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Helios 522

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by

Tom Guns

on 12 March 2014

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Transcript of Helios 522

Helios 522
Case Study
by
Tom Guns
Jonas Colpaert
Pre-flight maintenance
01:30


03:15
Unscheduled Maintenance
Pressurization test --> mode to "manual"

Maintenance completed
Logbook stated "airplane back to its initial condition"

BUT

Mode was still on "manual"
Man
Management
Pre-flight checklist
05:30



Crew did not notice pressurization was set to "manual"

Reasons:
Captain rushing
FO had a bad history with checklists
Auto-checklisting ("look without seeing")
"manual" --> GREEN light
Man
Machine
Media
Take-off / Climb
After TO checklist
Verify pressurization setting --> not done

High workload
Negligence
Man
Mission
06:07
Cabin altitude warning (FL120)
Man
Management
Machine
06:12
A/T disengaged, throttle retarded for 9 seconds, then re-engaged
Captain calls Helios Ops (FL160)
06:14
Total of 3 engineers speak to the captain but they are not able to identify the problem

Language problems
Unnecessary transfer between engineers
Hypoxia
Common audio alert (ground config warning)
Master Caution light (FL170)
Man
Management
Machine
06:16
Due to decreased density --> insufficient cooling
Visual warning, not cancelled for 53 seconds
PAX Oxygen masks
06:17
Visual warning, not noticed by Flight crew

Flight crew hypoxia
No cabin crew action
No additional warning if visual warning is not cancelled
Blame after investigation
Pilots
not spotting (or acting accordingly) the warnings

Maintenance officials

Helios
"deficiencies in the organization, quality management and safety culture"

Boeing
"ineffectiveness of measures taken in response to previous pressurization incidents in the particular type of aircraft"

Authorities
"inadequate execution of its safety oversight responsibilities"
Avoidance summary
Detailed maintenance report
State of aircraft before and after

CRM
Captain pressure on FO, FOs records

Warning
Green light & common sound
Warn when failed to cancel

Cabin crew training
No level off/descent after Pax masks

Ground technicians
Language & Intercommunication
Food for thought
Closed cockpit policy


or

Rod Eddington (BA Chief Executive)
January 2001

"We will not be locking the door because it does not make sense ... Locking the door would cause more safety problems than it would solve."
06:20
No more communication
06:23
Cruise FL340
07:21

08:24

08:38

08:50


09:00

09:04
Entered holding pattern KEA VOR

Intercepted by F16s

Person spotted in captain seat

Left engine flame out
2 Mayday messages recorded on CVR

Right engine flame out

Impact Grammatiko
Full transcript