PILOT error and, to a lesser degree, slack safety standards from Helios Airways were what caused a Being 737 jet to crash into a ravine outside Athens last August, killing all 121 people on board.
That is the verdict of the Greek air-accident investigating team under Akrivos Tsolakis, who yesterday handed the report to officials in Cyprus and in Greece.
Now 14 months in the making, the long-awaited fact-finding report gives a blow-by-blow account of what went on during the fateful day, going on to list the causes of the crash.
By and large, the 250-page report corroborates media reports and speculation over the past year.
“We are satisfied that we have reached the end of the road,” Tsolakis told Greek reporters early in the day after handing the report over to Greece’s Transport Minister, Michalis Liapis.
The chief investigator next shuttled to Cyprus, and by 6pm he was in Nicosia presenting the report to President Tassos Papadopoulos.
The probe classifies the causes into direct (immediate) and latent (underlying). It paints a picture of a chain of blunders and lapses on the ground and then in the air, leading up to the calamity.
Without actually naming names, it fingers captain Hans Juergen-Merten and co-pilot Pambos Charalambous on two counts: not carrying out the required checklists, and failing to act on the alarms that went off.
The pilots did not recognise “that the cabin pressurisation mode selector was in the MAN (manual) position during the performance of the Preflight procedure, the Before Start checklist and the After Takeoff checklist.”
Further, they did not identify “the warnings and the reasons for the activation of the warnings (Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication, Master Caution).”
Thereafter, the flight crew was incapacitated “due to hypoxia, resulting in the continuation of the flight via the flight management computer and the autopilot”; eventually, the fuel was depleted causing an engine flameout, in turn causing the aircraft to impact on the ground.
The sequence of events was as follows: On August 14, 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, Greece. The aircraft was cleared to climb to 34,000 feet.
As the aircraft climbed through 16,000ft, 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 and ended as the aircraft climbed through 28,900ft. Thereafter, there was no response to radio calls to the aircraft. During the climb, at an aircraft altitude of 18,200ft, the passenger oxygen masks deployed in the cabin. The aircraft levelled off and continued on its programmed route.
Shortly after 10:21, the aircraft flew over Athens International Airport. At 11:24 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 that at 11:32 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 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, he reported a person not wearing an oxygen mask entered the cockpit and occupied the Captain’s seat. The F-16 pilot tried to attract his attention without success. At 11:50, the left engine flamed out due to fuel depletion and the aircraft started descending. At 11:54, two MAYDAY messages were recorded.
At 12:00, the right engine also flamed out at an altitude of approximately 7,100 ft. The aircraft continued to fall and hit hilly terrain at 12:03 near the village of Grammatiko. The 115 passengers and six crew members on board died. The aircraft was destroyed.
Tsolakis’ team further concluded that the following factors could have contributed to the accident: “omission of returning the cabin pressurisation 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 pressurisation 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.”
Moving down the ladder, the airline and Civil Aviation shoulder some of the blame for cutting corners when it came to safety.
According to Tsolakis’ report, the latent causes for the crash are:
l Operator’s deficiencies in the organisation, quality management, and safety culture.
l Regulatory Authority’s inadequate execution of its safety oversight responsibilities.
l Inadequate application of Crew Resource Management principles.
Last but perhaps not least, Boeing is blamed for not addressing configuration setup and documentation issues: “Ineffectiveness of measures taken by the manufacturer in response to previous pressurisation incidents in the particular type of aircraft.”
On Boeing 737s, the sounds emitted for the decompression alarm and for a glitch in the positioning of the flaps are identical. Moreover, the manual for the Boeing 737-300 was vague: instead of explicitly instructing ground technicians to reset the decompression switch to auto, the manual simply said that the switch should be set “to the previous position”, ie from manual to auto.
