 737s, which became effective on July 7 the same year, nearly a year after the Helios crash.
This required revisions to the Airplane Flight Manual (AFM) within 60 days to advise the flight crew of improved procedures for pre-flight setup of the cabin pressurisation system, as well as improved procedures for interpreting and responding to the cabin altitude/configuration warning horn.
-----------------------------------------------------
Yellow card for ajet
By Jean Christou
THE EUROPEAN Commission yesterday placed ajet, formerly known as Helios, under heavy scrutiny and said it was limiting its flights within the EU.
It was the first time a European airline had faced such restrictions. The Commission said if the airline did not improve its safety standards, it could yet find itself blacklisted, according to reports from Brussels.
The Commission put two African airlines on its blacklist during its latest review, and gave ‘yellow cards’ to ajet, Russia's Pulkovo Aviation and Pakistan International Airways.
Although the Commission did not consider that the three airlines required an immediate ban due to safety concerns, more intense scrutiny and restrictions were called for.
There were no immediate details as to the extent of the restrictions on ajet flights.
Transport Commissioner Jacques Barrot, who announced the move at a news conference in Brussels, said the yellow card meant that EU authorities would place the airlines under much heavier scrutiny and would limit the number of flights they may land in the EU.
“We have announced measures to restrict the number of flights [from these airlines],” said Barrot. “We will keep a close eye on the carriers and there will be checks on the spot” to ensure safety measures are being adhered to.
Barrot's spokesman Michele Cercone confirmed that if the airlines given a "yellow card" yestrday did not improve their safety measures according to Commissions standards, they could find themselves blacklisted from landing anywhere within the EU
Last month, ajet was barred from landing in fog, after authorities deemed it could not guarantee safety in such conditions.
Reports at the time suggested that EASA, the European Aviation Safety Agency, had arrived at the same conclusion during an inspection last May. According to the reports, the airline lacked the adequate equipment, pilot training and experience to prove it could operate its jets in fog.
Copyright © Cyprus Mail 2006
Reaction to the official report
The report is interesting in the way it lists the causes.
There are several reasons why this accident happened but the first is that the engineers left the pressurisation switch in the MAN position instead of AUTO. The last step of the maintenance manual procedure is to “Put the Airplane Back to its Initial Condition”, which would have been AUTO. MAN is not a normal position and yet does not give an amber light, only green, perhaps this should be changed. The checklist has now been rewritten to specifically check the position of this switch, remember this is a switch that most pilots can go years or a career on type without ever switching.
The second reason is that the crew did not notice that the aircraft was not pressurising despite the clues.
1. Take-off config warning: This was in fact the cabin pressure warning. They should have known that you cannot get a take-off config warning when you are already in the air BUT it sounds identical and they hear a take-off config warning check in the flight deck preparation checks, so this is the one that they are familiar with. I am sure psychologists would tell you that this reaction is to be expected.
2. Equip cooling normal and alternate off-line: They would not know this but I do from my experience of airtests that this happens maybe 50% of the time during a depressurisation. They thought that this was a system fault and became preoccupied with locating the c/b’s to fix it.
3. Pressure on the ears: Any unpressurised take-off would be felt in the ears.
4. Temperature: When an aircraft depressurises or does not pressurise it gets cold inside - regardless of temp control position. If they had already turned the heating up as much as possible they would then have looked around for another reason.
5. The green MANUAL light on the pressurisation panel is not normally illuminated. Whilst this would not trigger master caution, it shows a lack of observation on the part of the crew, more specifically the F/O whose area of responsibility this is.
6. The cabin altitude and differential pressure indicators were not checked – very surprising when the cabin alt warning horn is sounding.
It also appears that the air-conditioning panel (page 50) was still configured for a bleeds off take-off. This should have been re-configured shortly after take-off or at the very latest when above MSA. You can clearly see that both engine bleed switches are OFF, the APU bleed may power the packs for a short time but will not be able to pressurise the aircraft all the way up to its cruise altitude. The bleeds off take-off procedure is not used very often and can be misremembered or the crew can forget to reconfigure after a busy take-off. It has been a source of mistakes on many occasions, see incidents on page 104 to 108, plus many more which will have gone unreported. It would be safer never to do this procedure but commercial pressures will obviously prevail.
In my opinion the engineers unwittingly set the trap, made possible by some poor/outdated design by Boeing; and the crew fell right into it because of their lack of awareness, training and system knowledge.
That said, I am sure that if the crew had recognised this as a pressurisation problem they would have sorted it out – so why didn’t they? One of the main reasons was clearly the ambiguous nature of the cabin altitude warning horn. You should know that when the 737 was designed, over 40 years ago, the only aural warnings were from the Aural Warning Module. This little box can give a variety of sounds such as horns, wailers, clackers, bells and chimes – but it cannot “speak”. Many years ago a second box called the Remote Electronics Unit was added for voice warnings such as GPWS, TCAS & Radio Altimeter. It is high time that the cabin altitude warning (and some of the others) were updated to a clear voice message such as “CABIN ALTITUDE” or similar.
We have seen how two pilots with considerable experience (Captain: 5,500hrs on type and F/O: 4,000hrs on type and an ex-engineer!) got it wrong. IT COULD HAPPEN AGAIN the new checklist tweaks will help but it is surely time to make this archaic system more user friendly.
S&L
There are several reasons why this accident happened but the first is that the engineers left the pressurisation switch in the MAN position instead of AUTO. The last step of the maintenance manual procedure is to “Put the Airplane Back to its Initial Condition”, which would have been AUTO. MAN is not a normal position and yet does not give an amber light, only green, perhaps this should be changed. The checklist has now been rewritten to specifically check the position of this switch, remember this is a switch that most pilots can go years or a career on type without ever switching.
The second reason is that the crew did not notice that the aircraft was not pressurising despite the clues.
1. Take-off config warning: This was in fact the cabin pressure warning. They should have known that you cannot get a take-off config warning when you are already in the air BUT it sounds identical and they hear a take-off config warning check in the flight deck preparation checks, so this is the one that they are familiar with. I am sure psychologists would tell you that this reaction is to be expected.
2. Equip cooling normal and alternate off-line: They would not know this but I do from my experience of airtests that this happens maybe 50% of the time during a depressurisation. They thought that this was a system fault and became preoccupied with locating the c/b’s to fix it.
3. Pressure on the ears: Any unpressurised take-off would be felt in the ears.
4. Temperature: When an aircraft depressurises or does not pressurise it gets cold inside - regardless of temp control position. If they had already turned the heating up as much as possible they would then have looked around for another reason.
5. The green MANUAL light on the pressurisation panel is not normally illuminated. Whilst this would not trigger master caution, it shows a lack of observation on the part of the crew, more specifically the F/O whose area of responsibility this is.
6. The cabin altitude and differential pressure indicators were not checked – very surprising when the cabin alt warning horn is sounding.
It also appears that the air-conditioning panel (page 50) was still configured for a bleeds off take-off. This should have been re-configured shortly after take-off or at the very latest when above MSA. You can clearly see that both engine bleed switches are OFF, the APU bleed may power the packs for a short time but will not be able to pressurise the aircraft all the way up to its cruise altitude. The bleeds off take-off procedure is not used very often and can be misremembered or the crew can forget to reconfigure after a busy take-off. It has been a source of mistakes on many occasions, see incidents on page 104 to 108, plus many more which will have gone unreported. It would be safer never to do this procedure but commercial pressures will obviously prevail.
In my opinion the engineers unwittingly set the trap, made possible by some poor/outdated design by Boeing; and the crew fell right into it because of their lack of awareness, training and system knowledge.
That said, I am sure that if the crew had recognised this as a pressurisation problem they would have sorted it out – so why didn’t they? One of the main reasons was clearly the ambiguous nature of the cabin altitude warning horn. You should know that when the 737 was designed, over 40 years ago, the only aural warnings were from the Aural Warning Module. This little box can give a variety of sounds such as horns, wailers, clackers, bells and chimes – but it cannot “speak”. Many years ago a second box called the Remote Electronics Unit was added for voice warnings such as GPWS, TCAS & Radio Altimeter. It is high time that the cabin altitude warning (and some of the others) were updated to a clear voice message such as “CABIN ALTITUDE” or similar.
We have seen how two pilots with considerable experience (Captain: 5,500hrs on type and F/O: 4,000hrs on type and an ex-engineer!) got it wrong. IT COULD HAPPEN AGAIN the new checklist tweaks will help but it is surely time to make this archaic system more user friendly.
S&L
CaptainSandL,
You raise some good points here. one of 'm is:
I guess it is about time that Boeing retrofits the GREEN Manual light and changes it to Amber, and make it one of the lights that reacts to the Master Caution system.
Easier said than done of course.
You raise some good points here. one of 'm is:
5. The green MANUAL light on the pressurisation panel is not normally illuminated. Whilst this would not trigger master caution, it shows a lack of observation on the part of the crew, more specifically the F/O whose area of responsibility this is.
Easier said than done of course.
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There are several reasons why this accident happened but the first is that the engineers left the pressurisation switch in the MAN position instead of AUTO. The last step of the maintenance manual procedure is to “Put the Airplane Back to its Initial Condition”, which would have been AUTO. ..........................................
3. Pressure on the ears: Any unpressurised take-off would be felt in the ears.
............................................................ ........................................
It also appears that the air-conditioning panel (page 50) was still configured for a bleeds off take-off. This should have been re-configured shortly after take-off or at the very latest when above MSA. You can clearly see that both engine bleed switches are OFF, the APU bleed may power the packs for a short time but will not be able to pressurise the aircraft all the way up to its cruise altitude.
3. Pressure on the ears: Any unpressurised take-off would be felt in the ears.
............................................................ ........................................
It also appears that the air-conditioning panel (page 50) was still configured for a bleeds off take-off. This should have been re-configured shortly after take-off or at the very latest when above MSA. You can clearly see that both engine bleed switches are OFF, the APU bleed may power the packs for a short time but will not be able to pressurise the aircraft all the way up to its cruise altitude.
It serves no purpose really, for someone who OBVIOUSLY has not read the report (like yourself), to write a little summary for us of the causes of this accident. You are misleading people here. By looking at the picture of the panel, you figured it all out.
I happened to read the report in detail and I must correct most of your inputs in this thread for the benefit of those who read your post.
1) REGARDLESS under what circumstances the switch was left in MANUAL, the 737 Overnight Parking Procedure (even today) clearly states the following
Note: Accomplish this procedure in case of night stop or prolonged parking without the availability of maintenance personnel.
If necessary apply Supplementary Procedure "ADVERSE WEATHER,
SECURE AIRPLANE".
(among other items)
Pressurization Mode Selector ..........................................................MA N
Outflow valve ............................................................ ...............Closed
ETC .......
Bearing in mind that the enginners left the aircraft some 4hrs before it was due to fly, in a warm summer night (insects etc), they should have accomplished this procedure. In this case they did not but that shows that it is not unheard of for the the switch to be found in MAN in the morning.
Additionally, the report DID NOT put the engineers actions neither on the primary OR the secondary causes of the accident. There is just the mention that the enginners were the ones that physically placed the switch to MAN the night before during a leak test.
2) Then you mention "unpressurised takeoff" Well the take off was not unpressurised. It was just not pressurised enough according to the report. There would be no significant ear pain under these conditions.
THAT WAS NOT A BLEEDS OFF TAKE-OFF. The switches appear to be OFF but they were just damaged. The report states that further investigation showed that :
ENG BLEED 1 - switch found OFF
ENG BLEED 2 - visually appeared to be OFF
APU BLEED - found OFF (the switch is broken)
LEFT PACK - switch found OFF
RIGHT PACK - too much damage to tell
Anyone can see (even from the angles of the switches) that the panel suffered major impact damage, and the switches could be forced to the positions found.
Also, the report in the section that shows the chain of events, makes no mention at all of a bleeds off t/o OR lack of bleeds restoration after t/o.
Going further, why would a -300 with 115 people onboard and 7000kg of fuel, would do a bleeds OFF and packs OFF takeoff? The runway is huge, there are no obstacles and it was too early for the summer heat to build up.
You are clearly see a case where the picture does not tell the story.
Respectfully, gonso
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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???)
Cruise ALT - - - - - - - - - - SET
Land ALT - - - - - - - - - - - SET
FLT/GRD Switch - - - - - - - GND
Press Mode Selector - - - - AUTO
Auto Fail Light - - - - - - - - OUT
Pressurisation Indicators:
Cabin Diff - - - -- - - - - - - ZERO
Cabin ROC/ROD- - - - - - - - ZERO
Cabin ALT - - - - - - - - - Field Elevation
There are several reasons why this switch could be found in the MAN position and returning the switch to AUTO should not be considered an unusual task.
Gonso,
Sigh… Of course I read the report.
Moving on…
You seem to be dismissing the overnight position of the pressurisation mode selector switch as either unimportant or something that the crew should have taking in their stride. In the real world crew will hardly ever find this switched to MANUAL and it is understandable that they missed it. I still maintain that if this switch had been returned to AUTO (IAW AMM procedures ie “Put the Airplane Back to its Initial Condition”) the accident may not have happened – Unless it was a regular procedure for their engineers to manually move the outflow valve and leave it in MANUAL, in which case the local crews would be used to it. Somehow I doubt this to be the case.
I did not say that the crew did an unpressurised take-off procedure, although the switch positions suggest a bleeds off take-off. But it stands to reason that if the outflow valve is fixed even partially open the aircraft will not pressurise sufficiently, therefore the physiological effects will be felt.
For you to say that “the panel suffered major impact damage, and the switches could be forced to the positions found” is unlikely. These switches are gated, to change position you have to pull the switch out, move it over the gate and release it into the new position. An impact could certainly bend the switch arm but not the position of the base of the switch, ie switch position.
Finally, I am curious why your response to my posting was so hostile. I merely gave my reaction to the report on an open forum. My opinion is as valid as anybody elses.
S&L
Sigh… Of course I read the report.
Moving on…
You seem to be dismissing the overnight position of the pressurisation mode selector switch as either unimportant or something that the crew should have taking in their stride. In the real world crew will hardly ever find this switched to MANUAL and it is understandable that they missed it. I still maintain that if this switch had been returned to AUTO (IAW AMM procedures ie “Put the Airplane Back to its Initial Condition”) the accident may not have happened – Unless it was a regular procedure for their engineers to manually move the outflow valve and leave it in MANUAL, in which case the local crews would be used to it. Somehow I doubt this to be the case.
I did not say that the crew did an unpressurised take-off procedure, although the switch positions suggest a bleeds off take-off. But it stands to reason that if the outflow valve is fixed even partially open the aircraft will not pressurise sufficiently, therefore the physiological effects will be felt.
For you to say that “the panel suffered major impact damage, and the switches could be forced to the positions found” is unlikely. These switches are gated, to change position you have to pull the switch out, move it over the gate and release it into the new position. An impact could certainly bend the switch arm but not the position of the base of the switch, ie switch position.
Finally, I am curious why your response to my posting was so hostile. I merely gave my reaction to the report on an open forum. My opinion is as valid as anybody elses.
S&L
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In the real world crew will hardly ever find this switched to MANUAL and it is understandable that they missed it. I still maintain that if this switch had been returned to AUTO (IAW AMM procedures ie “Put the Airplane Back to its Initial Condition”) the accident may not have happened – Unless it was a regular procedure for their engineers to manually move the outflow valve and leave it in MANUAL, in which case the local crews would be used to it. Somehow I doubt this to be the case.
The accident would definitely not have happened had the engineers put the switch in Auto.
I fly the 800 but I don't think there would be any need for a bleeds off take off for such a short sector (or even sectors if the crew intended to avoid refuelling in Athens). This can easily established by the investigators and I don't know what they said about this (I only read the first 50 pages until now). If the bleed switches were indeed OFF though, they could have been placed to OFF by someone else and missed by the crew as well.
Regarding earlier posts, making the Manual light amber would disagree with the overall thinkink behind the design, i.e., that things that don't work are amber and things that work are green. What should be cahnged is that apart from the horn there should be a red message, 'Cabin Altitude'!