a3
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The Final Report From A.A.I.A.S.B For Helios B737

Tue Oct 10, 2006 3:36 pm

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).
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a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 2:32 am

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.
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United787
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 3:29 am

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...
 
milan320
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 3:34 am

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
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a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 3:51 am

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
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PolymerPlane
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 3:52 am

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
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zeke
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 3:55 am

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
 
a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 4:14 am

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.
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sean377
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 4:39 am

Made the BBC a couple of hours ago:

http://news.bbc.co.uk/1/hi/world/europe/6036507.stm
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zeke
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 4:51 am

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
 
ebbuk
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 5:39 am

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?
 
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Buyantukhaa
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 9:07 am

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.
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ltbewr
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 9:20 am

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?
 
wjcandee
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 9:54 am

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.
 
a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 3:40 pm

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.
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Markhkg
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 4:50 pm

Thanks A3! That's totally awesome you're doing that.  Smile
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zeke
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Wed Oct 11, 2006 10:56 pm

Just read the CVR transcript....

Chilling to see that MAYDAY transmission on the descent.
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litz
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 12:17 am

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
 
katekebo
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 12:34 am

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.
 
a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 12:54 am

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
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CYatUK
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 2:16 am

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
 
OPNLguy
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 2:17 am

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...
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
OPNLguy
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 2:19 am

Quoting CYatUK (Reply 20):
Any ideas?

Yes, it's called denial.
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
Markhkg
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 2:22 am

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.
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a3
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RE: The Final Report From A.A.I.A.S.B For Helios B

Thu Oct 12, 2006 2:23 am

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]
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OPNLguy
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 2:30 am

Quoting A3 (Reply 24):
I just downloaded for test.
It works fine but a bit slow…
Any subjections where I can upload it for better speeds???

No suggestions, but if you could send a copy of the report as an email attachment to daopnlguy@yahoo.com I'd be grateful...  Wink
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
trojanAE
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 2:36 am

Quoting OPNLguy (Reply 21):
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...

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-field, just give them a fake email.
"My soul is in the sky." -William Shakespeare
 
a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 3:09 am

Quoting TrojanAE (Reply 26):
I have the same exact problem. PErhaps you could post it on www.yousendit.com and then paste the link here.

It¢s uploaded:
http://download.yousendit.com/9EC42D2E175FECCB
I think it stays there only for 7 Days.

Sorry for the inconvenience

Rgds
Anthony
Don't spend your money on airlines that don't respect your business.
 
 
desediez
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 6:34 pm

I have to confirm those problems..

Quoting OPNLguy (Reply 22):
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...

an even this

Quoting DeC (Reply 28):
Quoting TrojanAE (Reply 26):
I have the same exact problem. PErhaps you could post it on www.yousendit.com and then paste the link here.

It¢s uploaded:
http://download.yousendit.com/9EC42D2E175FECCB
I think it stays there only for 7 Days.

Sorry for the inconvenience

Rgds
Anthony

is not working anymore.

Could someone be so kind and send me the file by email?
I have still a lot of traffic available on my webspace to get the report spread to more interested users...
 
a3
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RE: The Final Report From A.A.I.A.S.B For Helios B

Thu Oct 12, 2006 8:05 pm

Quoting Desediez (Reply 29):
Could someone be so kind and send me the file by email?

Your mail address????
Don't spend your money on airlines that don't respect your business.
 
WSOY
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 8:13 pm

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 tracker pointer.

Meanwhile, you'll need to download and prepare the BitTorrent client part in order to participate.
The actual file to be transferred will be downloaded from your machine while you're receiving/have received it in parts by the others in the pool. The final result depends on everyone's good will to share!

http://www.bittorrent.com/download.html
"Nukkuessa tulee nälkä" (Nipsu)
 
desediez
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 8:44 pm

Quoting WSOY (Reply 31):
Your mail address????

It should be available to you right now in your email inbox  Smile
 
WSOY
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Thu Oct 12, 2006 11:19 pm

Filler -- stay tuned

[Edited 2006-10-12 16:31:41]
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AerospaceFan
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 1:35 am

I hope that someone posts an excerpt from the above-stated official government report, in English, stating how, by its conclusion, that Boeing's previous measures were ineffective.

I am very saddened to read of the chain of events that, according to the report, caused the loss of so many lives. This is clearly an aviation tragedy of the highest order.

Here are a few observations and questions as to which I would be most grateful if there would be informed comment:

1. (a.) In the Helios event, it is my impression, as a layman, that oxygen masks were not automatically dropped from the ceiling of the flight deck; is this correct? (b.) If so, is this because such oxygen masks are not available for such drop-down deployment? And, (c.) further, if so, isn't it true that standard training might call for the immediate use of oxygen bottles by the captain and co-pilot?

2. Further, if the above is true, how does the lack (if, indeed, there is such a lack) of drop-down flight deck oxygen masks on this particular model of aircraft compare with any equivalent feature in other modern aircraft?

3. If the government report is accurate, what features would possibly have been more effective in preventing this kind of accident? I would surmise that the automatic restoration of pressure could be contemplated as a possible solution.

Essentially, it is my observation, purely as a layman, that the feature I mentioned in "3", above, would tend to make an aircraft with such a feature "idiot-proof", so to speak, so that even if everyone on the flight deck were to have overlooked the meanings of all warnings, indications, and sounds, the aircraft itself would act as a "third pilot" of sorts, backing up the two human pilots to assure the safety of all aboard. (In using the term "idiot-proof" I do not, by so doing, ascribe any characteristic or fault to the captain or his co-pilot; it is nothing more than a turn of phrase.)

I appreciate the expertise on this Website and hope to read further responses in this thread addressing some of the issues stated above. Thank you in advance.

[Edited 2006-10-12 18:49:19]
What's fair is fair.
 
a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 1:40 am

One more download place

http://www.sendspace.com/file/7lspk1
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a3
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 1:48 am

Quoting AerospaceFan (Reply 34):
Essentially, it is my observation, purely as a layman, that the feature I mentioned in "3", above, would tend to make an aircraft with such a feature "idiot-proof", so to speak, so that even if everyone on the flight deck were to have overlooked the meanings of all warnings, indications, and sounds, the aircraft itself would act as a "third pilot" of sorts, backing up the two human pilots to assure the safety of all aboard.

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 – proof” systems is a must.
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AerospaceFan
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RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 1:54 am

Quoting A3 (Reply 36):
The same should be applied in case a TCAS system is turned off during flight (As Gol tragedy shows) “idiot – proof” systems is a must.

Perhaps this is so, and if so, I think that all aircraft manufacturers may wish to incorporate such features if reasonable.

Nevertheless, there is clearly a philosophical issue here, in that a manufacturer may expect that only qualified, alert, and competent pilots should fly its products. I believe that there should be no legal liability on the part of Boeing based on the conclusions I have read, second-hand, in the report. The reason for this is that the manufacturer has clearly given several signs of a critical misconfiguration -- including the master caution light and so forth. No manufacturer can anticipate every abnormal possibility and to hold any manufacturer liable for same would be grossly unfair, it seems to me.

The question might possibly be reduced to an issue of how unlikely a chain of events, as presented, may be.

The above notwithstanding, it is also my view that the possibilities of incorporating future measures by which an aircraft is further made "idiot-proof" should not be overlooked, because human error does occur, and it is certainly a beneficial outlook to adopt that reasonable improvements -- and I do emphasize "reasonable" -- should be made that account for the possibility of human error, no matter how remote.

[Edited 2006-10-12 18:57:48]
What's fair is fair.
 
desediez
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RE: The Final Report From A.A.I.A.S.B For Helios B

Fri Oct 13, 2006 2:11 am

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 about 8MB...
 
CYatUK
Posts: 388
Joined: Mon Apr 17, 2006 2:21 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 2:33 am

Quoting AerospaceFan (Reply 37):
Nevertheless, there is clearly a philosophical issue here, in that a manufacturer may expect that only qualified, alert, and competent pilots should fly its products.

The above notwithstanding, it is also my view that the possibilities of incorporating future measures by which an aircraft is further made "idiot-proof" should not be overlooked, because human error does occur, and it is certainly a beneficial outlook to adopt that reasonable improvements -- and I do emphasize "reasonable" -- should be made that account for the possibility of human error, no matter how remote

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. Indeed it is stupid but companies keep it there to stop people that spill the coffee on themselves from suing them.

Similarly, in this case Boeing should do whatever possible to ensure that a possible drop of pressure, is readily recongised by the crew even if other alarms are also sounding. I would expect that a computerised voice allerting the crew about the high cabin altitude should be the best possible way to ensure that this never happens again.
CY@Uk
 
a3
Posts: 212
Joined: Wed Oct 04, 2006 5:24 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 2:38 am

If you still have problems downloading the report send me your email and I¢ll send it .
Don't spend your money on airlines that don't respect your business.
 
katekebo
Posts: 678
Joined: Sat Apr 14, 2001 12:02 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 2:50 am

Quoting AerospaceFan (Reply 34):
In the Helios event, it is my impression, as a layman, that oxygen masks were not automatically dropped from the ceiling of the flight deck; is this correct?

The oxygen masks in the passenger cabin dropped automatically as soon as the cabin pressure dropped below a pre-established limit.

Quoting AerospaceFan (Reply 34):
how, by its conclusion, that Boeing's previous measures were ineffective

see reply 18
 
OPNLguy
Posts: 11191
Joined: Tue Jun 15, 1999 11:29 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 2:56 am

Quoting AerospaceFan (Reply 34):
1. (a.) In the Helios event, it is my impression, as a layman, that oxygen masks were not automatically dropped from the ceiling of the flight deck; is this correct? (b.) If so, is this because such oxygen masks are not available for such drop-down deployment? And, (c.) further, if so, isn't it true that standard training might call for the immediate use of oxygen bottles by the captain and co-pilot?

The oxygen system the flightdeck uses is different than that used in the passenger compartment. Unlike the passenger compartment, there are no "drop down" oxygen masks even installed up front. The pilots (and any observers up front) use a "quick-don" oxygen mask that's hanging on a clip immediately within reach behind the pilots seats. The regs say they have to be able to get them on within 5 seconds. That should cover your (a) and (b), and as for (c), I'm sure that's going to be a discussion point from the Helios report. Keep in mind that, given a decompression event, it's pretty clear when that occurs, and the reflexive response is to don their masks. That said, also keep in mind that this wasn't a depressurization event, it was a situation where they never properly pressurized to begin with, which is far more insidious to detect, which, of course, can delay or even preclude a proper response.

Quoting AerospaceFan (Reply 34):
2. Further, if the above is true, how does the lack (if, indeed, there is such a lack) of drop-down flight deck oxygen masks on this particular model of aircraft compare with any equivalent feature in other modern aircraft?

Every other airliner I can think of has quick-don oxygen masks for the flightcrews...

Quoting AerospaceFan (Reply 34):
3. If the government report is accurate, what features would possibly have been more effective in preventing this kind of accident? I would surmise that the automatic restoration of pressure could be contemplated as a possible solution.

Automatic pressurization restoration is hardly a solution, as one can't predict the exact scenario. If it's a depressurization, what's causing it? A malfunctioning outflow valve? A hole in the fuselage? Exactly how big a hole? Again, the Helios scenario was a failure to properly pressurize, and not a depressurization. If anything, I think you might eventually see separate and distinct-sounding warning horns for the takeoff warning system and the pressurization system. Now, the horn does double duty, depending whether the aircraft is on the ground (for takeoff, for the takeoff warning horn) or in the air (for the pressurization system).
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.
 
Markhkg
Posts: 838
Joined: Mon Dec 05, 2005 4:13 pm

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 4:12 am

Quoting OPNLguy (Reply 42):
If anything, I think you might eventually see separate and distinct-sounding warning horns for the takeoff warning system and the pressurization system. Now, the horn does double duty, depending whether the aircraft is on the ground (for takeoff, for the takeoff warning horn) or in the air (for the pressurization system).

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 already utilize a voice warning for their decompression alert. It astounds me how many different alert sounds a pilot needs to recognize during their training.
Release your seat-belts and get out! Leave everything!
 
AerospaceFan
Posts: 6990
Joined: Thu Dec 22, 2005 1:43 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 4:31 am

Quoting A3 (Reply 40):
If you still have problems downloading the report send me your email and I¢ll send it .

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 computer later today.

Quoting CYatUK (Reply 39):
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. Indeed it is stupid but companies keep it there to stop people that spill the coffee on themselves from suing them.

A very interesting observation. My layman's viewpoint is that Boeing appears to have fulfilled its legal obligations by providing at least one warning, and a rather strong one, at that, and that, further, if what the report seems to say, by second-hand description, is true, the actions of the flight crew in, for example, silencing the alarm in a manner inconsistent with good practice or even their training could be deemed to be a supervening proximate cause. Again, this is only from the vaguest of ideas in my head about what occurred, so please take this for what it's worth.

Boeing, I feel confident in assuming, together with flight training requirements of regulatory agencies and probably the airline itself must have set forth detailed and mandatory procedures that each flight crew member was and is required to follow upon hearing a cabin altitude, master caution, or other alarm, and if such procedures were ignored or incompletely followed, then it seems to me that Boeing cannot be put at fault. I believe that any manufacturer is entitled to believe that certified operators and their employees will exercise fundamental good sense and, in the airline industry, airmanship, to the common standards of the industry or market for which any product is manufactured, within limits. (This is without prejudice to whether the pilots in this Helios accident, or Helios itself, did what they could, as I have no knowledge of this matter.)

The manufacturer of any complex aircraft, I feel, is entitled to rely on certification, formal or not, that the operator and pilots of that aircraft are competent and well-trained, as may apply, in accordance with aircraft operation or flight manual requirements, regulations, general accepted practices, and custom. I believe that the implementation of the manufacturer's required practices as may be a precondition to the use of that aircraft must be deemed part and parcel of its safe operation, and I would imagine that Boeing would never assent to the operation of any aircraft it manufactures in any commercial or similar context if it believed that the airline or any operator or pilot could not or would not adhere to such required practices.

Everyone must be held to do their jobs, including not only the manufacturer, but the flight crew, whose fidelity to the requirements for the nominal operation of the aircraft, in this sense and given such certification, may be assumed during commercial flights.

Of course, it remains possible that the flight crew did not have a chance to react; not having read the report, I cannot rule this out, or any other similar possibility. I understand that there is dispute as to whether the report's conclusions, which I gather ascribe primary fault to human error, are correct.

The above is only my personal opinion, of course, and it is quite incomplete, but I think it is reasonable.

Quoting Katekebo (Reply 41):
The oxygen masks in the passenger cabin dropped automatically as soon as the cabin pressure dropped below a pre-established limit.



Quoting Katekebo (Reply 41):
see reply 18



Quoting OPNLguy (Reply 42):
Automatic pressurization restoration is hardly a solution, as one can't predict the exact scenario. If it's a depressurization, what's causing it? A malfunctioning outflow valve? A hole in the fuselage? Exactly how big a hole? Again, the Helios scenario was a failure to properly pressurize, and not a depressurization.

Thank you, Katekebo, for your reply.

OPNLguy, I would tend to agree. It may be impractical to automatically pressurize or repressurize an aircraft, particularly if, hypothetically, a switch was left on "manual" and could not physically be overridden by machine.

[Edited 2006-10-12 21:57:58]
What's fair is fair.
 
WSOY
Posts: 822
Joined: Tue Jun 13, 2006 10:24 pm

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 4:34 am

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 for the next 7 days. The link will be there behind all that ad junk allright!

[Edited 2006-10-12 21:40:42]
"Nukkuessa tulee nälkä" (Nipsu)
 
boysteve
Posts: 885
Joined: Sun Apr 25, 2004 7:02 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 4:54 am

Quoting United787 (Reply 2):
I find it shocking at how many fatal mistakes were made by the pilots. Why wouldn't they put their oxygen masks on?

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, explain the pressurisation problem symptoms, and descend back to 10,000feet.

Just my thoughts........
 
AerospaceFan
Posts: 6990
Joined: Thu Dec 22, 2005 1:43 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 5:08 am

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.timesonline.co.uk/article/0,,13509-2396691,00.html

For example, one source cited in the article says that, in addition to an audible alarm, there would be lighted visual indicators of the anomalous cabin pressure on the instrument panels above the pilots.

[EDIT]

Having just glanced through the government report on the Helios incident, I would add as follows:

Compare, however, Section 2.10.1(c) of the government report mentioned above, which references a June 20, 2003 Boeing response to one of several recommendations from the Ireland AAIU (Air Accident Investigation Unit) relating to a prior pressurization incident stating that, while an intermittent horn does sound in case of cabin pressurization failure, there is no light that illuminates specifically referring to cabin altitude, nor did Boeing, at the time of the response, plan to offer any such light.

Source: Op. cit.

[Edited 2006-10-12 22:36:41]
What's fair is fair.
 
AerospaceFan
Posts: 6990
Joined: Thu Dec 22, 2005 1:43 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 5:20 am

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 recommendations in the report, which Section states:

(Excerpt)

Quote:
2006 -- 42 EASA/JAA require aircraft manufacturers to install in newly manufactured aircraft, and on a retrofit basis in older aircraft, in addition to the existing cabin altitude warning horn, a visual and/or an oral alert warning when the cabin altitude exceeds 10 000 ft.


Source: Op. cit.

[Edited 2006-10-12 22:37:01]
What's fair is fair.
 
OPNLguy
Posts: 11191
Joined: Tue Jun 15, 1999 11:29 am

RE: The Final Report From A.A.I.A.S.B For Helios B737

Fri Oct 13, 2006 5:23 am

Quoting Boysteve (Reply 46):
Oxygen masks falling but you don't put them on!

The oxygen masks for the pilots do not not "fall" from anywhere. They have quick-don masks hanging behind then, within reach.

Quoting Boysteve (Reply 46):
Altitude warning horns!

There's only one horn here, and it serves two functions. On the ground, it sounds as a part of the takeoff warning system. Once in the air (and the aircraft "knows" this by a weight-on-wheels sensor), it's for the pressurization system.

Quoting Boysteve (Reply 46):
I am not a pilot but surely at this point any pilot would contact ATC, explain the pressurisation problem symptoms, and descend back to 10,000feet.

They didn't realize that they -had- a pressurization problem. They interpreted the dual-use horn as a problem with the takeoff warning system, even though they were already airborne. Not realizing they had a pressurization problem, they didn't put on their quick-don masks.

...and stop calling me Shirley...  Wink
ALL views, opinions expressed are mine ONLY and are NOT representative of those shared by Southwest Airlines Co.

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