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Cypriot airliner crash - the accident and investigation

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Old 25th Oct 2006, 11:34
  #321 (permalink)  
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ews - please read again my post
Whilst the quoted '2500-3000' rate of climb would probably be noticed by the passengers/crew, it would probably not cause any discomfort.
.

Your question regarding opening the door is misplaced. Please refer to page 22 of the report where you will see that the a/c was depressurised when the door was opened.

Far too much speculation!
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Old 25th Oct 2006, 11:54
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We have, from the FDR, both bleeds and packs 'ON'. I cannot determine from either the FDR or the NVM readings the Auto/Manual setting at departure from any of the data - is it there? There appear to be only 3 'events' from the crash flight NVM and they are all recorded with the a/c at FL 340. The enquiry says there is no evidence of the valve being 'toggled' in Manual -where do they deduce that? Would '14.6' degrees show as closed on the panel? Without that information, add the engineer's assurance that he placed the valve in Auto, posts like cargo boy's are far too simplistic. AFAIK we just do not really know what happened to the Auto/MAN setting or when it was placed in Manual. NB I may have missed the 'conclusive proof' that it was not placed there by the flight crew at some stage of the flight.

IMO, the 'Causes' on page 159 should be changed to move 3.2.3.2. from 'Contributing' to 'direct' - this without any implied criticism of the c/crew since we have NO IDEA what they did or tried to do until the last 30 minutes of the CVR, as per 3.1.2.4 - BUT the accident should have been avoidable had they entered the cockpit early and placed both crew on oxygen. The chance of a good recovery by at least 1 of the pilots was high.

Yes, the pilots failed to operate correctly. I do not see that as the end of it.
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Old 25th Oct 2006, 12:27
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Originally Posted by gonso
jbsharpe,
The report mentions the 4 portable oxy bottles in the cabin, each with endurance of 1:15h to 2:45. Only one bottle would have been enough. 2 or 3 were found used in the wreckage.
If you are asking the exact actions and survival techniques of the steward the first 2hrs of the flight, we will never know. That would be pure speculation. The reports (usually) don't speculate (much).
Thanks to ThinkRate also for your reply.

As you say it is pure speculation but one has to wonder why the steward didn't attempt to gain access to the cockpit sooner.

I assume there are also security issues concerning aspects of the discussion of same!
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Old 25th Oct 2006, 12:32
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EWS,
Thank you for the breakdown of testing done by Alan.

Couple of points.

"Let's start with the obvious question: Could the Ground Engineers Numbers One and Two of the Tsolakis Report open the door to exit the plane after their pressurisation test, if they had left the OFV almost closed at a 14.6-degree angle (which means the plane had barely 'depressurised' from its maximum 8psi differential reached during the test)?"

It makes complete sense for the switch to be left at MAN and at 14deg. After the leak test, how would Alan decompress the aircraft? .....SLOWLY. How's that achieved? By manually open the OFV a little bit (14deg!) to let the air out. If he had placed the switch to AUTO, the OFV would quickly drive to full open, bursting everyones eardrums.

How could they open the doors? Well, 5 minutes with the valve at 14deg and the packs off, does the trick. The aircraft would have been fully depressurized.

(I don't blame the engineers for this accident by the way)

You seem very sceptical and in disbelief of how the crew missed all these clues. Three times as you say. You don't seem equally sceptical of how they missed the Alt horn and they continued climbing. Not for an instance they considered stopping the climb to investigate. They had enough fuel onboard to sacrifice a few minutes level at 10-12000 ft before happily accepting FL340.
As I mentioned earlier, the investigators, during the test flight, they climbed to 10000ft with the OFV at 14deg. They did not notice anything very strange. I asked about the type of test the company or the engineers have conducted, and from what you say, the test went as far as engines started.

You also say,

"The Report does not consider any alternative scenario. "

Final reports SHOULD NOT INCLUDE alternative scenarios. If there still were other possible scenarios in the investigators minds, the report should not be out until they were ruled out or accepted as the cause of the accident. The fact that alternative scenarios are not included in the report, DOES NOT mean they were not investigated. I am sure ie. the malicious act scenario was considered initially as well and ruled out. It does not have to be in the report. It's findings and hard evidence that should be included.
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Old 25th Oct 2006, 12:43
  #325 (permalink)  
 
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Glider winch launches are probably faster then 2000ft/min. I can't say I've noticed any major ear discomfort - probably concentrating too hard on other things.
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Old 25th Oct 2006, 12:48
  #326 (permalink)  
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gonso - to re-inforce your point, from #328 -
Your question regarding opening the door is misplaced. Please refer to page 22 of the report where you will see that the a/c was depressurised when the door was opened.
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Old 25th Oct 2006, 14:41
  #327 (permalink)  
 
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14 degrees open seems like a reasonable setting to depressurise the plane after a ground leak check. Does anybody know what position the outflow valve normally would be during a normal take off? I remember the max ground pressurization is .125 PSI. I assume to have that at idle thrust the valve would not be full open. I remember something about at higher altitudes the outflow valve goes full closed and a smaller valve fine tunes the pressurization system. If that is true the 14 degrees open would be a big hole when the pressure differential increased. Maybe the initial climb at low differential pressure was quite normal and the gradual climb in cabin altitude was also not enough to cause discomfort. Even though they claim this is impossible have they actually taken off with the valve open 14 degrees to see what happens?
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Old 26th Oct 2006, 08:07
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Joint Resolution

Despite the FSF resolution on criminal liability and accident reports - I understand that the Kallis Inquiry in Cyprus is basing its findings on the AAI & ASB Final Report and will accept no argument about it. On Mon/Tues the UK CAA Inspector who audited Helios said that the Report had errors, that Helios were JAROPS compliant and that he could see no link between the airline management and the accident. It is interesting that this was the person who had the best evidence on the state of Helios and he was not even interviewed by the AAI&ASB. Funny old world
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Old 26th Oct 2006, 10:34
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What are the chances of having an OFV malfunction? What I mean is both DPCS's working but the OFV not responding, thus forcing the crew to try operating the valve manually?
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Old 26th Oct 2006, 11:42
  #330 (permalink)  
 
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The Cyprus Mail
Helios criminal case opened in Greece
(archive article - Wednesday, October 25, 2006)
AN ATHENS public prosecutor yesterday launched criminal proceedings into the Helios air crash of August 14, 2005.
The proceedings concern “voluntary manslaughter with probable malice against all involved parties,” or gross negligence leading to death.
It paves the way for Greek police investigators to begin questioning people both here and in Greece.
According to Phileleftheros today,
'Η Εισαγγελέας, που μελέτησε το πόρισμα της Επιτροπής Διερεύνησης Αεροπορικών Ατυχημάτων, άσκησε δίωξη όχι για αμέλεια, αλλά για το αδίκημα της ανθρωποκτονίας από πρόθεση με ενδεχόμενο δόλο.
which means that 'the Attorney General who studied the Tsolakis report will file charges not of negligence but of manslaughter with intent and probable malice '.
Based on the above I think that anyone who might be invloved in an accident in the future should be stupid to talk to any accident investigator since the report can be used against him when it's completed!
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Old 26th Oct 2006, 11:47
  #331 (permalink)  
 
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GearDown&Locked, ok , I can buy this scenario. The crew is struggling to use the manual mode to control the OFV. Unsuccesfully. Then there is the horn while they are working on the pressurizarion panel. And they miss it. And they keep climbing? That sounds even worse that the report's scenario.
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Old 26th Oct 2006, 14:51
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Since the captain's concern was the takeoff warning horn and the equipment cooling fans why does anyone think they would select manual pressurization to fix their problem. If they did eventually realize they had a pressurization problem why would they not go full closed instead of 14 degrees open. I believe the report is correct and maintenance left the switch in manual after their leak check. It of course was the flight crew's responsibility to have the switch in the correct position on their preflight checks. Since they know the aircraft altitude when the warning came on and when the masks dropped you would think they would have done a test flight with the valve 14 degrees open to see if it was in that manual position before takeoff.
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Old 26th Oct 2006, 15:21
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Originally Posted by bubbers44
Since they know the aircraft altitude when the warning came on and when the masks dropped you would think they would have done a test flight with the valve 14 degrees open to see if it was in that manual position before takeoff.
Bubbers, I suspect you are refering to the investigators. The warning horn activation is confirmed by the FDR printouts in the last pages of the report.
Don't assume they did the test flight with the OFV at 14deg.....they actully did it. They say so in the report. The dif from the actual flight was the fact they stopped the test just above 10'000 feet and the other dif was that the Olympic a/c they used (-300) has CPCS and not DCPCS. Not in the report that, but this is something I strongly believe. If anybody knows more about this, please tell us. I don't think it makes any dif. If you have MAN and the OFV at 14deg, it does not matter which system you actually use for test purposes.
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Old 26th Oct 2006, 17:35
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I went through the report again and still cannot find the page you mention duplicating a takeoff with the valve 14 degrees open. The DFR shows the cabin about 2000 feet below aircraft altitude when the warning sounded and the masks dropped. What page shows what the test flight showed under the same conditions?
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Old 26th Oct 2006, 19:23
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Page 72 of the report in english, pasted below is the relevant piece.


Before departure of the re-enactment flight from Larnaca to Athens, the air conditioning and pressurization system panels of the aircraft were preset according to the data from the NVM of the cabin pressure controller. The pressurization mode selector was set to the MAN (manual) position. The pointer of the aft OFV indicator was set in a position corresponding to approximately 15º opening position of the aft OFV, in order to maintain
the cabin differential pressure of 1 - 1.2 psi during take-off and climb.
After take-off, the aircraft climbed with a rate of 2 500 ft/min and the cabin followed at almost the same rate. The aircraft leveled off at 10 000 ft, where the cabin altitude reached 8 000 ft. Up to that moment, the cabin differential pressure did not exceed approximately 1.2 psi. At 10 000 ft, and after a video recording of the instrument panels,the pressurization system was restored by turning the mode selector to AUTO, thus allowing the valves to modulate and the cabin differential pressure to be restored. Then the aircraft continued to climb to FL340.


Gonso's comment. Note the fact that there is no mention of "painful ears" or "uncomfortable conditions during climb" or even " the excessive cabin rate of climb was quite noticeable". They would have if those conditions were noticeable, I am sure.
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Old 26th Oct 2006, 19:25
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Originally Posted by bubbers44
I went through the report again and still cannot find the page you mention duplicating a takeoff with the valve 14 degrees open. The DFR shows the cabin about 2000 feet below aircraft altitude when the warning sounded and the masks dropped. What page shows what the test flight showed under the same conditions?
page 72: 1.16.9 Re-enactment of the Accident Flight
Before departure of the re-enactment flight from Larnaca to Athens, the air conditioning and pressurization system panels of the aircraft were preset according to the data from the NVM of the cabin pressure controller. The pressurization mode selector was set to the MAN (manual) position. The pointer of the aft OFV indicator was set in a position corresponding to approximately 15º opening position of the aft OFV, in order to maintain the cabin differential pressure of 1 - 1.2 psi during take-off and climb.
After take-off, the aircraft climbed with a rate of 2 500 ft/min and the cabin followed at almost the same rate. The aircraft leveled off at 10 000 ft, where the cabin altitude reached 8 000 ft. Up to that moment, the cabin differential pressure did not exceed approximately 1.2 psi. At 10 000 ft, and after a video recording of the instrument panels, the pressurization system was restored by turning the mode selector to AUTO, thus
allowing the valves to modulate and the cabin differential pressure to be restored.-



TR
-----------------------------------
ThinkRate! ThinkRate! Don't Think!

Last edited by ThinkRate; 26th Oct 2006 at 19:27. Reason: because gonso is quicker off the mark than me
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Old 26th Oct 2006, 20:02
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Thanks Gonso and ThinkRate. It seems then that the valve position was in the same on takeoff as it was at the crash site. I had that warning horn on a descent one day flying with one pack. The FWD outflow valve decided to stay open too so the cabin got to 10,000 feet. My first thought was faullty takeoff warning horn then checked the cabin alt. and it was at 10K so put the other pack on to help. I see by the report that the FWD outflow valve should close when the OFV gets to 2 degrees from closed position. I have heard so many pilots talking about problems after maintenance has left circuit breakers and switches in the wrong position and not noticing until after takeoff. I have encountered my fair share and tried to be extra vigilant after maintenance has worked on my plane.
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Old 27th Oct 2006, 07:35
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From yesterday's Cyprus Mail, with emphasis (mine) added at the end:

Greek criminal probe to work in tandem with Cyprus
By Elias Hazou

CRIMINAL proceedings here in Cyprus into the Helios air disaster may run in tandem with those in Greece, Attorney-general Petros Klerides said yesterday.

The top law official yesterday convened a news conference – an uncommon event – to explain how the prosecution leg of the investigation would work in both countries.
On Tuesday an Athens public prosecutor launched criminal proceedings into the aviation accident.

These concern “voluntary manslaughter with probable malice against any and all involved parties,” – a convoluted legalistic term designating gross negligence leading to death.

The move paves the way for Greek police investigators to begin interviewing people both here and in Greece.

However, police on the island have already commenced their own investigations, questioning anyone involved in some way or another with the accident – including officials from the embattled airline and Civil Aviation.

But despite the ominous wording of the Greek process, Klerides said yesterday that it did not presuppose any guilty parties.

“It does not mean that authorities there have suspects. No court case has been filed.

Quite simply, Greek police will start gathering evidence, just like we are doing.”

Cypriot police officers have been travelling to neighbouring Greece to take affidavits, said Klerides.

Detectives in both countries would assist one another in this task, but once – and if – the next stage, actual prosecution, were reached then judicial authorities would go their own way.

According to the Attorney-general, in the event a person or legal entity were found guilty in one country, then proceedings against them would cease in the other.

But asked what would happen if someone were cleared in one of the courts, Klerides was hesitant, noting “We’ll have to wait and see.”

Unlike Cyprus the Greek legal system can try and sentence a person in absentia – for instance if one of the Cypriot witnesses refused to show up there.

And Klerides said it was entirely possible in Greece to subpoena Akrivos Tsolakis, the chairman of the committee that produced a report into the causes of the crash.
The whole arrangement has raised the question of whether this will turn into a race between the two countries.

Cyprus has a head start on Greece of a few months.

Yesterday Klerides would not comment on how far the Cypriot investigation had come or offer an estimate as to when it would wrap up.


“It’s hard to say. You interview one person, and then discover you need to talk to three more,” he said.

The police inquiry in Cyprus has already been mired in controversy, for two reasons. First, it was suspended for several months pending the publication of the Tsolakis report. Second, immediately after the Tsolakis report came out, Klerides took flak for saying that prosecuting anyone would be “very difficult – a belief he reiterated yesterday.

Without naming names, the accident report cited pilot error as the primary cause, but went on to say that operational deficiencies at Helios (now known as ajet) were a latent, or underlying, reason for the disaster.

When Klerides made the contentious remark, he was probably hinting at the fact the two aviators were now deceased, and also that it would be tough to establish a criminal link between an airline suspected of cutting corners and the actual accident.
But there is more. According to the latest interpretation, the Attorney-general will use the Tsolakis report together with the findings of an independent commission of inquiry to decide whether to prosecute.

The broad mandate of the commission, headed by ex Supreme Court judge Panayiotis Kallis, is to “recommend” who is responsible for the accident. The twist is that the commission’s findings are not legally binding on authorities.

Even more confusingly, this week Kallis said his commission would base its conclusions exclusively on the Tsolakis report – which begs the question of why the commission should function at all.

Moreover, Kallis’ assertion does not appear to be consistent with the chain of events: if the commission was to be based solely on the report, then why did it start convening before the report was out?

There is a growing suspicion the commission was cynically set up to give the victims’ relatives a channel to vent their anger.

Also, some ask what would happen if Tsolakis’ findings were at odds with the police investigation.

A tentative example: in a leaked police report appearing in Simerini on August 20, 2005, Alan Irwin, the airline’s chief engineer at the time, said that he asked the captain of the doomed flight:

“Did you reconfigure the pressurisation settings manually?”

But in the Tsolakis report, Irwin is said to have asked the captain:
“Did you change the pressurisation system to auto?”

The two statements are contradictory. In order to reconfigure the pressure settings manually, this entails that the plane took off in automatic mode. But if during the flight the engineer was asking the pilot whether he switched to auto, that means takeoff must have been done on manual.


Copyright © Cyprus Mail 2006
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Old 27th Oct 2006, 09:17
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The Cypriot investigation has reconvened. For the time being, the press has access to the proceedings, and below is today's article from the Cyprus Mail:

Air Accidents boss queries Tsolakis report
By Jean Christou

THE CHAIRMAN of the Cyprus Air Accidents and Investigation branch Costas Orphanos told the independent Helios committee yesterday that he disagreed with three aspects of the official report into the crash.

Orphanos was testifying before the committee chaired by Panayiotis Kallis, which is conducting an ongoing investigation.

The Civil Aviation official said he disagreed with references in the final Helios report by Greek investigator Akrivos Tsolakis to inadequacies within the Civil Aviation Department regarding flight safety.

Orphanos said he also disagreed with Tsolakis’ decision not to attach a report with the views of the airline, and also his omission of recommendations to Helios, even though it had made recommendations to Boeing.

According to Orphanos, the Civil Aviation Department, with the help of British experts, were doing a proper job with regard to flight safety, despite the official report’s references to weaknesses in the department.

He then criticised Tsolakis’ decision to omit the views of the airline, some of which he said should have been accepted an evaluated.

Referring to the Greek investigator’s recent comment that he could not make recommendations to an airline that did not exist, Orphanos said it was irrelevant that Helios had changed its name to ajet. It was still a legal entity, he said.

Cross-examining Orphanos, Helios lawyer Demetris Araouzos questioned Orphanos' authority to properly judge the seriousness of an event, since his qualifications lay in traffic control.

“You accept whatever they tell you, you record whatever you understand, whatever you don't understand you don't look into,'' Araouzos told Orphanos.

Reacting to the comment, Orphanos said it was offensive to question his 40 years of experience in all sections of the Department and was qualified to investigate any event.

The Kallis committee is running in parallel with a criminal investigation by the Cyprus police and may also include a criminal investigation in Greece.

On Tuesday an Athens public prosecutor launched criminal proceedings into the accident in which 121 passengers and crew died at Grammatiko, north of Athens on August 14, 2005.

Copyright © Cyprus Mail 2006
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Old 27th Oct 2006, 09:55
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Regarding the climb/descent feeling in ones ears. Some time ago I was on a KLM 737 flight from LIS to AMS. As we left LIS the plane skyrocketed straight away, and it felt like the space shuttle lift-off. Maybe they were cleared to climb that way or simply to avoid weather (it was winter time). Anyway apart from the Whoa sensation I didn't felt unconfortable with it although I had this mild cold (big mistake! as I later found out in a very painful way).
As we got close to AMS the plane literaly dropped like a stone. I would guess the descent rate was about the same as the climb rate earlier on. I have just one word to describe it - pain - unbearable pain.
So for an umpressurized TO climbing at a normal rate it would be like the one I've experienced at a higher rate but on a pressurized environment, as the cabin climb rate would be somehow similar. It wouldn't be noticed as a problem.
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