Helios Crash
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The investigation itself appears to be to a 1st world-country standard. The litigation side of things is a little different.
When are management finally liable for cutting costs in every area (apart from their own bonus schemes etc)? This may well rattle their cage and be a wake up call for every other goose out there that thinks they can keep cutting costs on training and safety, get away with it and claim to have increased efficiency.
The line has to be drawn somewhere and responsibilities must be accepted by those running the system. There is so much we can do when the system lets us down... I guess we could always leave..Perhaps.
When are management finally liable for cutting costs in every area (apart from their own bonus schemes etc)? This may well rattle their cage and be a wake up call for every other goose out there that thinks they can keep cutting costs on training and safety, get away with it and claim to have increased efficiency.
The line has to be drawn somewhere and responsibilities must be accepted by those running the system. There is so much we can do when the system lets us down... I guess we could always leave..Perhaps.
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Well said Trim Run I have known And worked with Alan some 20 years and is one of the most knowledgable engineers I have meat
The Greek authorities have insufficient evidence to convict the engineer however
There has to be a scape goat for the the friends and families of the victims
This is nothing but a kangaroo court and I think time the UK CAA and the AAIB we're involved.
The Greek authorities have insufficient evidence to convict the engineer however
There has to be a scape goat for the the friends and families of the victims
This is nothing but a kangaroo court and I think time the UK CAA and the AAIB we're involved.
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alan irwin ia a first class engineer who’s knowledge of aircraft is second to none. The report on the helios crash shows he did his job correctly and iaw the amm as always. It would seem he is being blamed for being there and not for any failures. this growing trend of justices systems in many different countries to persecute hard working proffesionals just to try and prove that something has been done will lead to a lowing of safty standards due to the reluctance of all aviation personnel to speak out on any safty issue before or after an incident due to fear of self incrimination.
Has any of you received an aircraft from maintenance and always found all switches in the correct position? Don't we preflight the aircraft to ensure serviceably, check switch positions and function check items? When I accept an aircraft I assume some switches that should be either off or on are incorrectly set and it's my job is to make sure they are correct. Insane to charge the engineer for this.
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It was a "freak" accident because so many holes in the cheese had to line up that day;
door report---switch left in manual after maintenance action---FO misses switch setting in pre-flight scan---Captain misses the same---horn at ten thousand cabin confuses not one but BOTH pilots-Equip cooling problem that is due to lack of pressurization SIDETRACKS both pilots from the real issue---Master Caution oxygen drop annunciation is missed due masking---Plane is light and quickly climbs to its cleared level 340---Captain is EAST German native and accent is strong---FO has just failed captain upgrade and is feeling resentful---they DONT like each other---Helios FA's and flt deck didnt brief together---who knew the code???--FA's remain sitting while plane climbs and climbs---would you sit in your seat while the plane continues to climb?
Who would believe such a scenario?It sounds like science fiction.Precedents of this type of accident (insidious failure to pressurize) have happened but there was always something that broke the chain eg,one flight crew member recognizes what is going on OR FA's making their way to the flight deck regardless of SOP.
If you factor in the old design of the B737 (one horn for 2 different problems) and the fact that failure to pressurize in a climb is insidious and could be a nasty trap,theres no doubt in my mind that this was a "one off" crash and that the flight crew were responsible.Were they unfit?No,pilots have taken off without flaps and stalled.Pilots stalled a 737 on final because they werent monitoring airspeed.Mistakes are part of human nature.
If the two pilots did not get on and were both viewed as weak under pressure,then I would have some measure of agreement in the accusation that they should not have flown together as a crew.But hindsight is 20/20.
door report---switch left in manual after maintenance action---FO misses switch setting in pre-flight scan---Captain misses the same---horn at ten thousand cabin confuses not one but BOTH pilots-Equip cooling problem that is due to lack of pressurization SIDETRACKS both pilots from the real issue---Master Caution oxygen drop annunciation is missed due masking---Plane is light and quickly climbs to its cleared level 340---Captain is EAST German native and accent is strong---FO has just failed captain upgrade and is feeling resentful---they DONT like each other---Helios FA's and flt deck didnt brief together---who knew the code???--FA's remain sitting while plane climbs and climbs---would you sit in your seat while the plane continues to climb?
Who would believe such a scenario?It sounds like science fiction.Precedents of this type of accident (insidious failure to pressurize) have happened but there was always something that broke the chain eg,one flight crew member recognizes what is going on OR FA's making their way to the flight deck regardless of SOP.
If you factor in the old design of the B737 (one horn for 2 different problems) and the fact that failure to pressurize in a climb is insidious and could be a nasty trap,theres no doubt in my mind that this was a "one off" crash and that the flight crew were responsible.Were they unfit?No,pilots have taken off without flaps and stalled.Pilots stalled a 737 on final because they werent monitoring airspeed.Mistakes are part of human nature.
If the two pilots did not get on and were both viewed as weak under pressure,then I would have some measure of agreement in the accusation that they should not have flown together as a crew.But hindsight is 20/20.
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In the light of the judgement, I (as an engineer) would have to think long & hard about working either on a Greek registered aircraft or one located there.
10 years for leaving a switch in a certain position & a European arrest warrant meaning you'll probably have to try & get help from your Greek jail cell......
This has shades of the carbon monoxide case, where resort reps were held responsible for a hotel's poor boiler installation.
10 years for leaving a switch in a certain position & a European arrest warrant meaning you'll probably have to try & get help from your Greek jail cell......
This has shades of the carbon monoxide case, where resort reps were held responsible for a hotel's poor boiler installation.
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Many holes in the cheese, indeed...
Akrivos Tsolakis final report :
Latent causes
1. The Operator’s deficiencies in organization, quality management and safety culture, documented diachronically as findings in numerous audits.
2. The Regulatory Authority’s diachronic inadequate execution of its oversight responsibilities to ensure the safety of operations of the airlines under its supervision and its inadequate responses to findings of deficiencies documented in numerous audits.
/…/
Akrivos Tsolakis final report :
Latent causes
1. The Operator’s deficiencies in organization, quality management and safety culture, documented diachronically as findings in numerous audits.
2. The Regulatory Authority’s diachronic inadequate execution of its oversight responsibilities to ensure the safety of operations of the airlines under its supervision and its inadequate responses to findings of deficiencies documented in numerous audits.
/…/
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Alan Irwin
Like Trim Run and TOON737, I have known Alan Irwin for a long time - almost 20 years - and can honestly say he is one of the most professional and diligent engineers that I have had the pleasure to work with.
His knowledge and experience on the B737 (and other aircraft types) is beyond reproach and, I can only reiterate other comments made here, that he is being made a scapegoat for, what is basically, 3rd world politics.
Fight them with as much as you've got Al and prove that you are innocent in this affair. It will mean fighting at a high level but you can do it and hit these
where it hurts. There must be many LAE's questioning their job right now and the only way to stop this nonsense is to prove that following AMM procedures is not an offence - my best wishes are with you in this fight!
His knowledge and experience on the B737 (and other aircraft types) is beyond reproach and, I can only reiterate other comments made here, that he is being made a scapegoat for, what is basically, 3rd world politics.
Fight them with as much as you've got Al and prove that you are innocent in this affair. It will mean fighting at a high level but you can do it and hit these
where it hurts. There must be many LAE's questioning their job right now and the only way to stop this nonsense is to prove that following AMM procedures is not an offence - my best wishes are with you in this fight!
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Such a lack of CRM...
Hi All,
This case is particularly pertinent to me and I have taught it a couple of times at work.
The fault in question was reported as "loud knocking noise heard from the aft (starboard) service door during flt" in the cabin defect log. That was transposed into the tech-log as "aft service door requires full inspection". Without getting into the nitty-gritty, the latter is a very different comment. Crew are advised to write symptoms into the log in order for the engineers to work out the cure.
This lead the engrs to carry out the incorrect task, however, the CAUSE of the pressurisation failure should have been picked up by THE FLIGHT CREW. The engineering checks do not require them to put the a/c back to a "standard flight" condition. As a consequence we (pilots) are generally pretty aware of switch positions post maintenance.
I did my training with Andreas Prodromou who was the number 4 steward and he had swapped onto the trip to be with his girlfriend who was the number 3. Andreas had a job starting with Astraeus at the end of the summer season apparently. He would have known what he was looking at when he finally got into the flight deck: we did our MCC on the 737 at Oxford.
The skipper was an incompitent autocrat who thought CRM was a hinderance.
Helios paid lip service to CRM with little formal training.
Jet2 refused to renew the skipper's contract and he ended up at Helios.
Another mate of mine flew with the skipper and when he heard who it was showed no surprise.
This accident could have been avoided had the captain (notice use of lower case "c"):
a) not had 12 jobs in 12 years. It is questionable whether-or-not the captain had covered all the a/c systems within a 3 year period as a result.
b) believed in CRM
c) levelled off when the "gear" horn sounded (the horn was in fact the cabin press warning).
The Hellenic investigators comment in the report:
"...There was such a lack of evidence of CRM that it was considered a major contributrary cause to the accident..."
Sadly, in my humble opinion, whilst there were failings with the Helios management hierarchy and it is right and proper that punative measures are taken, this accident would PROBABLY have been avoided with any other captain.
I strongly agree with all comments reference Engineers and pilots checking switches but think it is EXCEEDINGLY unfair to punish the engineers. This was solely, after the engineering checks, a flight crew related error.
My summary to the courses usually runs along the following lines:
Captains: write SYMPTOMS not the cure into the tech-log.
Cabin Crew: if the masks drop and you still carry on climbing, do what you can to get onto the flight deck
Cause: One switch was in the wrong place and it should have been picked up about 6 times before FL100.
CRM: As per the Hellenic board, "...there was such a lack of evidence of CRM that it was considered to be a major contributrary cause of the accident..."
This case is particularly pertinent to me and I have taught it a couple of times at work.
The fault in question was reported as "loud knocking noise heard from the aft (starboard) service door during flt" in the cabin defect log. That was transposed into the tech-log as "aft service door requires full inspection". Without getting into the nitty-gritty, the latter is a very different comment. Crew are advised to write symptoms into the log in order for the engineers to work out the cure.
This lead the engrs to carry out the incorrect task, however, the CAUSE of the pressurisation failure should have been picked up by THE FLIGHT CREW. The engineering checks do not require them to put the a/c back to a "standard flight" condition. As a consequence we (pilots) are generally pretty aware of switch positions post maintenance.
I did my training with Andreas Prodromou who was the number 4 steward and he had swapped onto the trip to be with his girlfriend who was the number 3. Andreas had a job starting with Astraeus at the end of the summer season apparently. He would have known what he was looking at when he finally got into the flight deck: we did our MCC on the 737 at Oxford.
The skipper was an incompitent autocrat who thought CRM was a hinderance.
Helios paid lip service to CRM with little formal training.
Jet2 refused to renew the skipper's contract and he ended up at Helios.
Another mate of mine flew with the skipper and when he heard who it was showed no surprise.
This accident could have been avoided had the captain (notice use of lower case "c"):
a) not had 12 jobs in 12 years. It is questionable whether-or-not the captain had covered all the a/c systems within a 3 year period as a result.
b) believed in CRM
c) levelled off when the "gear" horn sounded (the horn was in fact the cabin press warning).
The Hellenic investigators comment in the report:
"...There was such a lack of evidence of CRM that it was considered a major contributrary cause to the accident..."
Sadly, in my humble opinion, whilst there were failings with the Helios management hierarchy and it is right and proper that punative measures are taken, this accident would PROBABLY have been avoided with any other captain.
I strongly agree with all comments reference Engineers and pilots checking switches but think it is EXCEEDINGLY unfair to punish the engineers. This was solely, after the engineering checks, a flight crew related error.
My summary to the courses usually runs along the following lines:
Captains: write SYMPTOMS not the cure into the tech-log.
Cabin Crew: if the masks drop and you still carry on climbing, do what you can to get onto the flight deck
Cause: One switch was in the wrong place and it should have been picked up about 6 times before FL100.
CRM: As per the Hellenic board, "...there was such a lack of evidence of CRM that it was considered to be a major contributrary cause of the accident..."
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Helios Trial
A few facts;
the CVR was 30 minutes so the last 30 minutes was recorded
it was ASSUMED the engineer left the PMS in MAN because it was found "past MAN" having been severely damaged in the impact and he was the last person who admitted touching it
there is evidence that he did return it to AUTO
there is evidence that it was in AUTO at impact but was moved by the impact
both bleeds were OFF before impact
both audio switches were to MASK
Alan Irwins comments to the investigation were "lost" then "found" but were not considered because they had not been "adopted" by UK AAIB.
The message - be careful what you say to investigators, you can never be certain it won't be used against you
You want me to go on or do you accept someone was stitched up!
the CVR was 30 minutes so the last 30 minutes was recorded
it was ASSUMED the engineer left the PMS in MAN because it was found "past MAN" having been severely damaged in the impact and he was the last person who admitted touching it
there is evidence that he did return it to AUTO
there is evidence that it was in AUTO at impact but was moved by the impact
both bleeds were OFF before impact
both audio switches were to MASK
Alan Irwins comments to the investigation were "lost" then "found" but were not considered because they had not been "adopted" by UK AAIB.
The message - be careful what you say to investigators, you can never be certain it won't be used against you
You want me to go on or do you accept someone was stitched up!
Last edited by airsnoop; 23rd Apr 2012 at 17:14.
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AAIB Involvement
TOON737 - Alan Irwin is a first class engineer and did nothing wrong.
To answer your last remark, he did appeal to the UK AAIB for help when the Greeks "lost" his submission that showed he could not have left the PMS in MAN - unfortunately they declined to help him clear this up.
They had not appointed an accredited representative because "there was no UK involvement - Safety oversight by UK CAA/JAR 145 Maintenance organisation ATC Lasham/pilots checked out by UK TREs/Alan was a UK LAe/ etc etc - so could not participate in the investigation even though entitled.
Appears to come under the heading of all too difficult and the excuse was not getting involved in criminal proceedings - if Alan is right it is an air safety concern as the investigation has missed the real cause of this accident.
To answer your last remark, he did appeal to the UK AAIB for help when the Greeks "lost" his submission that showed he could not have left the PMS in MAN - unfortunately they declined to help him clear this up.
They had not appointed an accredited representative because "there was no UK involvement - Safety oversight by UK CAA/JAR 145 Maintenance organisation ATC Lasham/pilots checked out by UK TREs/Alan was a UK LAe/ etc etc - so could not participate in the investigation even though entitled.
Appears to come under the heading of all too difficult and the excuse was not getting involved in criminal proceedings - if Alan is right it is an air safety concern as the investigation has missed the real cause of this accident.
The Greek authorities have insufficient evidence to convict the engineer however
If the MM didn't specify that the switch should have been returned to a set position after maintenance, what can he be charged with?
Seems to me as though the Greeks have their scapegoats in a line.
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This is a very interesting thread.
Very sad for all involved.
I have not read the details for a long time, but a few points that come to mind.
1. Press switch/knob not the clearest/ind/de-tents.
2. Press mode light/ind cluster as above, waiting to happen.
3. Boeing made previous hi-lights of the above. "Beware"
4. MM checks of this system did not state switch positions after checks.
From memory, some layover/nightstop aircraft would have the outflow valve closed for various reasons, I think method was often by putting selector to Man, run closed, pull aircraft power and then select mode to Auto, next power up all back to normal, no problems.
Thinking about item 2 above, did we not see a good example of this indicator type on a LH 747 at NBO (1975ish ???) that was poss external lighting issues, but even a filament or two failures may not be of help, again thinking back, I recall Green was Auto and Blue was Man ????
Lets hope some lessons are learnt and save others in the future.
I also find it hard to understand how the Engineer is finding himself in this position, what do they say about the law ??????
My last thought for the day, on turnaround/transit aircraft, check panels well, nightstop/layover aircraft check panels well, after maint performed check panels well, after cockpit cleaning check panels well. Don't use Autoscan, use Manscan and keep it interesting(rev scan using other hand works for me)
Cheers all.....
Very sad for all involved.
I have not read the details for a long time, but a few points that come to mind.
1. Press switch/knob not the clearest/ind/de-tents.
2. Press mode light/ind cluster as above, waiting to happen.
3. Boeing made previous hi-lights of the above. "Beware"
4. MM checks of this system did not state switch positions after checks.
From memory, some layover/nightstop aircraft would have the outflow valve closed for various reasons, I think method was often by putting selector to Man, run closed, pull aircraft power and then select mode to Auto, next power up all back to normal, no problems.
Thinking about item 2 above, did we not see a good example of this indicator type on a LH 747 at NBO (1975ish ???) that was poss external lighting issues, but even a filament or two failures may not be of help, again thinking back, I recall Green was Auto and Blue was Man ????
Lets hope some lessons are learnt and save others in the future.
I also find it hard to understand how the Engineer is finding himself in this position, what do they say about the law ??????
My last thought for the day, on turnaround/transit aircraft, check panels well, nightstop/layover aircraft check panels well, after maint performed check panels well, after cockpit cleaning check panels well. Don't use Autoscan, use Manscan and keep it interesting(rev scan using other hand works for me)
Cheers all.....
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Does any one here have the original verdict by the Greek Judge, or is it not available on internet? I am really very curious to his/her motivation and the underlaying reasoning to convict these 4 seen the availability of proof in this case.
An other matter is offcourse the use of non-punitive information being transformed in punitive, a very very scary development and as such I presume a serious threat to flight safety as such. Forgive me if I am wrong, but I still did not see any evidence of gross negliance or willful misconduct in this matter by the 4 involved.
An other matter is offcourse the use of non-punitive information being transformed in punitive, a very very scary development and as such I presume a serious threat to flight safety as such. Forgive me if I am wrong, but I still did not see any evidence of gross negliance or willful misconduct in this matter by the 4 involved.
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"Scapegoat...for 3rd world politics"
Post #27 inter alia
i) Interesting to compare this judicial decision with similar proceedings in Kingdom of Spain re Spanair accident at Madrid ?
ii) Very interesting to compare and to contrast this decision with likely outcome (no criminal proceeedings; natch?) for the yet-to-be-resolved investigation into the Cork accident, involving as it does a myriad of state supervisory and private organisations and companies [not to mention "ticket sellers"] registered in:
Kingdom of Spain
The United Kingdom
Republic of Ireland
(Banana Republic?) of Isle of Man
[plus overall "control" by the EU]
not to mention original manufacture in the US of A ?
How many "3rd world standard" procedure will that one reveal, I ask
i) Interesting to compare this judicial decision with similar proceedings in Kingdom of Spain re Spanair accident at Madrid ?
ii) Very interesting to compare and to contrast this decision with likely outcome (no criminal proceeedings; natch?) for the yet-to-be-resolved investigation into the Cork accident, involving as it does a myriad of state supervisory and private organisations and companies [not to mention "ticket sellers"] registered in:
Kingdom of Spain
The United Kingdom
Republic of Ireland
(Banana Republic?) of Isle of Man
[plus overall "control" by the EU]
not to mention original manufacture in the US of A ?
How many "3rd world standard" procedure will that one reveal, I ask
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Greek Registered Aircraft
Just to amplify a point made by Wenwe; the aircraft was neither Greek registered nor located there. It was a Cypriot registered aircraft based and operated from Larnaca.
This could happen to any of you who manage or work on any aircraft that operates into Greece from UK.
Greece was the State of Occurrence in ICAO speak and the State that conducted the investigation and the State whose legal system allows prosecution on evidence that would not apparently be acceptable in a UK ciminal court.
This could happen to any of you who manage or work on any aircraft that operates into Greece from UK.
Greece was the State of Occurrence in ICAO speak and the State that conducted the investigation and the State whose legal system allows prosecution on evidence that would not apparently be acceptable in a UK ciminal court.
for the safety of my freedom.
ICAO Annex 13
I think its worth pointing out this extract from ICAO Annex 13:
5.4.1 Recommendation.— Any judicial or administrative
proceedings to apportion blame or liability should be
separate from any investigation conducted under the
provisions of this Annex.
We all need to think how we would react now if asked to 'co-operate' in an Air Accident Investigation when a European Court can take information from an Accident Investigation Report, which is not intended to apportion blame to an acceptable level to that of a criminal investigation, and use it as evidence of criminal guilt. Imagine what a Jury or non technical Judge could make from and Accident Investigation that was being used by the Prosecution and quoted from in order to apportion blame. Next then, think of the ease in which people can be extradited from the UK to another European State. Can I suggest we all lobby the BALPA and ALAE/Prospect Reps, maybe a joint BALPA/ALAE campaign might be the way forward?
5.4.1 Recommendation.— Any judicial or administrative
proceedings to apportion blame or liability should be
separate from any investigation conducted under the
provisions of this Annex.
We all need to think how we would react now if asked to 'co-operate' in an Air Accident Investigation when a European Court can take information from an Accident Investigation Report, which is not intended to apportion blame to an acceptable level to that of a criminal investigation, and use it as evidence of criminal guilt. Imagine what a Jury or non technical Judge could make from and Accident Investigation that was being used by the Prosecution and quoted from in order to apportion blame. Next then, think of the ease in which people can be extradited from the UK to another European State. Can I suggest we all lobby the BALPA and ALAE/Prospect Reps, maybe a joint BALPA/ALAE campaign might be the way forward?
Criminal Prosecution Insurance
Perhaps a question we should all be asking our Employers is whether the Company has us covered for Criminal Prosecution Insurance?
Many Airlines would not have this sort of cover to protect its Employees from and at around about an average of one million euros required to defend a person involved in a fatal Transport Aircraft crash its way beyond peoples personal means. Lets also not forget we are not just talking about Pilots and Engineers here but everyone involved in an Airline Operation, Managers, Trainers etc etc
Many Airlines would not have this sort of cover to protect its Employees from and at around about an average of one million euros required to defend a person involved in a fatal Transport Aircraft crash its way beyond peoples personal means. Lets also not forget we are not just talking about Pilots and Engineers here but everyone involved in an Airline Operation, Managers, Trainers etc etc