Greek crash CRM nightmare....

[DE727UPS]

Crew confusion found in Athens plane crash
By Don Phillips International Herald Tribune
WEDNESDAY, SEPTEMBER 7, 2005


PARIS The crew members of a Cypriot airliner that crashed Aug. 14 near
Athens became confused by a series of alarms as the plane climbed, failing
to recognize that the cabin was not pressurizing until they grew mentally
disoriented because of lack of oxygen and passed out, according to several
people connected with the investigation.

Complicating the cockpit confusion, neither the German pilot nor the young,
inexperienced Cypriot co-pilot could speak the same language fluently, and
each had difficulty understanding how the other spoke English, the worldwide
language of air traffic control.

A total of 121 people were killed in the crash after the plane climbed and
flew on autopilot, circling near Athens as it was programmed to do until one
engine stopped running because of a lack of fuel. The sudden imbalance of
power, with only one engine operating, caused the autopilot to disengage and
the plane to begin its final descent.

The Greek authorities have made cryptic statements hinting at oxygen
problems but have so far not announced the full findings of investigators.

The people interviewed for this article agreed to do so on condition that
they not be identified because none are official spokesmen for the
investigation and because of political sensitivities arising from a Cypriot
plane crashing in Greece.

Investigators pieced together the story of the crash from numerous sources.
In the wreckage, they found the first solid clues - the pressurization valve
and an air outflow valve set incorrectly. Air traffic control tapes provided
information on the confusion in the cockpit.

The plane had a sophisticated new flight data recorder that provided a
wealth of information. There were maintenance records from the night before,
and investigators interviewed the mechanics who worked on the plane.

Among other things, the investigators determined that the pilot was not in
his seat because he was up trying to solve a problem that turned out to be
not the greatest threat facing him.

The plane that crashed, a Boeing 737, underwent maintenance the night
before. The maintenance crew apparently left a pressurization controller
rotary knob out of place, according to the officials connected to the
investigation, and the crew did not catch the mistake during preflight
checks the next day. This meant that the plane could not pressurize.

At 10,000 feet, or 3,000 meters, as designed, an alarm went off to warn the
crew that the plane would not pressurize. However, the crew members
mistakenly thought that the alarm horn was a warning to tell them that their
controls were not set properly for takeoff, the officials said.

The same horn is used for both conditions, although it will sound for
takeoff configuration only while the plane is still on the ground.

The crew continued the climb on autopilot. At 14,000 feet, oxygen masks
deployed as designed and a master caution light illuminated in the cockpit.
Another alarm sounded at about the same time on an unrelated matter, warning
that there was insufficient cooling air in the compartment housing avionics
equipment.

The radio tapes showed that this created tremendous confusion in the
cockpit. Normally an aircraft cabin is held at 8,000 feet pressure, so the
crew at over 14,000 feet would already be experiencing some disorientation
because of a lack of oxygen.

During this time, the German captain and the Cypriot co-pilot discovered
they had no common language and that their English, while good enough for
normal air traffic control purposes, was not good enough for complicated
technical conversation in fixing the problem.

The crew members called the maintenance base in Cyprus and were told that
the circuit breaker to turn off the loud new alarm was in a cabinet behind
the captain. The captain got up from his seat to look for the circuit
breaker, apparently ignoring the confused co-pilot.

As the plane continued to climb on autopilot, the air grew so thin that the
crew became seriously impaired. The captain passed out first on the floor of
the cockpit, followed by the co-pilot, who remained in his seat, according
to the officials.

The autopilot did as it was programmed to do, flying the plane at 34,000
feet to Athens and entering a holding pattern. It remained in a long
circling pattern, shadowed by Greek military jets, until fuel ran low and
one engine quit.

Boeing, the maker of the plane, is-sued a notice shortly after the crash to
airlines that it would revise flight crew training manuals to stress to
crews that they must understand how the various warning systems work and
what to do about them.

The notice stresses that the takeoff configuration warning horn will not
sound under any circumstances after the plane has left the ground.

The same horn will then be used only for a cabin altitude warning. The
company notice said there had been other instances of confusion over the
horn by pilots.

"Confusion between the cabin altitude warning horn and the takeoff
configuration warning horn can be re-solved if the crew remembers that the
takeoff configuration warning horn is only armed when the airplane is on the
ground," the notice said. "If this horn is activated in flight, it indicates
that the cabin altitude has reached 10,000 feet."

[E_Dawg]

[ QUOTE ]
Boeing, the maker of the plane, is-sued a notice shortly after the crash to
airlines that it would revise flight crew training manuals to stress to
crews that they must understand how the various warning systems work and
what to do about them.

[/ QUOTE ]

So people died because the pilots didn't know what the warning systems were telling them, nor could they figure it out because they couldn't even understand each other. That's on par with running out of fuel IMO.

[Minnesota_Flyer]

[ QUOTE ]
Complicating the cockpit confusion, neither the German pilot nor the young, inexperienced Cypriot co-pilot could speak the same language fluently, and each had difficulty understanding how the other spoke English, the worldwide language of air traffic control.
. . .
During this time, the German captain and the Cypriot co-pilot discovered they had no common language and that their English, while good enough for normal air traffic control purposes, was not good enough for complicated technical conversation in fixing the problem.

[/ QUOTE ]

[JEP]

Just goes to show that is never "one" thing that does it. It is the "Chain of Events" that eventually does one in.

[pilot602]

This is the finish line of the race to the bottom, folks.


Ugly, ain't it?

[Doug Taylor]

Just wait to see what happens if they're successful eroding 'cabotage laws'!

[pilot602]

That was my exact thought!

But this is also waiting to happen here if 300 hour wonders* keep getting into jets... the Pinnacle jet fiasco comes to mind ...










*Not all 300 hour pilots are incapable of handling it but the majority are.

[mpenguin1]

And people wonder why the preflight check is so important:

[ QUOTE ]
The plane that crashed, a Boeing 737, underwent maintenance the night before. The maintenance crew apparently left a pressurization controller rotary knob out of place, according to the officials connected to the investigation, and the crew did not catch the mistake during preflight checks the next day. This meant that the plane could not pressurize.

[/ QUOTE ]

That is a CRM nightmare, we may add this to our CRM class....

[asl]

Aren't there supposed to be checklists issued by either the airline or the manufacturer for what to do when such and such an alarm sounds? If they'd pulled these out and followed them, none of this would've happened. Yes there is a chain of events starting with poor maintenance, and obviously a CRM communication problem - BUT the biggest failure is not following procedures immediately when a certain alarm sounds.... this is pure and simple pilot error (I hate to say so, but it is in my opinion), the other things are contributing factors which could probably be put down to a lack of adequate training of the pilots.

[Kristie]

so is it commonplace to check that valve to make sure it's closed during the precheck??

[Doug Taylor]

I'm sure there's more to the situation, but keep in mind that it's a newspaper article and not a factual report from an official investigation.

But curiously, the takeoff warning horn and the cabin altitude warning may have the same sound, however, if I remember correctly, I wonder what was up with the annunciator? I can't imagine a scenario when I'd hear a generic aural warning and not refer to the annunciator panel.

I'm sure there's more to the story than the information from the article.

[Doug Taylor]

[ QUOTE ]
so is it commonplace to check that valve to make sure it's closed during the precheck??

[/ QUOTE ]

If I remember correctly, there's a valve position indicator on the pressurization controller on the 737, in addition to a cabin altitude readout and a "differential pressure" indicator that's normally checked during the after takeoff checklist.

In the MD-80 series aircraft, there's this weird yellow-colored 'trim wheel' type thing on the right side of the throttle quadrant that indicated valve position.

But even if it's indicating closed, if you're not getting some pressure differential and your cabin altitude VSI is climbing like made, physically you're going to notice.

[Baronman]

[ QUOTE ]
so is it commonplace to check that valve to make sure it's closed during the precheck??

[/ QUOTE ]

That's a question u should ask mr ex 737 driver, Mr. Jetcareers, Mr Taylor himself tonight just before going to sleep....

I'll preface this by saying I'm not a 737 pilot but....During preflight checks there are certain switches/buttons that are 99% of the time in their correct position, others you have to manipulate and check something every time. THose that are normally in their correct positions are the one's that could bite u in the arse if you're just carelessly going through the motions.

[Ophir]

[ QUOTE ]
so is it commonplace to check that valve to make sure it's closed during the precheck??

[/ QUOTE ]

Yes, it is standard in the preflight insure that the pressurization system is set to AUTO, the barometric pressure matches the actual and the rate of climb/descent is set. For us, we then need to confirm this on the pre-start checklist and also set the cabin altitude for the flight.

Dunno the way Boeing does it but my understanding is that most pressurization systems are pretty similar. But even in our little Brasilia that can't go that high, but it can go high enough to kill ya, that we have a CABIN ALTITUDE annunciator. But we still have to call back to the FA to see if the rubber jungle came down.

[Doug Taylor]

Heck, a 182 can climb high enough to kill ya!

It's all in thte ISA my friend!

[Kristie]

rubber jungle?

[Baronman]

[ QUOTE ]
rubber jungle?

[/ QUOTE ]
When all the oxygen masks come falling down....creating the illusion of a rubber jungle! (Minus the gorillas of course).

[Kristie]

ahh.. that's what i thought it was! thanks for the clarification!

[DE727UPS]

Here's what happened. A really loud horn went off...beep beep beep. This horn is the same horn that goes off on the ground if you don't have the flaps set to a takeoff setting, if the speed brakes aren't stowed, or it the stab trim isn't in the green band. It's called a takeoff configuration warning. So this horn starts going off at 10K on the climb. Beep, beep, beep, and it's REALLY loud. (same horn is the cabin altitude warning)

The Capt has heard this horn before and it's always been on the ground with something not set right for takeoff. So he hears it in the air and automatically thinks it's some weird takeoff config warning in flight. These damn old airplanes are always breaking in bizarre ways. The F/O, who is probably clueless since cockpit prep is his job and he missed the "rotary switch" being in the wrong position, plus he's low time, plus he can't speak the Capt's language, is unable to help with the situation.

All the Capt can think about is making that horn stop. Where is the friggen breaker. The F/O's just sitting there watching and has no idea what's going on.

Capt passes out cause he's out of the seat trying to make the horn stop with the impossible takeoff config problem and not on O2. F/O passes out cause he's not on O2 and has no idea what that beeping noise means....how could you get a takeoff config warning at altitude????

Of couse, this scenario is all speculation.

On the 727-100, same vintage as 737-200's, basically. The first thing the F/E did after walking in the plane was turn the knob on the oxygen bottle which was located behind the F/E panel. As an F/O, the first thing I did after sitting down was making sure the F/E had turned the O2 bottle on, as it was easily within reach. Not sure if you'd call an oxygen valve knob on the top of the O2 bottle a "rotary selector" or not, but if they didn't have the O2 bottle on, nobody in the cockpit is gonna get any oxygen. We need a 737-200 guy on here to tell us about the cockpit O2 setup.

[Doug Taylor]

I could look it up when I get home tonight. I think I might still have some 737-200/300 manuals are the home office.

[mpenguin1]

[ QUOTE ]
HWe need a 737-200 guy on here to tell us about the cockpit O2 setup.

[/ QUOTE ]

I'll ask my 737 instructors about this in the morning....

[ComplexHiAv8r]

[ QUOTE ]
I'll preface this by saying I'm not a 737 pilot but.

[/ QUOTE ]

you stayed at a Holiday Inn Express last night????

[mpenguin1]

[ QUOTE ]
so is it commonplace to check that valve to make sure it's closed during the precheck??

[/ QUOTE ]

I asked my 737 instructors/pilots this morning & they said that this should have been caught during the preflight, the control should have been set to "Auto"..

[Doug Taylor]

Yup, I'm digging thru my old -200 manual and there's a "FLT/GND" switch. I remember we used to flip it to "FLT" during the taxi check. Also a "outflow valve position indicator" which may have been helpful in troubleshooting along with an annunciator which I forgot about: "Off Sched Descent".

[DE727UPS]

I was thinking back to the 727-100 F/E days. We had a switch back on the panel that ran a fan that actually sucked the outflow valve open on the ground. That was how we fully depressurized on the ground. As I recall, though, the air ground sensor would override that switch in the air and the cabin would get pressure no matter what. Kinda surprised the "advanced", for it's day, 737-200, didn't have that.