Helios Crash
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Of course, PLovett, but therein lies the problem. It was not just the Helios crew that were 'confused'. You need to read the whole previous thread to understand the psychology involved in why quite a few 'competent' crews had mis-diagnosed the warning as well over the years of the 737. It was not until post-Helios that this became an established teaching point and the subject of a notice from Boeing. Even then it IS possible to have the TOCW sound in the air given certain failures - see other thread.
I do recommend that those joining in here should visit that original thread. You will see there that while they were the final flawed link it was not just the 'crew' that contributed to the accident - there were many failings along the way elsewhere, including the question as to why the Captain had been employed in the first place with his 'record'. Why did the cabin crew not respond earlier? Why was the panel left incorrectly configured. Indeed a classic 'Swiss Cheese'.
I do recommend that those joining in here should visit that original thread. You will see there that while they were the final flawed link it was not just the 'crew' that contributed to the accident - there were many failings along the way elsewhere, including the question as to why the Captain had been employed in the first place with his 'record'. Why did the cabin crew not respond earlier? Why was the panel left incorrectly configured. Indeed a classic 'Swiss Cheese'.
I think you're spot on. 'Good habits' [AKA airmanship].
Check lists are there for a damned good reason, but having a regular scan as and when time permits is so important to maybe, just maybe, spot something before you need to read ECAM or a QRH.
PS. Hump, small twins and turbo props may not be as complex, but they can kill you just the same.
Check lists are there for a damned good reason, but having a regular scan as and when time permits is so important to maybe, just maybe, spot something before you need to read ECAM or a QRH.
PS. Hump, small twins and turbo props may not be as complex, but they can kill you just the same.
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Blame The Dead Pilots
Well it is easy to blame dead pilots for the accident, lets take a closer look at the processors of the then airline.
Have a look at what Boeing has done since this accident, at least Boeing trying to do something positive.
How easy to blame the pilots
Yeah and don't get me started about all those people who are demanding airlines should be flying with the risk of volcanic ash shutting down turbines.
"well I paid my money I should be able to fly now god dam it"
These are the same f*cks who are the first to sue claiming pilot error when it is the unthinking majority who blackmail airlines into flying. F*ck the self loading freight who have no idea.
Have a look at what Boeing has done since this accident, at least Boeing trying to do something positive.
How easy to blame the pilots
Yeah and don't get me started about all those people who are demanding airlines should be flying with the risk of volcanic ash shutting down turbines.
"well I paid my money I should be able to fly now god dam it"
These are the same f*cks who are the first to sue claiming pilot error when it is the unthinking majority who blackmail airlines into flying. F*ck the self loading freight who have no idea.
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Well it is easy to blame dead pilots for the accident
"Pilots are normally first on the scene of a crash. Aeroplanes do not normally back into mountains"
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Have you taken your pills today, Sir?
For b737800capt06:
Having a bad day, are we?
Perhaps you should consider a job that does not involve stupid f*cks and/or SLF?
Having a bad day, are we?
Perhaps you should consider a job that does not involve stupid f*cks and/or SLF?
A37575
I'm with you on this
I'm warry now of any name with 737 in it due to past experience
but just to keep the thread going
My view is not one of blame but what the heck are we going to do to address the causes.
If the accident report can not find a causal chain with a significant weak link other than the pilot then we need to address the crew functions,
Me thinks that a much greater majority would be very unhappy to fly if we were to walk away from many accidents saying it must have been an act of God or alignment of the stars
I must say that the user-name of B737800capt06 says something about it's owner.. The rest of the text rather proves it.
I'm warry now of any name with 737 in it due to past experience
but just to keep the thread going
My view is not one of blame but what the heck are we going to do to address the causes.
If the accident report can not find a causal chain with a significant weak link other than the pilot then we need to address the crew functions,
Me thinks that a much greater majority would be very unhappy to fly if we were to walk away from many accidents saying it must have been an act of God or alignment of the stars
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Now girls , enough handbags for the evening thankyou..........
I have just visited this thread for the 1st time in ages , cannot believe the bickering still going on.
The Airbus pilots giving it stick about the 'archaic' 737 pressurisation system ? Strange that MILLIONS of flights on 73's were ok , including ( the ) 1of the thousands of 73 flights I have commanded which actually had a Press Warning ( documented on this thread ages ok ) and which caused me to don my O2 mask etc etc ......bit of a non-event really , although it was a creeping cabin rise to 10,000+ ' , Why did I not think , even for 1 second , that I had a CONFIG warning ? I do not know , but perhaps one of you experts can advise me ?
I am certainly not happy that the crew are unable to defend themselves , because they paid the highest price for their mistake.
Did they have any feedback from the Cabin Crew ie ' Captain , why have the masks dropped down , is there a problem ? ' ( One of the 1st actions of F Deck is to switch seatbelts sign ON , but NO Emergency Descent announced , normal cruise climb still happening , why would masks drop ?) , this happened at Kegworth too. CRM courses have used that accident as a big stick in the many years gone by .This disaster should be twinned with Kegworth for future safety.
We have all exhausted our excuses for the crew , can we not just accept that this was one of those HUGE accidents which have no real lesson apart from ' WITHOUT COMMUNICATION , WE ARE DOOMED TO MISUNDERSTAND EACH OTHER ' .
.
The continuing Court cases in Nicosia are not helping anybody , the grieving families more so , can somebody please put an end to it all and tell them all that '**** Happens' , nothing can bring them back , how do the crews families feel about all this while they are still also grieving ?
Or is that classic Cypriot thing - blame everybody else , it makes you feel better ?
Very , very sad ................
I have just visited this thread for the 1st time in ages , cannot believe the bickering still going on.
The Airbus pilots giving it stick about the 'archaic' 737 pressurisation system ? Strange that MILLIONS of flights on 73's were ok , including ( the ) 1of the thousands of 73 flights I have commanded which actually had a Press Warning ( documented on this thread ages ok ) and which caused me to don my O2 mask etc etc ......bit of a non-event really , although it was a creeping cabin rise to 10,000+ ' , Why did I not think , even for 1 second , that I had a CONFIG warning ? I do not know , but perhaps one of you experts can advise me ?
I am certainly not happy that the crew are unable to defend themselves , because they paid the highest price for their mistake.
Did they have any feedback from the Cabin Crew ie ' Captain , why have the masks dropped down , is there a problem ? ' ( One of the 1st actions of F Deck is to switch seatbelts sign ON , but NO Emergency Descent announced , normal cruise climb still happening , why would masks drop ?) , this happened at Kegworth too. CRM courses have used that accident as a big stick in the many years gone by .This disaster should be twinned with Kegworth for future safety.
We have all exhausted our excuses for the crew , can we not just accept that this was one of those HUGE accidents which have no real lesson apart from ' WITHOUT COMMUNICATION , WE ARE DOOMED TO MISUNDERSTAND EACH OTHER ' .
.
The continuing Court cases in Nicosia are not helping anybody , the grieving families more so , can somebody please put an end to it all and tell them all that '**** Happens' , nothing can bring them back , how do the crews families feel about all this while they are still also grieving ?
Or is that classic Cypriot thing - blame everybody else , it makes you feel better ?
Very , very sad ................
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Most posts seem to be rather subjective on this issue.
The bottom line in this case is that an operator on a tight budget tried to provide air service and it doing so it failed.
You can go around the houses for as long as you want but the truth to the matter is that this crew were ill equipped from the word go.
How many 737 operators around the world have operated the same aeroplane for decades and have had the same problem such as this crew?Not many.In fact not many at all but its easy and convenient to divert attention from the real issue here. Training or lack of it. With proper training these perceived deficiencies would have been ironed out at the training stage and subsequent recurrent training. This operator was not the only operator of such aeroplane that the design of it has to be scrutinised subjectively as it has been here.
One horn for two systems? Ok design flaw. Or from the manufacturer's logic- air and ground. The after take off checklist completion, the way it is carried out it frees the PF to get on with the task of flying the aeroplane at a critical phase of flight, so diverting his attention to the inside should be his last thing on his mind(but we know that we have to do this due airmanship or if the other guy can actually be bothered because.....). But experience tell us that that monitoring the monitoring pilot is highly recommended.
Lastly maybe the system should have just come out and said '' don oxygen masks'' too. But that suggestion would have a flaw in itself, the human might forget to arm it in the first place. So no matter what when it comes to operating an aeroplane, the manufacturer's procedures should be closely followed and one's perception on how it should be, just like how some instructors would like to operate&teach outside of those confines should be taken as airmanship points and not gospel. How many times have we had a question from the checking chap asking '' where is that written?''
The system should not on trial here, it is the operation and understanding of it instead. No matter how poor the design of such system, the operator should be adequately trained in order to operate it competently. Period.
Poorly trained crews will inevitably fail in one form or another should the situation arise.
This accident is a testament to the fact that anyone can start an ''airline'' and hope that the crew will makeup the for the company's intentionally introduced deficiencies. Or so called self funded type rating training agencies pumping out ill prepared crew whilst being too busy conducting an airservice themselves, instead of teaching what they are meant to?
Trying to blame the manufacturer is a poor attempt at exonerating one self from all responsibility. No matter how sophisticated the system might be, the human always attempts to outsmart the system, and on each occasion it has and always failed short of the mark in doing so instead of just following the instructions on the tin. Numerous accidents are available to show that the human element is the weakness in the system and somehow always resorts to blaming the system rather than itself. There is truth to what I once heard from a wise man, that the human is the only animal that repeatedly stumbles on the same stone time and time again.
The sole responsibility should lie with the company for not providing the necessary tools to its workforce,in order for them to be able to carry out their duties in the most safe, efficient and professional manner but as usual in a case like this the management are not on trial!
The bottom line in this case is that an operator on a tight budget tried to provide air service and it doing so it failed.
You can go around the houses for as long as you want but the truth to the matter is that this crew were ill equipped from the word go.
How many 737 operators around the world have operated the same aeroplane for decades and have had the same problem such as this crew?Not many.In fact not many at all but its easy and convenient to divert attention from the real issue here. Training or lack of it. With proper training these perceived deficiencies would have been ironed out at the training stage and subsequent recurrent training. This operator was not the only operator of such aeroplane that the design of it has to be scrutinised subjectively as it has been here.
One horn for two systems? Ok design flaw. Or from the manufacturer's logic- air and ground. The after take off checklist completion, the way it is carried out it frees the PF to get on with the task of flying the aeroplane at a critical phase of flight, so diverting his attention to the inside should be his last thing on his mind(but we know that we have to do this due airmanship or if the other guy can actually be bothered because.....). But experience tell us that that monitoring the monitoring pilot is highly recommended.
Lastly maybe the system should have just come out and said '' don oxygen masks'' too. But that suggestion would have a flaw in itself, the human might forget to arm it in the first place. So no matter what when it comes to operating an aeroplane, the manufacturer's procedures should be closely followed and one's perception on how it should be, just like how some instructors would like to operate&teach outside of those confines should be taken as airmanship points and not gospel. How many times have we had a question from the checking chap asking '' where is that written?''
The system should not on trial here, it is the operation and understanding of it instead. No matter how poor the design of such system, the operator should be adequately trained in order to operate it competently. Period.
Poorly trained crews will inevitably fail in one form or another should the situation arise.
This accident is a testament to the fact that anyone can start an ''airline'' and hope that the crew will makeup the for the company's intentionally introduced deficiencies. Or so called self funded type rating training agencies pumping out ill prepared crew whilst being too busy conducting an airservice themselves, instead of teaching what they are meant to?
Trying to blame the manufacturer is a poor attempt at exonerating one self from all responsibility. No matter how sophisticated the system might be, the human always attempts to outsmart the system, and on each occasion it has and always failed short of the mark in doing so instead of just following the instructions on the tin. Numerous accidents are available to show that the human element is the weakness in the system and somehow always resorts to blaming the system rather than itself. There is truth to what I once heard from a wise man, that the human is the only animal that repeatedly stumbles on the same stone time and time again.
The sole responsibility should lie with the company for not providing the necessary tools to its workforce,in order for them to be able to carry out their duties in the most safe, efficient and professional manner but as usual in a case like this the management are not on trial!
Last edited by abc1; 1st May 2010 at 06:17.
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abc - agree with much of that, but we are treading over old ground here on this accident. There is no attempt solely 'to blame the manufacturer'. You will see that the accident was primarily caused by poor flight and cabin crew performance. HOWEVER, as with all accidents, the other factors are contributory.
Many airlines had inadequate training on the horn activation pre-Helios - BA had several instances of 'confusion' in the simulator lasting varying amounts of time for reasons well-covered in the old thread. Only post-Helios was the manufacturer's information, QRH actions and training emphasis updated. Cabin crew were made more aware of the ramifications of mask drop, door procedures were looked at, engineering procedures amended. Only post-Helios did we discover that a particular failure mode CAN allow the TOCW to sound when airborne (via PPRune?).
We have (hopefully) learnt a lot from this accident.
Many airlines had inadequate training on the horn activation pre-Helios - BA had several instances of 'confusion' in the simulator lasting varying amounts of time for reasons well-covered in the old thread. Only post-Helios was the manufacturer's information, QRH actions and training emphasis updated. Cabin crew were made more aware of the ramifications of mask drop, door procedures were looked at, engineering procedures amended. Only post-Helios did we discover that a particular failure mode CAN allow the TOCW to sound when airborne (via PPRune?).
We have (hopefully) learnt a lot from this accident.
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Centaurus:
Fail safe.
A CABIN ALT warning caption is unambiguous and hard to ignore when coupled with flashing red warning captions and the engineering easy enough to implement. Similarly, the convenience item of having the AT command idle at 27' RA shouldn't lead to a situation where the AT will snatch power back to idle due to an otherwise insignificant failure of the RA, when the pilot has manually commanded max thrust while attempting to recover from an inadvertent stall. The Airbus RETARD call design is a much simpler and elegant implementation of the KISS principal, which allows the pilot to determine if actually retarding the throttles is the right call in a particular instance. In both these accidents there is no getting away from the fact that better design implementation by the aircraft manufacturer would likely have allowed the passengers to survive their encounters with an inadequate crew.
Regards.
The Turkish Airlines accident is a classic example where the crew apparently just watched in disbelief at what was occuring in front of their noses - and did nothing...
A CABIN ALT warning caption is unambiguous and hard to ignore when coupled with flashing red warning captions and the engineering easy enough to implement. Similarly, the convenience item of having the AT command idle at 27' RA shouldn't lead to a situation where the AT will snatch power back to idle due to an otherwise insignificant failure of the RA, when the pilot has manually commanded max thrust while attempting to recover from an inadvertent stall. The Airbus RETARD call design is a much simpler and elegant implementation of the KISS principal, which allows the pilot to determine if actually retarding the throttles is the right call in a particular instance. In both these accidents there is no getting away from the fact that better design implementation by the aircraft manufacturer would likely have allowed the passengers to survive their encounters with an inadequate crew.
Regards.
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Awareness (ref my post #51)
For those of you that blame the crew:
Some major f--k-ups, where properly trained and highly experienced pilots were involved:
1977 - KL in Tenerife.
1995 - AA in Cali
2000 - SQ in Taipei.
2009 - FDX in Narita.
And some close call f--k-ups:
1994 - RO A310 stalled over Paris.
1997 - EK A310 sat on its tail at holding position in CDG.
2000 - HF A310 glided into Wien.
2001 - EK A310 almost hit tower in AUH on G/A.
2004 - EK A340 just about took off in JNB.
2009 - EK A340 just about took off in MEL.
How would you feel if you or someone you know was involved in above cases?
Were all crews inadequately trained or below par? Investigations of civil aviation incidents and accidents should be used solely to provide data and experience in improving airline safety.
In the criminal cases in Larnaca (Cyprus) and Athens (Greece) that are presently being heard, lawyers and authorities are trying to set a precedent that will take civil aviation back to the Middle Ages. Our colleagues are standing trial for manslaughter!
Not only this - the Greek and Cypriot authorities are taking a direct part in the blame game by allowing mental and physical abuse of the defendants during the hearings. Mob rule in EU countries in the 21st century!
Why put the Helios employees on trial - just put them on the cross!!!
P.S:
from Wiki:
Private investigation
One year after the accident, the Discovery Channel aired a documentary detailing a private investigation, made in cooperation with Advanced Aviation Technology Ltd., arguing that a design failure of the Boeing 737 may have contributed to the accident.
All wiring for the pressurization system was in one wiring loop to the outflow valve in the aft of the Boeing 737. During a Boeing 737-436 G-DOCE flight in May 2003, a failure in this loop opened the outflow valve, which caused the cabin to depressurize. The same wiring failure probably caused erroneous indications to the crew that the standby pressurization system had failed and that the outflow valve was fully closed and unresponsive to pilot input. After seeing indication of the standby pressurization failure, the crew switched the pressurization control to manual mode and made an emergency descent.
Discovery Channel reported its findings on the G-DOCE incident to the Hellenic Republic's Air Accident Investigation & Aviation Safety Board.
The Board reported no evidence of wiring failure in Flight 522, and did not mention the G-DOCE incident. Because all available flight data showed the pressurization control in manual mode and the outflow valve open at a constant angle, and because there was no evidence the flight crew ever changed the pressurization mode, the Board concluded that the pressurization system had been set to manual for the entire flight, which caused the pressurization failure.
Some major f--k-ups, where properly trained and highly experienced pilots were involved:
1977 - KL in Tenerife.
1995 - AA in Cali
2000 - SQ in Taipei.
2009 - FDX in Narita.
And some close call f--k-ups:
1994 - RO A310 stalled over Paris.
1997 - EK A310 sat on its tail at holding position in CDG.
2000 - HF A310 glided into Wien.
2001 - EK A310 almost hit tower in AUH on G/A.
2004 - EK A340 just about took off in JNB.
2009 - EK A340 just about took off in MEL.
How would you feel if you or someone you know was involved in above cases?
Were all crews inadequately trained or below par? Investigations of civil aviation incidents and accidents should be used solely to provide data and experience in improving airline safety.
In the criminal cases in Larnaca (Cyprus) and Athens (Greece) that are presently being heard, lawyers and authorities are trying to set a precedent that will take civil aviation back to the Middle Ages. Our colleagues are standing trial for manslaughter!
Not only this - the Greek and Cypriot authorities are taking a direct part in the blame game by allowing mental and physical abuse of the defendants during the hearings. Mob rule in EU countries in the 21st century!
Why put the Helios employees on trial - just put them on the cross!!!
P.S:
from Wiki:
Private investigation
One year after the accident, the Discovery Channel aired a documentary detailing a private investigation, made in cooperation with Advanced Aviation Technology Ltd., arguing that a design failure of the Boeing 737 may have contributed to the accident.
All wiring for the pressurization system was in one wiring loop to the outflow valve in the aft of the Boeing 737. During a Boeing 737-436 G-DOCE flight in May 2003, a failure in this loop opened the outflow valve, which caused the cabin to depressurize. The same wiring failure probably caused erroneous indications to the crew that the standby pressurization system had failed and that the outflow valve was fully closed and unresponsive to pilot input. After seeing indication of the standby pressurization failure, the crew switched the pressurization control to manual mode and made an emergency descent.
Discovery Channel reported its findings on the G-DOCE incident to the Hellenic Republic's Air Accident Investigation & Aviation Safety Board.
The Board reported no evidence of wiring failure in Flight 522, and did not mention the G-DOCE incident. Because all available flight data showed the pressurization control in manual mode and the outflow valve open at a constant angle, and because there was no evidence the flight crew ever changed the pressurization mode, the Board concluded that the pressurization system had been set to manual for the entire flight, which caused the pressurization failure.
Last edited by swish266; 2nd May 2010 at 04:58.
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Sorry for their faith.
Now I am retired and don't know the last QRH but, some common sense issues may be said.
1. SOP discipline. First thing first. HORN IS YELLING :
- "ALT HOLD".
- RECALL ITEMS done: OXYGEN MASK .....ON&100%
- QRH read-out
Period.
NO OTHER ITEM DONE IS in a good SOP LOGIC! Or other habit is tolerable!
2. GOOD COMPANY EXPERIENCE passed on by experienced trainers:
From BAC1-11 days my trainers were saying at every 5000ft.:
- 5000ft.... Cabin Altitude is CLIMBING....PASS. Cabin Temperature is OK.
I was doing the same thing flying with other companies. Some copilots were smiling maliciously, others, considered it a good CRM habit.
May I say that this habit would have save those poor guys?
I know I may!
What a pity the poor speedy training!
1. SOP discipline. First thing first. HORN IS YELLING :
- "ALT HOLD".
- RECALL ITEMS done: OXYGEN MASK .....ON&100%
- QRH read-out
Period.
NO OTHER ITEM DONE IS in a good SOP LOGIC! Or other habit is tolerable!
2. GOOD COMPANY EXPERIENCE passed on by experienced trainers:
From BAC1-11 days my trainers were saying at every 5000ft.:
- 5000ft.... Cabin Altitude is CLIMBING....PASS. Cabin Temperature is OK.
I was doing the same thing flying with other companies. Some copilots were smiling maliciously, others, considered it a good CRM habit.
May I say that this habit would have save those poor guys?
I know I may!
What a pity the poor speedy training!
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Pilot error does seem to be the logical conclusion here.
Checking the tech log once boarding would have been the first warning. There must have been a maint entry stating the work carried out overnight.
- check pressurization system
- normal cockpit preparation checklist
- mistaking the press warning for config warning.
For those blaming the company, lets take it one step further. Who is it that issued this company with an AOC and who is responsible for oversight (making sure they comply with the rules).
Maybe the Cypriot CAA should be the one being sued.
Assy
Checking the tech log once boarding would have been the first warning. There must have been a maint entry stating the work carried out overnight.
- check pressurization system
- normal cockpit preparation checklist
- mistaking the press warning for config warning.
For those blaming the company, lets take it one step further. Who is it that issued this company with an AOC and who is responsible for oversight (making sure they comply with the rules).
Maybe the Cypriot CAA should be the one being sued.
Assy
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With respect, the warning horn thing was well known before Helios 522 and had been subject of accident investigation recommendations to change (Norway in 2001 and others). NASA issued a special bulletin on it in December 2004 and another one after Helios 522. Implicitly they were warning that if something weren't done something very bad could happen -- Helios 522 was it.
Boeing refuses to change it, relying on "grandfather" clauses to persist with a warning system that would be permitted on no new aircraft design. It is not a question of endlessly adding new warnings, but of getting rid of bad ones and conforming to modern manufacturing and design standards. And as for the human factors issues, competence etc,. it is a truism that, as remarked above, the best pilots can have the worst accidents. The critical path here is about accurate and unambiguous warning devices, not training or airmanship deficiencies.
Boeing refuses to change it, relying on "grandfather" clauses to persist with a warning system that would be permitted on no new aircraft design. It is not a question of endlessly adding new warnings, but of getting rid of bad ones and conforming to modern manufacturing and design standards. And as for the human factors issues, competence etc,. it is a truism that, as remarked above, the best pilots can have the worst accidents. The critical path here is about accurate and unambiguous warning devices, not training or airmanship deficiencies.
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Boeing refuses to change it, relying on "grandfather" clauses to persist with a warning system that would be permitted on no new aircraft design. It is not a question of endlessly adding new warnings, but of getting rid of bad ones and conforming to modern manufacturing and design standards. And as for the human factors issues, competence etc,. it is a truism that, as remarked above, the best pilots can have the worst accidents. The critical path here is about accurate and unambiguous warning devices, not training or airmanship deficiencies
The fact the two pilots were too stupid to see the error is the not the case.
Why make such a ridiculous "fail non-safe" system" ?
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To Yaw Damper
Having suffered five years on the 1-11 with it's attrocious air system, I totally agree with you that the 'every 5000' check would probably have caught the problem. It was drummed into me by 'The Skip' in FR (the greatest Training Pilot I have met in 35 years flying) and I carried it with me to Boeing and all it's advanced types until my dotage and to hell with it if it wasn't a standard call.
Having suffered five years on the 1-11 with it's attrocious air system, I totally agree with you that the 'every 5000' check would probably have caught the problem. It was drummed into me by 'The Skip' in FR (the greatest Training Pilot I have met in 35 years flying) and I carried it with me to Boeing and all it's advanced types until my dotage and to hell with it if it wasn't a standard call.