Cypriot airliner crash - the accident and investigation
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Wizofoz, I wish you could read !
The checklist says If necessary apply Supplementary Procedure "ADVERSE WEATHER, SECURE AIRPLANE"..
THATS AN ADDITIONAL PROCEDURE !!!
It does not say that you should do the Overnight Parking Procedure only on adverse weather.
CaptSandL ,
On both the unpressurised take-off AND the Eng Bleeds off take off procedures, the packs should be in AUTO. Both of them. The fact that they appeared to be off or it is too difficult to tell, proves that they can be forced to off by 20+g on impact. Unless you now suggest that the crew took off with both bleeds off both packs off, apu bleed off and press mode selector in MANUAL ...just for fun or negligence. The report you claim you read does not suggest that at all.
Don't compare a brand new switch with a 15 Year old one. There is significant wear on these toggle switches , I am sure you know that.
I am not hostile by nature, I just think that your post would be more relevant in the first weeks after the crash when everyone was speculating. You write these things 3 days after the report is out although we now have undisputed facts in hand that definitely contradict to your thoughts.
If the engineers left both windows open overnight and the a/c was taking off and both pilots became hypoxic and then froze to death, we would all say "how stupid" !!!
Missing a vital item in the preflight scan is something that can (has) happen(ed) to all of us. On top of that though, to miss it in 2 different checklists, and on top of that to miss a cab alt horn and a master caution for pax oxy on , is am afraid criminal negligence and the repeort says that, not me.
The checklist says If necessary apply Supplementary Procedure "ADVERSE WEATHER, SECURE AIRPLANE"..
THATS AN ADDITIONAL PROCEDURE !!!
It does not say that you should do the Overnight Parking Procedure only on adverse weather.
CaptSandL ,
On both the unpressurised take-off AND the Eng Bleeds off take off procedures, the packs should be in AUTO. Both of them. The fact that they appeared to be off or it is too difficult to tell, proves that they can be forced to off by 20+g on impact. Unless you now suggest that the crew took off with both bleeds off both packs off, apu bleed off and press mode selector in MANUAL ...just for fun or negligence. The report you claim you read does not suggest that at all.
Don't compare a brand new switch with a 15 Year old one. There is significant wear on these toggle switches , I am sure you know that.
I am not hostile by nature, I just think that your post would be more relevant in the first weeks after the crash when everyone was speculating. You write these things 3 days after the report is out although we now have undisputed facts in hand that definitely contradict to your thoughts.
If the engineers left both windows open overnight and the a/c was taking off and both pilots became hypoxic and then froze to death, we would all say "how stupid" !!!
Missing a vital item in the preflight scan is something that can (has) happen(ed) to all of us. On top of that though, to miss it in 2 different checklists, and on top of that to miss a cab alt horn and a master caution for pax oxy on , is am afraid criminal negligence and the repeort says that, not me.
The Analog Kid
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Particularly if the aircraft was partially pressurised (report says stabilised at 24,000ft IIRC), are we not talking similar ranges of climb rate? Because I wouldn't expect to feel a thing and neither would any glider pilot I know.
Cheers,
Rich.
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I wonder if anyone has REALLY read the report reading some of the posts here.
The fixation on the switch is unbelieveable. So the unwitting engineers left the switch in the wrong position and the unwitting crews didn't notice and the unwitting passengers died. Thats it then, lets all go home and wait for the next one because nobody here has yet taken on board the significance of ALL the events that took place.
The Helios accident was an accident just waiting to happen, an accident in Cyprus was just waiting to happen. There have been significant "known" airworthiness issues with the Cypriot authority for some time now. We should all be aware that airworthiness doesn't just fall on the shoulders of the last engineer to touch the plane or the next unwitting crew.
This accident unfortunately says more about a culture that is slowly inflicting our industry than it does about individual failures. I am not talking about the Cypriot culture either. This type of accident could also have happened in many other countries. The culture or lack of a safety culture within the system is the issue here. It started years ago with an ineffective, if not incompetent authority. It was compounded by both JAA and EASA not being able to effectively solve the "KNOWN" issues. It was further compounded because an airline was allowed to operate without the proper controls in place to ensure a minimum acceptable safety culture. It was further compounded because all employees played along.
The last thing this accident is about is that damned switch. This accident is about incompetence and an inability to correct that stretches right back to the beginning of the chain.
Unfortunately the next accident wont be too long in coming because those same fundamental issues that were the real cause of the tragic Helios accident are still out there thriving today and most commentators appear to have missed the point completely.
The fixation on the switch is unbelieveable. So the unwitting engineers left the switch in the wrong position and the unwitting crews didn't notice and the unwitting passengers died. Thats it then, lets all go home and wait for the next one because nobody here has yet taken on board the significance of ALL the events that took place.
The Helios accident was an accident just waiting to happen, an accident in Cyprus was just waiting to happen. There have been significant "known" airworthiness issues with the Cypriot authority for some time now. We should all be aware that airworthiness doesn't just fall on the shoulders of the last engineer to touch the plane or the next unwitting crew.
This accident unfortunately says more about a culture that is slowly inflicting our industry than it does about individual failures. I am not talking about the Cypriot culture either. This type of accident could also have happened in many other countries. The culture or lack of a safety culture within the system is the issue here. It started years ago with an ineffective, if not incompetent authority. It was compounded by both JAA and EASA not being able to effectively solve the "KNOWN" issues. It was further compounded because an airline was allowed to operate without the proper controls in place to ensure a minimum acceptable safety culture. It was further compounded because all employees played along.
The last thing this accident is about is that damned switch. This accident is about incompetence and an inability to correct that stretches right back to the beginning of the chain.
Unfortunately the next accident wont be too long in coming because those same fundamental issues that were the real cause of the tragic Helios accident are still out there thriving today and most commentators appear to have missed the point completely.
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Totally totally agree with you Yamaha. I would definitely believe someone claiming that there are at least 20 airlines and 10 civil aviation authorities with similar symptoms (if not worse) in Europe alone.
And the worst thing is that nothing will change. If anything, things will go further downhill.
We are "enjoying" the fruits of cost cutting.
And the worst thing is that nothing will change. If anything, things will go further downhill.
We are "enjoying" the fruits of cost cutting.
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An item that is not properly covered by the report imho is the fact that master caution (triggered by the equipment cooling alert) was not cancelled for 56 seconds. The subsequent cabin alt pressure warning was therefore most likely missed. It should be clearly mentioned that a master caution requires cancellation asap not to miss subsequent alerts.
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Pegase Driver
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Excellent remarks Yamaha , fully agree with you .
The : " everything is OK as long as we do not get caught " of the 1960's has been replaced by the " we fix problems as they come along" in the 1970s. Unfortunately for some State's regulators ( for those who even have them ) the world of safety management seems to have stopped in 1970 .
The : " everything is OK as long as we do not get caught " of the 1960's has been replaced by the " we fix problems as they come along" in the 1970s. Unfortunately for some State's regulators ( for those who even have them ) the world of safety management seems to have stopped in 1970 .
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You can argue the semantics of switch positions and safety cultures till the cows come home. It is the crews responsibility to ensure that the aircrfat is in an airworthy condition and that means checking the air con settings. It is also the crews responsibility to know the meaning of a warning horn that obviously had nothing to do with the take off config. A totally avoidable accident by the flight crew, time to go by train.
D246,
You are correct it was the crews responsibility to check the switch positions and diagnose the problem etc and they should have done much better.
Yamaha,
Yes maybe the safety culture is an issue, although I don’t know anything about their operation so I cannot comment.
My point is that this happened to a crew with almost 10,000hrs on type and there is a history of 737 pressurisation/pneumatics panel errors from things like misconfiguring bleeds off take-offs to forgetting to reconfigure afterwards, misidentifying the cabin alt warning horn etc. This tells us that these panels/procedures can be confusing, even to experienced crew. The system is 40 years old and was Boeings first with a two man crew; these panels were previously managed by a flight engineer. 40 years and 121 lives down the road can we not make some improvements to the panels, like those I suggested above, to make the system more fool proof.
S&L
You are correct it was the crews responsibility to check the switch positions and diagnose the problem etc and they should have done much better.
Yamaha,
Yes maybe the safety culture is an issue, although I don’t know anything about their operation so I cannot comment.
My point is that this happened to a crew with almost 10,000hrs on type and there is a history of 737 pressurisation/pneumatics panel errors from things like misconfiguring bleeds off take-offs to forgetting to reconfigure afterwards, misidentifying the cabin alt warning horn etc. This tells us that these panels/procedures can be confusing, even to experienced crew. The system is 40 years old and was Boeings first with a two man crew; these panels were previously managed by a flight engineer. 40 years and 121 lives down the road can we not make some improvements to the panels, like those I suggested above, to make the system more fool proof.
S&L
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To solve a problem, you need to identify the cause and treat it. Treating symptoms alone always will and always has had only limited success.
Airworthiness is a subject that is wildly misunderstood and often poorly implemented. Getting an aircraft from A to B safely is a team game.
Had an airworthiness infrastructure been in place that provided the right surroundings for a safety culture to develop, things would almost certainly have been different.
Part of the problem is recognising that fact.
Given the set of circumstances in Cyprus many professionals may have missed the vital clues, given the same situation in a company where a safety culture exists, the action of the crew switching back to "auto" should the switch ever be in the wrong position, will never get a mention.
That is of course an extremely simplified example of an extremely complex subject. However, if we cannot move our fixation away from the switch, such accidents will of course continue to appear in the future and then you may well be correct with your uneducated/unresearched statement of take the train.
Airworthiness is a subject that is wildly misunderstood and often poorly implemented. Getting an aircraft from A to B safely is a team game.
Had an airworthiness infrastructure been in place that provided the right surroundings for a safety culture to develop, things would almost certainly have been different.
Part of the problem is recognising that fact.
Given the set of circumstances in Cyprus many professionals may have missed the vital clues, given the same situation in a company where a safety culture exists, the action of the crew switching back to "auto" should the switch ever be in the wrong position, will never get a mention.
That is of course an extremely simplified example of an extremely complex subject. However, if we cannot move our fixation away from the switch, such accidents will of course continue to appear in the future and then you may well be correct with your uneducated/unresearched statement of take the train.
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After reading the whole report, I was concerned about the fact that there isn't a master caution warning regarding the pressurization panel left in MANUAL. It's a silly thing, when you get all sorts of non-vital aural and visual cues or aids. This particular system is designed as if Boeing is expecting the FO to operate manually the pressurization like a normal thing on a day to day basis, with its green indicator for MAN selection and no master caution warning whatsoever, when in reality it's one of the most critical systems that requires an highly degree of automation.
If the horn is used in two different situations, one of them being the cabin alt warning, why not couple it with the pressurization panel set to MANUAL as a bad take-off configuration item like flaps etc? That would make sense, as then we would have a real connection between the two significances for that particular aural warning.
GD&L
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Indeed it is. And no one can assume that the other guy in the process chain has made his/her work properly. Of course this has nothing to do with competence or professionalism. If you're a part in the process and you do your work to the best of your abilities you'll certainly pick most if not all of those vital misconfigurations that can happen, be it from the previous crew, the engineers, or even from your own partner. Easier said than done but that's the way it is.
After reading the whole report, I was concerned about the fact that there isn't a master caution warning regarding the pressurization panel left in MANUAL. It's a silly thing, when you get all sorts of non-vital aural and visual cues or aids. This particular system is designed as if Boeing is expecting the FO to operate manually the pressurization like a normal thing on a day to day basis, with its green indicator for MAN selection and no master caution warning whatsoever, when in reality it's one of the most critical systems that requires an highly degree of automation.
If the horn is used in two different situations, one of them being the cabin alt warning, why not couple it with the pressurization panel set to MANUAL as a bad take-off configuration item like flaps etc? That would make sense, as then we would have a real connection between the two significances for that particular aural warning.
GD&L
After reading the whole report, I was concerned about the fact that there isn't a master caution warning regarding the pressurization panel left in MANUAL. It's a silly thing, when you get all sorts of non-vital aural and visual cues or aids. This particular system is designed as if Boeing is expecting the FO to operate manually the pressurization like a normal thing on a day to day basis, with its green indicator for MAN selection and no master caution warning whatsoever, when in reality it's one of the most critical systems that requires an highly degree of automation.
If the horn is used in two different situations, one of them being the cabin alt warning, why not couple it with the pressurization panel set to MANUAL as a bad take-off configuration item like flaps etc? That would make sense, as then we would have a real connection between the two significances for that particular aural warning.
GD&L
It is legal to take off and fly a route unpressurized up to 10,000 feet so the take off would have to be in manual mode. For this reason it can not be connected to the master caution system.
"The last step of the maintenance manual procedure is to “Put the Airplane Back to its Initial Condition”
I don't remember ever reading that load of "twaddle"!
I am sure Maintenance Manuals would never state such rubbish as that.
It would be better to state that the mere mechanic should prepare the flight deck for the next Sector to..... stand to attention at the front door and get ready to doff his cap!
It remains the pilots' responsibilities to ready their aircraft for flight. It is their responsibility to perform the flight to the best of their capability.
It remains the engineers responsibility to ensure the aircraft is in a safe condition. Not to ensure the switches are where the next pilot wants them to be.
Yes, the postition of the switch was "A contributory factor" as is the lack of remedy by Boeing, but it/they were not the cause of this accident.
The cause of this accident is squarely on the lack of recognition of the switch position and subsequent aural warnings.
That ignorant statement got me going.
Rant over
Rigga
I don't remember ever reading that load of "twaddle"!
I am sure Maintenance Manuals would never state such rubbish as that.
It would be better to state that the mere mechanic should prepare the flight deck for the next Sector to..... stand to attention at the front door and get ready to doff his cap!
It remains the pilots' responsibilities to ready their aircraft for flight. It is their responsibility to perform the flight to the best of their capability.
It remains the engineers responsibility to ensure the aircraft is in a safe condition. Not to ensure the switches are where the next pilot wants them to be.
Yes, the postition of the switch was "A contributory factor" as is the lack of remedy by Boeing, but it/they were not the cause of this accident.
The cause of this accident is squarely on the lack of recognition of the switch position and subsequent aural warnings.
That ignorant statement got me going.
Rant over
Rigga
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As operating in MANUAL is not a standard config, at least for most of the 737 operators, the horn would sound if you're on MANUAL at the bad TO config and if you still wanted to proceed with that setting you could easely cancel the horn with its own button, again directing the attention to the Pressurization panel.
GD&L
Rigga,
The step is there in the 737-3/4/500 AMM, ref TASK 05-51-91-702-001 Cabin Pressure Leak Test.
Near the end is the following:
“F. Put the Airplane Back to its Usual Condition
S 862-026
…
(4) Move the pressurization mode selector on the forward overhead panel to AUTO.”
I don’t know if this step was there at the time of the Helios work but the report suggests that it was.
The statement is not ignorant, it is merely quoting from the AMM. It is not at all like “preparing the flight deck for the next sector”, it is so that switches which are very rarely moved and hence could be overlooked by the flight crew are not left in a dangerous position.
The step is there in the 737-3/4/500 AMM, ref TASK 05-51-91-702-001 Cabin Pressure Leak Test.
Near the end is the following:
“F. Put the Airplane Back to its Usual Condition
S 862-026
…
(4) Move the pressurization mode selector on the forward overhead panel to AUTO.”
I don’t know if this step was there at the time of the Helios work but the report suggests that it was.
The statement is not ignorant, it is merely quoting from the AMM. It is not at all like “preparing the flight deck for the next sector”, it is so that switches which are very rarely moved and hence could be overlooked by the flight crew are not left in a dangerous position.
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CaptainSandL,
As an engineer I have to agree with you, it is in the manual and also should be common practice to leave the flight deck setup correctly.
It's also the flight crews' responsibility to action a thourough checklist before flight to catch such problems. Hard burden to bear if you're the man who starts the chain of events
As an engineer I have to agree with you, it is in the manual and also should be common practice to leave the flight deck setup correctly.
It's also the flight crews' responsibility to action a thourough checklist before flight to catch such problems. Hard burden to bear if you're the man who starts the chain of events
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Why a warning horn if you are in manual? It's a configuration that the crew can employ if they wish. As for 10000 hrs experience, it doesn't mean a thing, only that they have not been challenged in all that time with a simple problem such as this. The reliability and automation built into aeroplanes these days means that the quality of operator and of recurrent training can be variable to put it mildly. This situation would have been a non event to a competent crew.
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Gear Down & Locked:
Implications of operating pressurised under 10,000ft? There are none. Pressurisation is a gradual process that starts whilst the aircraft is still on the ground. With the system in Auto and throttles fully advanced for t/off, the fuselage is subjected to a 0.5psid pressure (Thats 0.5 psi differential above airfield pressure ). From there as the airframe climbs, the pressure within the cabin is gradually increased up to a maximum of around 8psi above outside pressure. Once descent starts, the pressure within the cabin is gradually decreased until the aircraft has landed when the pressure within the cabin will equal that outside.
I'm not sure what you are aiming at with the 2nd paragraph. If the horn sounds at the end of the runway prior to take off, there is a configuration problem that could / would stop the aircraft from being able to take off. Such things that are monitored include: Park Brake On / Off, T/Edge Flap posn, L/Edge Slat posn, Stab Trim posn and Speed Brake lever posn. If the horn goes off, crew should check all of these before continuing.The horn cannot be cancelled on the ground (at least not a 737NG). Should a crew attempt to take off with the horn sounding and miraculously succeed,once in the air the horn will silence (Take Off Config only active on ground). As the cabin altitude climbs, if it reaches 10,000 ft, the horn goes off again. This horn can be cancelled to allow the crew the comfort of a quiet flight deck to concentrate on the problem in hand. In my experience (engineer), as soon as crews hear this in flight they don O2 masks and initiate rapid descent to 10,000ft. The rate at which the cabin altitude is climbing will determine how long it takes to go from 10,000ft to 14,000ft when the cabin masks will drop.
I was once involved in 'test' flight with a 737 that was suffering pressurisation problems, being unable to maintain pressure on a single pack. When the horn sounded, crews did as above whilst myself and 1 other engineer raced around cabin activating the test stops to prevent a rubber jungle. We made it, as did the crew, as the latches weren't activated, they managed to get us to 10,000ft before cabin reached 14,000ft.
What happened in Cyprus, IMHO, is a classic 'Human factors chain of events'. All accidents involving human error, can be described as a chain. If just 1 link in the chain can be broken, the accident is stopped. This particular chain had a link where the enginers left the switch in MAN, a link where the crew failed to spot it on pre departure checks, and even more links in flight when they failed to identify what the horn was about and act accordingly, and not take appropriate action when the cabin masks dropped. Who knows there could even be more links further back when the local regulatory authority failed to take Helios to task over safety issues?
Sorry for rambling
MM
Implications of operating pressurised under 10,000ft? There are none. Pressurisation is a gradual process that starts whilst the aircraft is still on the ground. With the system in Auto and throttles fully advanced for t/off, the fuselage is subjected to a 0.5psid pressure (Thats 0.5 psi differential above airfield pressure ). From there as the airframe climbs, the pressure within the cabin is gradually increased up to a maximum of around 8psi above outside pressure. Once descent starts, the pressure within the cabin is gradually decreased until the aircraft has landed when the pressure within the cabin will equal that outside.
I'm not sure what you are aiming at with the 2nd paragraph. If the horn sounds at the end of the runway prior to take off, there is a configuration problem that could / would stop the aircraft from being able to take off. Such things that are monitored include: Park Brake On / Off, T/Edge Flap posn, L/Edge Slat posn, Stab Trim posn and Speed Brake lever posn. If the horn goes off, crew should check all of these before continuing.The horn cannot be cancelled on the ground (at least not a 737NG). Should a crew attempt to take off with the horn sounding and miraculously succeed,once in the air the horn will silence (Take Off Config only active on ground). As the cabin altitude climbs, if it reaches 10,000 ft, the horn goes off again. This horn can be cancelled to allow the crew the comfort of a quiet flight deck to concentrate on the problem in hand. In my experience (engineer), as soon as crews hear this in flight they don O2 masks and initiate rapid descent to 10,000ft. The rate at which the cabin altitude is climbing will determine how long it takes to go from 10,000ft to 14,000ft when the cabin masks will drop.
I was once involved in 'test' flight with a 737 that was suffering pressurisation problems, being unable to maintain pressure on a single pack. When the horn sounded, crews did as above whilst myself and 1 other engineer raced around cabin activating the test stops to prevent a rubber jungle. We made it, as did the crew, as the latches weren't activated, they managed to get us to 10,000ft before cabin reached 14,000ft.
What happened in Cyprus, IMHO, is a classic 'Human factors chain of events'. All accidents involving human error, can be described as a chain. If just 1 link in the chain can be broken, the accident is stopped. This particular chain had a link where the enginers left the switch in MAN, a link where the crew failed to spot it on pre departure checks, and even more links in flight when they failed to identify what the horn was about and act accordingly, and not take appropriate action when the cabin masks dropped. Who knows there could even be more links further back when the local regulatory authority failed to take Helios to task over safety issues?
Sorry for rambling
MM