Human error blamed for 2005 Greek crash

[mpenguin1]

Investigators cited human error Tuesday as the main cause of the Helios Airways crash that killed all 121 passengers and crew near Athens on Aug. 14, 2005, the deadliest air disaster in the history of Greece and Cyprus.

The two pilots of the Cypriot 737-300 failed to competently operate controls regulating cabin pressure and misinterpreted a subsequent warning, which eventually led to the crew passing out and the crash of the jetliner north of the Greek capital, according to a report delivered to Greece's transport minister.

Maintenance officials left pressure controls on an incorrect setting, the report said, and the aircraft's manufacturer, Boeing, was cited for "ineffectiveness of measures taken in response to previous pressurization incidents in the particular type of aircraft."

http://news.yahoo.com/s/ap/20061010/...e_helios_crash

[meritflyer]

Always the pilots fault..

[TXaviator]

i can see its ultimately the pilots' fault, but sounds like MX didnt do them any favors either

[falconvalley]

Unfortunately, that's one of those things that maintenance can screw up that pilots can still catch. Be careful out there. Even if the warning doesn't make sense to you doesn't mean that it's erroneous. Sometimes the most dangerous abnormalities can appear to be just curious anomolies.

[ananoman]

Originally Posted by meritflyer

Always the pilots fault..

In this case it sure was.

[TonyC]

Originally Posted by meritflyer

Always the pilots fault..

Sometimes it IS the pilots' fault. This appears to be one of them.


This story is a media account of the events, and offers little detail to explain what happened.


First, there's the position of the Cabin Pressure Controller switch. 99% of the time it was likely in the AUTO position, and required no action on the part of either pilot. Although it's almost certain that one of the pilots was required to verify the correct position of this switch before flight, it's easy to see how it could be missed, and cause no problem. If the switch is in AUTO, but it's not verified to be in AUTO, it still works. If it's not verified the next flight, but it's in AUTO, it still works. If it's not verified in AUTO, but it's in AUTO, it still works. Pretty soon, a habit has evolved that fails to verify the switch in AUTO. Then one day it's not in AUTO - - it doesn't work.


So, what are the symptoms of the problem when it doesn't work? Well, as it happens, the Aural Alert that sounds when the cabin altitude exceeds 10,000' or so is the exact same Aural Alert that sounds when there is a problem with the configuration of flaps, landing gear, and throttles. If you attempt to takeoff with the flaps up, the horn sounds when you push up the throttles. Or, if you lower the flaps to a landing setting without lowering the landing gear, the horn sounds. Or, if you retard the throttles to idle (below a certain altitude, in some cases), the same horn sounds. It's not uncommon to hear that horn on every flight. In fact, it's likely tested during preflight.


So, you're climbing along, fat, dumb, and happy, and this horn sounds. What's your first instinct? As many times as I've been through the drill in the sim, my first instinct is STILL to check the throttles, flaps, and landing gear. I can understand how the pilots would focus on that, and ignore the other clues. It's easy to understand how a little annunciator light indicating the masks had dropped in the cabin could have been overlooked. It's not like a mask dropped in front of THEIR faces. So, they're preoccupied with this landing gear warning horn, maybe decide to get up and pull the circuit breaker to make it stop squawking, and before you know it, they're hypoxic.

Add to this scenario the fact that the only language they shared was English, and neither one of them spoke it well, and you have a recipe for disaster.


It's something to think about the next time you consider skimming through the preflight. The chain could have been broken right there.





.

[DE727UPS]

"Pretty soon, a habit has evolved that fails to verify the switch in AUTO. Then one day it's not in AUTO - - it doesn't work"

If there's one thing that will bite you in the butt it's not checking ALL the switches in your cockpit setup. The kind of complacency is pretty common (seen it in myself). Mechanics get up there between flights and do all kinds of weird things with switches, sometimes. Then they don't put them back. You gotta force yourself to check all them switches.

[Italianaviator]

That really makes me think about the preflight more indepth. Because I know I always overlook the ELT switch in the Cessna 172 because it's always armed and just like TonyC said if it's always armed you just take it for granted.

[frog_flyer]

Any time a foreign aircraft crashes it's pilot error.

Less Aeroflot where it is 50/50 for catostrophic mechanical failure : pilot error

[TonyC]

Originally Posted by frog_flyer

Any time a foreign aircraft crashes it's pilot error.

Less Aeroflot where it is 50/50 for catostrophic mechanical failure : pilot error

I don't recall anyone saying "any time a foreign aircraft crashes it's pilot error." IN THIS crash, however, pilot error DOES appear to be the causal factor.

In case you think I made up the above, I'm posting a link to a more reputable source:

Aviation Safety Network: Helios Flight 522







.

[PGT]

one of the F16 pilots Saw a person walk through the cabin door, they tried to contact him but nothing.

On 14 August 2005, a Boeing 737-300 aircraft, registration number 5B-DBY, operated by Helios Airways, departed Larnaca, Cyprus at 09:07 h for Prague, Czech Republic, via Athens, Hellas. The aircraft was cleared to climb to FL340 and to proceed direct to RDS VOR. As the aircraft climbed through 16 000 ft, the Captain contacted the company Operations Centre and reported a Take-off Configuration Warning and an Equipment Cooling system problem. Several communications between the Captain and the Operations Centre took place in the next eight minutes concerning the above problems and ended as the aircraft climbed through 28 900 ft. Thereafter, there was no response to radio calls to the aircraft. During the climb, at an aircraft altitude of 18 200 ft, the passenger oxygen masks deployed in the cabin. The aircraft leveled off at FL340 and continued on its programmed route.

At 10:21 h, the aircraft flew over the KEA VOR, then over the Athens International Airport, and subsequently entered the KEA VOR holding pattern at 10:38 h. At 11:24 h, during the sixth holding pattern, the Boeing 737 was intercepted by two F-16 aircraft of the Hellenic Air Force. One of the F-16 pilots observed the aircraft at close range and reported at 11:32 h that the Captain�s seat was vacant, the First Officer�s seat was occupied by someone who was slumped over the controls, the passenger oxygen masks were seen dangling and three motionless passengers were seen seated wearing oxygen masks in the cabin. No external damage or fire was noted and the aircraft was not responding to radio calls. At 11:49 h, he reported a person not wearing an oxygen mask entering the cockpit and occupying the Captain�s seat. The F-16 pilot tried to attract his attention without success. At 11:50 h, the left engine flamed out due to fuel depletion and the aircraft started descending. At 11:54 h, two MAYDAY messages were recorded on the CVR.

At 12:00 h, the right engine also flamed out at an altitude of approximately 7 100 ft. The aircraft continued descending rapidly and impacted hilly terrain at 12:03 h in the vicinity of Grammatiko village, Hellas, approximately 33 km northwest of the Athens International Airport. The 115 passengers and 6 crew members on board were fatally injured. The aircraft was destroyed.