Cypriot airliner crash - the accident and investigation

[airsnoop]

Bleeds Off

On the accident site, the mode selector was found to be about 7 mm clockwise from the MAN mark and the mode selector shaft was confirmed to be in the manual position when examined at the Boeing Laboratory.
The air conditioning panel suffered significant trauma during the impact sequence and a majority of the switches were damaged. Both pack switches and the isolation valve switch appeared to be in the normal flight position, AUTO. However, the engine and APU bleed switches were all found in the OFF position. The #1 engine bleed switch was clearly in the OFF gate and it appears not to have been damaged in the impact. There is no evidence in the Final Report that these switches were examined at the Boeing Laboratory.
Thereis no discussion in the Final Report about the preimpact position of either the mode selector or the engine bleed switches.
However, based on this post impact evidence, the Final Report makes the unsupported assumption that the mode selector was in MANual from the time of the unscheduled maintenance and the abnormal position of the engine bleed switches is not discussed.

[fyrefli]

Originally Posted by late developer

EWS - I have an open mind about it. If by 'hardly noticeable' you mean no excrutiating pain on the way up experienced by anyone at +2500 feet per min then I can easily accept Sea Level to 2500 as a no real fuss situation. You might just have to gulp frequently to overcome it. Going higher at the same rate I have no idea. If you have a cold then I am sure you would have big problems but otherwise I am not sure you would. Like BOAC I am more sensitive than most I think. Personally I know the pain on the way down, but have never experienced anything worse than the dull pop-puffing feeling on the way up. As an A to B touring PPL, I have experienced 1000 feet per minute ascents straight off the runway to about 2400 feet in my favourite light aircraft and they are nothing to write home about either.
Perhaps aerobatic pilots and divers can offer more observations and any PP who has deliberately gone up at that rate unpressurised.

As I posted a couple of pages back - and which has been corroborated by all pilot posts since - para/hang/fixed wing glider pilots regularly take prolonged climbs at 1000-2000ft/min, particularly in mountainous regions, and, in twelve years, I have not experienced, or heard a single piece of anecdotal evidence for, significant ear pain whilst so doing. And remember that the aircraft was partially pressurised. I have personal experience of these sorts of climbs up to a little over 13000ft.

Whilst we are talking in the Helios case about ascent, mention has also been made here of rapid descent. A properly locked in spiral dive on a paraglider might typically end up having a descent rate of 1000-1400ft/min. I personally held in a spiral all the way from a little over 12000ft to land at just over 4000ft in Himachal Pradesh last year. Aside from breaking the spiral once to reverse direction, the majority of this descent was at 12-1300ft/min. Whilst the gs and the need to maintain a fixed point of reference no doubt provide a distraction, I felt nothing in my ears.

Cheers,

Rich.

[Wizofoz]

When will they learn.....

"If you think safety is expensive, try having an accident!"

[Mercenary Pilot]

If you think hiring good pilots is expensive, try having an accident.

[aardvark2zz]

Can someone pls clarify why it took hrs for the cabin crew to enter the cockpit ??

What happened that alllowed them to finally open the door ??

There are several questions about this unclear topic even after reading that portion of the report.

Note: The engines flamed out after someone entered the cabin.

[BOAC]

Note: The engines flamed out after someone entered the cabin

- good questions, aardvark. To answer this one, the fuel ran out at that point. Nothing to do with the c/crew entering the f/deck.

[bubbers44]

The cockpit door is held in the locked position electrically. When the engine quit or at least when the second engine quit the door would unlock. I have no idea why they couldn't put the code in the key pad before this happened. They must not have known the correct code.

[ATC Watcher]

Originally Posted by bubbers44

The cockpit door is held in the locked position electrically. When the engine quit or at least when the second engine quit the door would unlock. I have no idea why they couldn't put the code in the key pad before this happened. They must not have known the correct code.

Read the report before posting that will help : The stew opened the door BEFORE the first engine ran out , (and that would not unlock the door anyway )

[aardvark2zz]

I highlighted parts of the answer in an email and I forgot its significance

see section 2.2.7

"...someone using the prescribed access procedure to enter the cockpit, followed by sounds similar to the flight deck door opening...."

Still doesn't explain the reason why it took hrs !??? We may never know

[BOAC]

MOD NOTE:

Please keep this thread 'on target' in respect of the accident and the report. Discussion of legal claims/name changes/ceasing ops etc on the Airline, Airports and Routes thread, please.

[aardvark2zz]

FTR,

In another section, written in more detail than above.

"...From the sounds recorded on the CVR, however, the Board could ascertain that this cabin attendant entered the cockpit using the emergency access code to open a locked cockpit door...."

[Juud]

Aardvark, been pondering the same question for quite a while now. Had the male FA entered the cockpit and put the pilots' masks on their faces before the pilots succumbed to hypoxia, the whole thing might have ended very differently.
Could the simple answer be that the CC weren't trained for this particular scenario and thus simply stuck to procedures they were trained for?

I recently brought this up during a SEPs session. None of the other FAs knew about the details of the Helios incident, and the instructor did not find it a relevant discussion since "the manual covers this eventuality".
Our manual gives 2 alternatives after a decompression. A quick descent followed by the command to remove masks, or a remain-at-level and a command to keep masks on. I've checked with people working at other airlines and the situation is similar.
There is no procedure for what to do when neither of the above happens.


Regarding the hiring of FAs, European airlines can roughly be separated into 2 categories these days. That separation could well be relevant to what you are wondering about.

• Hire minimally educated young people desperate to get into the business, pay them low wages, give them the legal minimum of SEP training and work them so hard that they leave as soon as anybody else will have them. To avoid any initiatives that might cost money, drum into them strict adherence to company SOPs, and let them know that they will be fired should they deviate in any way from these SOPs.

• Hire people of all ages with either a reasonable education or relevant life/work experience. Pay them a living wage and give them reasonable T&Qs. Establish career planning by having in place teaching and training requirements, thereby ensuring that the senior FA/CSD/No1 is someone with a lot of flying experience and more knowledge of the operation than just knowing how to serve a Manhattan. Give them a solid training in SEPs, and emphasize the fact that not everything can be covered by SEPs and SOPs. Encourage the FAs to think for themselves when necessary, and empower them to do so.

The second category of airlines has a fighting chance of having in place FAs who are willing and able to think on their feet and take appropriate initiatives when a situation occurs that was not covered by their training.

[bubbers44]

Originally Posted by ATC Watcher

Read the report before posting that will help : The stew opened the door BEFORE the first engine ran out , (and that would not unlock the door anyway )

Our 757 doors had to be locked mechanically for security reasons over night because when the external power was removed the doors were not locked. I think the door is locked with an electrical solenoid and when the bus that controlled the door lost power, the door would be unlocked and since the FA couldn't get in before during this 2 hr flight, the loss of generators let them In. I have read a lot of the report but don't have two days to read all of the pages. If the flight attendants couldn't figure out how to open the cockpit door in the first two hours, they didn't know the code.. The pilots can override it but only if they are conscious. Something let them into the cockpit and it probably was an electrical interruption.

[BOAC]

bubbers and Juud - both your points are covered in the report. It is worth reading first!

bubbers - the F16 pilot was in formation with the 737 when he 'saw' the steward in the seat. Unlikely if both engines had failed?
From the report:
08:48:05 F16 reports ?steward? entering flight deck. CVR confirms, with noise of f/deck door opening using 'correct' procedure
08:49:50 From FDR, first engine flames out
08:59:47 From FDR second engine flames out


(pages 126/127)

juud - c/crew drill was commented on as it requires the c/crew to take a mask and sit down - until the emergency descent is complete (page 136). This is a yawning chasm which most of us have now closed, but I am not aware of any 'new' drill for c/crew yet.

[bubbers44]

BOAC. I agree that the door was opened less than two minutes before the first engine shut down but why for the two hours before this why couldn't they open the door? If they knew the code they would have opened the door. If the engine quit less than two minutes after they finally got in, maybe the fuel sloshing around in the bottom of the tank caused a partial engine spool down that put the generator off line and released the door lock. I haven't flown the 737 since the new doors but our 757's require electrical power to keep the door locked. That is why we need the key lock to secure it at night with no power. I have been retired for three years so don't know what bus the door lock is on but six months ago we had a discussion here that one of our guys suggested this is what happened. It, in my mind solved the puzzle about why nobody could get in to the cockpit.

We tested the lock first flight of the day and our guarded switch in the cockpit electrically locked the door. No electricity, no lock. It would be quite a coincidence if they remembered the code less than two minutes before the first engine shut down after two hours of trying to figure it out.
I think the engine was surging in tha last two minutes and the generator went off line.

Then again, I could be wrong. Anybody else know why they couldn't get in the cockpit before they ran out of fuel?

[BOAC]

Yes - it is possible - as the report says - it is a puzzle. It would still take a double flame-out to de-power the door, which would have shown on the FDR, so I think your scenario unlikely - but who knows? I can only direct you to the FDR trace (expanded) around the time of door opening which shows steady No1 and No 2 N1s.

Do we campaign for 5 hour CVR's?

[Rananim]

After the Captain asked him about the location of the associated circuit
breakers,the ground engineer asked him to confirm that the pressurization mode selector was set to AUTO.

PAge 123 of the report.

I have serious doubts about the believability of this testimony from the ground engineer.


According to FDR data,less than one minute into the radio communication exchanges between the Captain and the Helios Operations Dispatcher,at an aircraft altitude of about 17000 feet,the MASTER CAUTION light was activated and was not cancelled for 53 seconds.

Page 122 of report.

The Captain's communication with the Engineer centered around the cooling problem .From this we can logically conclude that it was the equip cooling OFF lights that triggered the MASTER CAUTION and NOT the PAX O2 drop.The report doesnt commit itself one way or another.

Anybody else know why they couldn't get in the cockpit before they ran out of fuel?

PARALYSIS.FEAR.The sight of the F-16's was perhaps the prompt that he had to try and do something.

[bubbers44]

BOAC, where can I find the report that shows the N1 readings were normal when he entered the cockpit? I have looked but can't find anything. I thought a momentary drop out of a generator might have released the door lock before the engine finally failed due to fuel starvation. Still curious why they couldn't get in until right before the first engine quit. Is the door lock on a transfer bus?

[BOAC]

There are links to the report. At post#341 you say

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 FDR traces and the text tell you what I understand.

It bears repeating - we do NOT (and never will) KNOW what happened in or around the cockpit from the end of the R/T contact on departure to the last 30 minutes of the CVR. Hence my query - should CVRs run for longer - say 6 hours?

I do not have information on the exact power source for the door.

[Frangible]

The door was powered all the time, does not default to open when power fails, and the steward used the code to get in (the chimes are heard on the CVR). The report finds it "quite puzzling" that he "might not" have gone to the flight deck for hours, but there it is. No one will ever know if they entered before the occasion when the F16 pilot saw him.

Six -hour CVRs are not such a bad idea, but what accident investigators are campaigning for, and getting in the US, is two-hour CVRs. They also want, and this is vital, a few minutes -- three I believe -- of independent, i.e. battery power to the recorders so they don't stop recording when power goes, as at present.