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The Final Report From A.A.I.A.S.B For Helios B737  
User currently offlineA3 From Greece, joined Oct 2006, 262 posts, RR: 8
Posted (8 years 3 weeks 1 day 20 hours ago) and read 16311 times:

The final report from A.A.I.A.S.B for Helios B737 -31S crash (5B-DBY flight 522 ) is published today.

The 230 pages long report is published today.

Roughly, the reports is pointing to the lack of inspection from Cyprus Civil Aviation authorities, Criminal negligence at ground personnel and the crew.

As soon I get my hands on it I¢ll post it (or a link).


Don't spend your money on airlines that don't respect your business.
60 replies: All unread, showing first 25:
 
User currently offlineA3 From Greece, joined Oct 2006, 262 posts, RR: 8
Reply 1, posted (8 years 3 weeks 1 day 9 hours ago) and read 15907 times:

As Published...............................
-------------------------
SYNOPSIS IN ENGLISH


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.

The Air Accident Investigation and Aviation Safety Board (AAIASB) of the Hellenic Ministry of Transport & Communications investigated the accident following ICAO practices and determined that the accident resulted from direct and latent causes.
The direct causes were:

* Non-recognition that the cabin pressurization mode selector was in the MAN (manual) position during the performance of the Preflight procedure, the Before Start checklist and the After Takeoff checklist.
* Non-identification of the warnings and the reasons for the activation of the warnings (Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication, Master Caution).
* Incapacitation of the flight crew due to hypoxia, resulting in the continuation of the flight via the flight management computer and the autopilot, depletion of the fuel and engine flameout, and the impact of the aircraft with the ground.

The latent causes were:

* Operators deficiencies in the organization, quality management, and safety culture.
* Regulatory Authority diachronic inadequate execution of its safety oversight responsibilities.
* Inadequate application of Crew Resource Management principles.
* Ineffectiveness of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft.


The AAIASB further concluded that the following factors could have contributed to the accident: omission of returning the cabin pressurization mode selector to the AUTO position after non-scheduled maintenance on the aircraft; lack of cabin crew procedures (at an international level) to address events involving loss of pressurization and continuation of the climb despite passenger oxygen masks deployment; and ineffectiveness of international aviation authorities to enforce implementation of actions plans resulting from deficiencies documented in audits.

In the months following the accident, the AAIASB made seven interim safety recommendations: five recommendations to the National Transportation Safety Board and to the manufacturer, four of which already resulted in the implementation of corrective actions, one recommendation to the Cyprus Air Accident and Incident Investigation Board and the airlines based in Cyprus, for which corrective action had already been taken, and one recommendation to the Hellenic Civil Aviation Authority (HCAA), which also resulted in the implementation of corrective action. In addition, the FAA in the United States issued an Airworthiness Directive (AD) which informed flight crews about upcoming, improved procedures for pre-flight setup of the cabin pressurization system, as well as improved procedures for interpreting and responding to the Cabin Altitude Warning Horn and to the Takeoff or Landing Configuration Warning Horn.

The report also identifies a number of additional safety deficiencies pertaining to: maintenance procedures; pilot training, normal and emergency procedures; organizational issues of the Operator; organizational issues related to safety oversight of maintenance and flight operations by Cyprus DCA, EASA/JAA and ICAO; issues related to the aircraft manufacturer�s documentation for maintenance and flight operations; and issues related to handling by the International Authorities of precursor incident information so as to implement preventive measures in a timely manner. As a consequence of the above, in its Final Report the AAIASB promulgated an additional eleven safety recommendations, addressed to the Republic of Cyprus, EASA, JAA and ICAO.

In accordance with ICAO Annex 13, paragraph 6.3, copies of the Draft Final Report were sent on 18 May 2006 to the States that participated in the investigation, inviting their comments. The comments sent to the AAIASB by the relevant Authorities in Cyprus, the United Kingdom and the United States were taken into account in the Final Report.

Note: All the above times are local.



Don't spend your money on airlines that don't respect your business.
User currently offlineUnited787 From United States of America, joined May 2005, 2733 posts, RR: 2
Reply 2, posted (8 years 3 weeks 1 day 8 hours ago) and read 15836 times:

I find it shocking at how many fatal mistakes were made by the pilots. Why wouldn't they put their oxygen masks on?

I also find it scary at how many accident reports I read where the pilots can't figure out what a certain alarm is telling them. You would think that we have the technology to be have more specific alarms. Don't the newer planes have this type of technology? Where the computer actually tells you, "pull up" etc...


User currently offlineMilan320 From Canada, joined Jan 2005, 869 posts, RR: 11
Reply 3, posted (8 years 3 weeks 1 day 8 hours ago) and read 15825 times:

Quoting A3 (Reply 1):
Ineffectiveness of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft.

Does anyone know what were these "ineffective" measures that were taken by Boeing earlier? The report makes mention of them, but from I can see, doesn't cite them in detail.
Milan320



I accept bribes ... :-)
User currently offlineA3 From Greece, joined Oct 2006, 262 posts, RR: 8
Reply 4, posted (8 years 3 weeks 1 day 8 hours ago) and read 15789 times:

Quoting Milan320 (Reply 3):
Does anyone know what were these "ineffective" measures that were taken by Boeing earlier? The report makes mention of them, but from I can see, doesn't cite them in detail.

Sorry, I could only find the summary,
Details of that problem are on the full report.
I Cant get until now the total 230 pages long report. .
When I have it , I¢ll put a link for download.
Rgds
Anthony



Don't spend your money on airlines that don't respect your business.
User currently offlinePolymerPlane From United States of America, joined May 2006, 991 posts, RR: 3
Reply 5, posted (8 years 3 weeks 1 day 8 hours ago) and read 15789 times:

Quoting A3 (Reply 1):
lack of cabin crew procedures (at an international level) to address events involving loss of pressurization and continuation of the climb despite passenger oxygen masks deployment;

This strikes me most. The aircraft continued to climb even the oxygen masks were deployed. Logic tells me that if the oxygen masks deployed one should immediately descent to a safe altitude and asses the situation. I am not a pilot, so I do not know the actual procedure. Just an intuition.

Cheers,
PP



One day there will be 100% polymer plane
User currently offlineZeke From Hong Kong, joined Dec 2006, 9176 posts, RR: 76
Reply 6, posted (8 years 3 weeks 1 day 8 hours ago) and read 15778 times:

Quoting A3 (Reply 4):
Sorry, I could only find the summary,

From what I understand the report is complete, however it is not on the public domain. I understand that it is still awaiting some form of local approval for release.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineA3 From Greece, joined Oct 2006, 262 posts, RR: 8
Reply 7, posted (8 years 3 weeks 1 day 8 hours ago) and read 15734 times:

Quoting Zeke (Reply 6):
I understand that it is still awaiting some form of local approval for release.

It¢s officially published.
The comity¢s actions are very independent. There is not any need for approval.

However, until now I can only find the summary in English.



Don't spend your money on airlines that don't respect your business.
User currently offlineSean377 From United Kingdom, joined Mar 2001, 1225 posts, RR: 40
Reply 8, posted (8 years 3 weeks 1 day 7 hours ago) and read 15676 times:

Made the BBC a couple of hours ago:

http://news.bbc.co.uk/1/hi/world/europe/6036507.stm



Flying is the second greatest thrill known to man... Landing is the first!
User currently offlineZeke From Hong Kong, joined Dec 2006, 9176 posts, RR: 76
Reply 9, posted (8 years 3 weeks 1 day 7 hours ago) and read 15645 times:

Quoting A3 (Reply 7):
It¢s officially published.
The comity¢s actions are very independent. There is not any need for approval.

In the press it said ...

"Tsolakis is expected to land at Larnaca airport at around 3.30pm, where he will meet with Communication and Works Minister Harris Thrassou at 4.30pm.

From there, the chief investigator will be driven to the Presidential Palace where he will present President Tassos Papadopoulos with copies of the document in English and Greek.

Cypriot Air Accident Investigating Committee Chairman Costas Orfanos is also expected to receive a copy of the report."

Everything that has been printed so far from my understanding has come from briefings to the press, not be release of the report, e.g...

"According to David Learmount, the Operations and Safety Editor of Flight International magazine who has been briefed on the final report, the switch had been set to manual because ground engineers were testing the airliner's seals after a reported leak"

This seems like a normal process, as the report has been prepared on behalf of the government.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineEbbUK From , joined Dec 1969, posts, RR:
Reply 10, posted (8 years 3 weeks 1 day 6 hours ago) and read 15589 times:

What is this reference in the BBC report about Boeing,

"In addition, the plane's manufacturers Boeing took "ineffective" measures in response to previous pressurisation incidents in the particular type of aircraft, the report said."

A bit odd for Boeing to be so slack on safety. Is it correct?


User currently offlineBuyantUkhaa From Mongolia, joined May 2004, 2907 posts, RR: 3
Reply 11, posted (8 years 3 weeks 1 day 3 hours ago) and read 15473 times:

Quoting Milan320 (Reply 3):
Does anyone know what were these "ineffective" measures that were taken by Boeing earlier?

Could it be the fact that the warning signal is the same as the take-off configuration warning, leading to confusion? It might seem obvious that when you get such a warning when flying, it is not for the take-off configuration. Falling oxygen masks would be obvious to anyone - if they weren't slightly incapacitated already. So to have to different warning sounds, unnecessary as it may seem, might actually just make the difference one day. It can't be that hard to implement...

But then again, they might be referring to something totally different. I am curious to read the report.



I scratch my head, therefore I am.
User currently offlineLTBEWR From United States of America, joined Jan 2004, 13148 posts, RR: 15
Reply 12, posted (8 years 3 weeks 1 day 3 hours ago) and read 15455 times:

At least we have a very good invesigation result of what and how went wrong in this tragedy. Most important from this final report are the recommendations, apparently already in place or in process to be placed soon by a number of parties to reduce the risk of a similar situation in the future.
One question I ask is this: shouldn't the Auto-pilot feature somehow go into a suspend mode when there is a pressurization problem, or at least make the aircraft descend altitude with signals to ATC, other aircraft, ground terrain to get to a level where the natural air pressurization is safe?


User currently offlineWjcandee From United States of America, joined Jun 2000, 5267 posts, RR: 24
Reply 13, posted (8 years 3 weeks 1 day 2 hours ago) and read 15424 times:

This just confirms what was discussed on here months ago. Most importantly, several of the pilots who post on here had some not-too-flattering observations about the number of mistakes (apparently due to lack of training, airmanship and oversight) made by these pilots to get into this situation.

User currently offlineA3 From Greece, joined Oct 2006, 262 posts, RR: 8
Reply 14, posted (8 years 3 weeks 20 hours ago) and read 15305 times:

Good day all,

Now I have the total 230 pages of the report.

Unfortunately I have only the Greek version so I don¢t think I should upload it cause it will not be useful to many.

In case there is some one that wants it please pm me .
In Case I get also the English version I will upload it and post the links.



Don't spend your money on airlines that don't respect your business.
User currently offlineMarkHKG From United States of America, joined Dec 2005, 960 posts, RR: 2
Reply 15, posted (8 years 3 weeks 19 hours ago) and read 15234 times:

Thanks A3! That's totally awesome you're doing that.  Smile


Release your seat-belts and get out! Leave everything!
User currently offlineZeke From Hong Kong, joined Dec 2006, 9176 posts, RR: 76
Reply 16, posted (8 years 3 weeks 13 hours ago) and read 15097 times:

Just read the CVR transcript....

Chilling to see that MAYDAY transmission on the descent.



We are addicted to our thoughts. We cannot change anything if we cannot change our thinking – Santosh Kalwar
User currently offlineLitz From United States of America, joined Dec 2003, 1767 posts, RR: 0
Reply 17, posted (8 years 3 weeks 12 hours ago) and read 15013 times:
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Just out of curiosity ... wouldn't there have been some sort of warning horn in the cockpit? Specifically when the pax O2 masks dropped due to the altitude/pressure problems?

I've heard GPS warnings go off - on a MD88 you can clearly hear it through the cockpit door, all the way to the back of first class; it has to be LOUD in the cockpit itself ...

- litz


User currently offlineKatekebo From United States of America, joined Apr 2001, 704 posts, RR: 6
Reply 18, posted (8 years 3 weeks 11 hours ago) and read 14991 times:

Quoting Litz (Reply 17):
wouldn't there have been some sort of warning horn in the cockpit?

Yes, there is an audible alarm. As decribed above, the alarm sound is the same as wrong take-off configuration. Apparently, the manufacturer thought that it was OK to use the same sound for two different conditions as the pilot should discern the cause of the problem based on the flight phase. The take-off configuration alarm sounds as soon as throttle is advanced for take-off roll and flaps are not configured properly (there was a LAPA accident in Buenos Aires few years ago in which the pilots took off without flaps and the audible alarm can be heard clearly on the CVR). If the same alarm sounds at altitude it indicates cabin pressure problems. In both cases, it's almost unbelievable that the pilots did not act upon the alarm. Why in hell would pilots ignore an obvious alarm and continue with the take-off is beyond comprehension. In the Helios crash it's also hard to believe that the pilots could confuse the take-off configuration alarm with cabin pressure alarm during the climb phase.


User currently offlineA3 From Greece, joined Oct 2006, 262 posts, RR: 8
Reply 19, posted (8 years 3 weeks 11 hours ago) and read 14956 times:

As promised!!

The original full report in English in every detail !!

Pls Note that is a large (8.3Mb)Zipped PDF .

http://homepages.pathfinder.gr/aas/Helios522.zip

R.I.P. Helios522



Don't spend your money on airlines that don't respect your business.
User currently offlineCYatUK From United Kingdom, joined Apr 2006, 810 posts, RR: 0
Reply 20, posted (8 years 3 weeks 10 hours ago) and read 14873 times:

Quoting Katekebo (Reply 18):
If the same alarm sounds at altitude it indicates cabin pressure problems. In both cases, it's almost unbelievable that the pilots did not act upon the alarm. Why in hell would pilots ignore an obvious alarm and continue with the take-off is beyond comprehension. In the Helios crash it's also hard to believe that the pilots could confuse the take-off configuration alarm with cabin pressure alarm during the climb phase.

Nobody knows why the pilots did not react to this alarm.

The company (renamed aJet) have today announced that they do not accept the report and claim that there is no way that the pressurisation configuration could be left on manual since this would cause very unconfortable ear pain during take off. Also, they claim that even the system was left on manual, the valve should be closed hence again ear pain would be caused during take off. However, I am wondering why do they assume that the engineers who checked the aircraft during the previous night, left the valve at the closed position. Couldn't they leave it at manual and open?

Any ideas?



CY@Uk
User currently offlineOPNLguy From , joined Dec 1969, posts, RR:
Reply 21, posted (8 years 3 weeks 10 hours ago) and read 14873 times:

Quoting A3 (Reply 19):
The original full report in English in every detail !!

Pls Note that is a large (8.3Mb)Zipped PDF .

Anyone else having problems downloading it? I'm on cable @ 6.3 MBPS and the file shows a 2 hour + download @ a measly 400 kbps, but the download errors out after :30 to :45 seconds. Clicking on the downloaded file shows it to be corrupted and unusable...


User currently offlineOPNLguy From , joined Dec 1969, posts, RR:
Reply 22, posted (8 years 3 weeks 10 hours ago) and read 14870 times:

Quoting CYatUK (Reply 20):
Any ideas?

Yes, it's called denial.


User currently offlineMarkhkg From United States of America, joined Dec 2005, 960 posts, RR: 2
Reply 23, posted (8 years 3 weeks 10 hours ago) and read 14854 times:

Quoting CYatUK (Reply 20):
Any ideas?

The insidious nature of hypoxia clouding appropriate judgement may have been a factor.

I am quite frankly upset that Boeing had not designed a better cabin altitude alert considering that it has been an issue before.



Release your seat-belts and get out! Leave everything!
User currently offlineA3 From Greece, joined Oct 2006, 262 posts, RR: 8
Reply 24, posted (8 years 3 weeks 10 hours ago) and read 14855 times:

I just downloaded for test.
It works fine but a bit slow…
Any subjections where I can upload it for better speeds???

[Edited 2006-10-11 19:26:28]


Don't spend your money on airlines that don't respect your business.
25 Post contains images OPNLguy : No suggestions, but if you could send a copy of the report as an email attachment to daopnlguy@yahoo.com I'd be grateful...
26 Post contains links TrojanAE : I have the same exact problem. PErhaps you could post it on www.yousendit.com and then paste the link here. Don't fill out anything but the email-fie
27 Post contains links A3 : It¢s uploaded: http://download.yousendit.com/9EC42D2E175FECCB I think it stays there only for 7 Days. Sorry for the inconvenience Rgds Anthony
28 Post contains links DeC : Here it is for the Greek-reading members of a.net http://www.phileleftheros.com/extras/helios_1.pdf http://www.phileleftheros.com/extras/helios_2.pdf
29 Desediez : I have to confirm those problems.. an even this is not working anymore. Could someone be so kind and send me the file by email? I have still a lot of
30 A3 : Your mail address????
31 Post contains links WSOY : This one looks like an ideal job for BitTorrent! http://en.wikipedia.org/wiki/BitTorrent If and when I get the complete file, I'll let you know the tr
32 Post contains images Desediez : It should be available to you right now in your email inbox
33 WSOY : Filler -- stay tuned[Edited 2006-10-12 16:31:41]
34 AerospaceFan : I hope that someone posts an excerpt from the above-stated official government report, in English, stating how, by its conclusion, that Boeing's previ
35 Post contains links A3 : One more download place http://www.sendspace.com/file/7lspk1
36 A3 : It seams that this is only one case. The same should be applied in case a TCAS system is turned off during flight (As Gol tragedy shows) “idiot
37 AerospaceFan : Perhaps this is so, and if so, I think that all aircraft manufacturers may wish to incorporate such features if reasonable. Nevertheless, there is cl
38 Post contains links Desediez : Report is now also available for download here, as long as the traffic lasts... http://www.rndt.eu/FINAL_REPORT_5B-DBY.pdf Please note: The file is ab
39 CYatUK : Your analysis about the "idiot-proof" aircraft reminds me of the very common caution for very hot content found on cups of popular coffee firms. Inde
40 A3 : If you still have problems downloading the report send me your email and I¢ll send it .
41 Katekebo : The oxygen masks in the passenger cabin dropped automatically as soon as the cabin pressure dropped below a pre-established limit. see reply 18
42 OPNLguy : The oxygen system the flightdeck uses is different than that used in the passenger compartment. Unlike the passenger compartment, there are no "drop
43 MarkHKG : Or switch to a "bit*hing betty/bob" alarm saying "Cabin altitude!" instead of just a horn, just like EGPWS or TCAS alerts...some jet aircrafts alread
44 AerospaceFan : Thank you, A3. I did attempt to download the report an hour or two ago, but it is not on the computer I am currently using. I will check that first c
45 Post contains links WSOY : Sorry,some issues with my NAT so I couldn't Peer-2-Peer, but see http://www.filefactory.com/file/64c30e/ I paid for a space that will serve 440 a day
46 Boysteve : Me too? Oxygen masks falling but you don't put them on! Altitude warning horns! I am not a pilot but surely at this point any pilot would contact ATC
47 Post contains links AerospaceFan : I found the photograph in the following Times Online story to be instructive. The story is also interesting and perhaps worth a read: http://www.times
48 AerospaceFan : I have just glanced through the last part of the government report, and of particular interest to me was Section 4.2.1.2, a part of the recommendation
49 Post contains images OPNLguy : The oxygen masks for the pilots do not not "fall" from anywhere. They have quick-don masks hanging behind then, within reach. There's only one horn h
50 AerospaceFan : I find it a bit odd that in the last several years, there have been cabin pressurization incidents relating to the 737, and yet the basic 737 aircraft
51 AMSSFO : May be you should have read the thread first before posting your rant, particularly the posts quoted below: It is definitely puzzling why the pilots
52 PipoA380 : Actually, from what I read in a book about the Helios crash, the plane was in maintenance the night before the crash, and the pressurisation valve at
53 PipoA380 : With SO many thing indicating a problem, why would the flight crew even think of continuing to climb? Why not just level at the current altitude and
54 A3 : Sadly so true………
55 Boysteve : Chill! I wasn't ranting, but you will know when I am!
56 MarkHKG : I'm wondering why the Accident Report did NOT recommend that dual use horns be changed/discontinued to avoid human factor confusion.
57 CYatUK : Sorry, maybe my question was not clear Helios say that "even if the system was on Manual, the outflow valve must have been closed hence it would caus
58 A3 : Chapter 5 Recommendations Page 162 Par 4.1.4 actions by the FAA.
59 AMSSFO : These were the conclusions of the investigation committee regarding Boeing: 1. The description in the Boeing AMM for the procedure for the pressuriza
60 MarkHKG : Thanks, you guys. Didn't see that. I wonder what the response from Boeing will be. Does anyone know what the cabin altitude warning is like on other
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