Greek 737 unofficial crash analysis

[bSr.LCsta]

Interesting read from a pilot friend of mine......

 

 

The following text comes from emails sent between some pilots who sent these photos to each other. I am including the text here as it is interesting although it is the opinion of the writers only and does not reflect any official finding that I know of. Still it is very interesting

 

The emails:

 

Got this from a friend, thought it interesting. Included are some shots of the F-16s that went up to see what was going on. Sad to think that when the pictures were taken all on the plane were either already dead, or about to be.

 

 

I just can not believe 2 pilots would make so many fatal mistakes.

 

Notice the sequence of events that caused this plane to eventually crash near Athens on August 14th. The plane was a 737-300 and was in LNAV (lateral Navigation) VNAV (Vertical Navigation) and the altitude alerter was sent to 34000. The autopilot performed as it was supposed to until the electrical power failed due to fuel starvation. The pilots and everyone else were unconscious and I presume dead by the time this all happened and the plane entered a graveyard spiral and quickly thereafter impacted the planet Earth in Greece.

 

The two pilots ignored the cabin altitude warning siren, MASTER WARNING, cabin pressurization RED Light and the Oxygen masks dropped and they thought it was the Takeoff Configuration Warning (Were you on the runway, you IDIOT!!) and the Capt called Maintenance Control and was out of his seat busily trying to pull the C/B to silence the horn. The FO didn't speak his language (German) and neither of them spoke English enough to communicate with each other; but, hey, I'll bet they worked CHEAP !!!

 

Cockpit Confusion Found in Crash of Cypriot Plane

By DON PHILLIPS, "International Herald Tribune"

Published: September 7, 2005

 

PARIS, Sept. 6 - The crew members of a Cypriot airliner that crashed Aug. 14 near Athens became confused by a series of alarms as the plane climbed, failing to recognize that the cabin was not pressurizing until they grew mentally disoriented because of lack of oxygen and lost consciousness, according to several people connected with the investigation into the crash.

 

Complicating the cockpit confusion, neither the German pilot nor the young, inexperienced Cypriot co-pilot could speak the same language fluently, and each had difficulty understanding the other's English, the worldwide language of air traffic control.

 

A total of 121 people were killed in the crash after the plane climbed and flew on autopilot, circling near Athens until one engine stopped running because of a lack of fuel. The sudden imbalance of power, with only one engine operating, caused the autopilot to disengage and the plane to begin to fall.

 

So far, the Greek authorities have hinted at oxygen problems, but have not announced the full findings of investigators. The people interviewed for this article agreed to speak only on the condition that they not be identified because none are official spokesmen for the investigation and because of political sensitivities arising from a Cypriot plane's crashing in Greece.

 

Investigators pieced together the story of the crash from many sources. In the wreckage, they found the first solid clues: the pressurization valve and an air outflow valve set incorrectly. Air traffic control tapes provided information on the confusion in the cockpit.

 

The plane had a sophisticated new flight data recorder that provided a wealth of information. There were maintenance records from the night before, and investigators interviewed the mechanics who worked on the plane.

 

Among other things, the investigators determined that the pilot was not in his seat because he was up trying to solve a problem that turned out to be one of the lesser threats facing the plane.

 

The plane that crashed, a Boeing 737-300, underwent maintenance the night before. The maintenance crew apparently left pressurization controller rotary knob out of place, according to the officials connected to the investigation, and the crew did not catch the mistake during preflight checks the next day. This meant that the plane could not pressurize properly.

 

At 10,000 feet, an alarm went off to warn the crew that the plane would not pressurize. Crew members mistakenly thought that the alarm horn was a warning to tell them that their controls were not set properly for takeoff, the officials said.

 

The same horn is used for both conditions, although it will sound for takeoff configuration only while the plane is still on the ground.

 

The climb continued on autopilot. At 14,000 feet, oxygen masks deployed as designed, and a master caution light illuminated in the cockpit. Another alarm sounded at about the same time on an unrelated matter, warning that there was insufficient cooling air in the compartment housing avionics equipment.

 

The radio tapes showed that this created tremendous confusion in the cockpit. Normally, an aircraft cabin is held at 8,000 feet pressure, so the crew at over 14,000 feet would already be experiencing some disorientation because of a lack of oxygen. During this time, the captain and co-pilot discovered that they had no common language and that their English was not good enough for the complicated technical conversation required to fix the problem.

 

The crew members called the maintenance base in Cyprus and were told that the circuit breaker to turn off the loud new alarm was in a cabinet behind the captain. The captain got up from his seat to look for the circuit breaker, apparently ignoring the confused co-pilot.

 

As the plane continued to climb on autopilot, the air grew so thin that the crew became seriously impaired. The captain lost consciousness first on the floor of the cockpit, followed by the co-pilot, who remained in his seat, according to the officials.

 

The autopilot did as it was programmed to do, flying the plane at 34,000 feet to Athens and entering a holding pattern. It remained in a long circling pattern, shadowed by Greek military jets, until fuel ran low and one engine quit.

 

Boeing, the maker of the plane, issued a notice shortly after the crash to airlines that it would revise flight crew training manuals to emphasize to crews that they must understand how the various warning systems work and what to do about them.

 

The notice emphasizes that the takeoff configuration warning horn will not sound under any circumstances after the plane has left the ground. The same horn will then be used only for a cabin altitude warning. The company notice said there had been other instances of confusion over the horn by pilots.

 

"Confusion between the cabin altitude warning horn and the takeoff configuration warning horn can be resolved if the crew remembers that the takeoff configuration warning horn is only armed when the airplane is on the ground," the notice said. "If this horn is activated in flight, it indicates that the cabin altitude has reached 10,000 feet."

 

(continued next post......)

[bSr.LCsta]

-----

Addendum from John:

To be honest, I am INSULTED to think two pilots who were in my previous line of work could be as cumulatively STUPID as these two were! So what if they couldn't communicate with each other? They demonstrated that they were incapable of THINKING in the first place! Talking was not their biggest problem. They were an embarrassment to professional pilots everywhere. I think they should both be entered in this year's 'Darwin Awards' competition. They've got a fair chance of winning. Unfortunately, while doing their noble part to cleanse the gene pool, they had to take quite a few innocents with them! That's the very sad part.

 

Just for the record and to make things crystal clear, the pilots have an oxygen system which is *entirely* separate and a completely different design than the oxygen system which is provided for passengers and flight attendants. In addition, flight attendants have access to portable, emergency, oxygen bottles, located around the cabin in various lockers to be used, for example, when fighting fires and smoke.

 

So, here's what I think happened: The bottom line is that the pilots (using no supplemental oxygen at any time) probably lapsed into unconsciousness first. Then the passengers would follow 30 minutes later, since that is the certified amount of time their kind of masks will provide oxygen. Finally, the flight attendants would be last, since they would have supplemental oxygen bottles to breathe from after their 'passenger-style' oxygen was all used up. All three categories would, in order, simply lapse into unconsciousness, like fainting or going to sleep at some point. Some minutes later - while still unconscious - their hearts would simply give out due to oxygen deprivation - and die *painlessly*, since they were still "asleep" in a manner of speaking. Hours would pass while the fuel was all used up. Though the plane certainly made a loud bang and a big hole when it hit the ground, all the people inside had died a long time earlier. And there would be little or no fire.

 

When I first heard about this event and before reading or hearing about any published accident investigation results, establishing the cause of the accident, which this article does now, I guessed the *only* way both pilots could be incapacitated, via hypoxia - lack of oxygen - would be if the First Officer/Copilot *failed* to manually open the oxygen bottle's valve prior to flight as he is certainly supposed to do. This oxygen bottle is located on his side, the extreme right side of the cockpit and far away from the Captain's visual or manual access. Otherwise, if the oxygen bottle valve *was* open, even if one pilot somehow screwed up during some pressurization emergency, the other would still continue to have access to oxygen - and remain alive - and fly the plane. That's why I felt the valve being closed was the only answer. Even the exotic idea of a terrorist smuggling a nerve gas agent onto the airplane, say in a hair spray can, and discharging same likely wouldn't work. Some passenger cabin air IS recirculated, but only back into the passenger cabin, not into the cockpit. The cockpit gets "new" air in almost all cases, unless that -300 model is different than other 737's.

 

Of course, in addition to that setup scenario-fault, a pressurization problem would also have to occur. If a rapid, high altitude depressurization took place (very rare, but possible), and if both pilots *believed* the valve had been opened - as it should have, they might then don their masks and righteously *assume* they were getting oxygen, but in fact were not. Without the valve open, they were getting only ambient air - at ambient (high altitude) air pressure into their oxygen masks. That is useless and won't sustain consciousness - or life - at 35,000 feet. At that altitude, you might have 30 seconds of useful consciousness - or even much less, depending upon your age and fitness and the rate of depressurization. IF neither of the pilots discovered in that short amount of time they were *not* getting oxygen for some reason - and retained the presence of mind to check (and then open) the valve on the bottle, they're cooked. Toast. End of story.

 

Even that scenario is a bit of a stretch for multiple reasons; not least of which because the default "standby" switch position on each pilot's Oxygen Control Panel is always to have 100% oxygen selected (as opposed to a mixture of oxygen and ambient air, as necessary and the percentage of which depends upon measured cabin altitude.) With oxygen panel controls (a separate one exists for each pilot) set properly, if the oxygen valve itself were *closed*, each pilot would not be able to 'draw' or breathe air while their oxygen masks were on. The mask would be sealed and nothing would get in; even ambient air. In the event of a pressurization emergency, the first pilot to get his mask on would instantly start yelling about 'opening that damned valve!' as their automatic response. In any case, each mask *should* be tested on the ground, prior to a flight. That also would be another huge 'clue' to the pilots that the valve was still closed. So, the only theoretical explanation I could conjur to explain what happened seemed flawed, too.

 

It never occured to me that another plausible reason could exist - since pilots would catch any other kind of failure, wouldn't they?

 

But, obviously, a valve left closed was *not* THE cause in this case. The 'setup' for the accident was faulty maintenance. O.K. That happens - and is not all that rare. Pressurization problems happen. Maintenance people sometimes make mistakes, but the pilots are paid well to detect and correct such errors in 'real time' - at any time. It so happens that I had an extremely similar thing happen to me when taking off from Los Angeles one day. As I was passing through about 5,000 feet, I somehow "sensed" that the aircraft was not pressurizing properly. I'm no genius or clairvoyant, so I'm not bragging, but it just didn't "feel" right, so I looked up at the cabin pressurization gauges overhead and saw the cabin altitude was the same as our aircraft's altitude; and there was no pressure differential building between inside and outside of the aircraft. So, I immediately requested a 'level off' altitude at 5,000 feet. The Altitude Warning Horn never got to sound off. No red lights lit. No masks dropped. No emergency took place. We took action *before* reaching 10,000 feet! We cruised around off shore, talked with our Los Angeles maintenance people, took some corrective actions to correct a maintenance screwup, and the plane started pressurizing as it was supposed to. And we then climbed and flew on to our destination. No biggie. I doubt our passengers ever knew anything was going on.

[bSr.LCsta]

The pilots are the "last line of defense" against (among other things) stupidity and human error, starting with those of other people, but including 'trapping' their own errors before they become serious problems. The TRUE cause of the accident was that *both* pilots were brain-dead STUPID. They didn't understand how their aircraft works, what the warning systems were trying to tell them, and did not perform their essential function!! They started working on the solution before they really had identified the problem! Egad! I wonder how they ever completed transition training to fly that aircraft - and how the Captain ever passed his "Type Rating" checkride, to fly as Pilot-in-Command of that type of aircraft!!!

 

It doesn't matter what model of jet aircraft you fly; ANY TIME you hear the cabin altitude warning go off (regardless of what kind of sound and/or warning lights turn on), EVERY emergency checklist is going to have as it's first, #1 Action: "Put on your oxygen mask." Period. Everything else is secondary!! We are all trained, just like Pavlov Dogs, to react instantly and without any decision-making at all required when certain, critical things, like that, occur. It never dawned on either of them that they NEEDED oxygen. Duh! Where was *their* training?

 

Yes, the horn used to warn the pilots about not having their flaps, speed brakes, wheel brakes, and a few other things set "properly" for takeoff - is the same one that is used to warn the pilots that the cabin altitude is too high (meaning that air pressure is too low) when such a condition is sensed by the aircraft's pressure sensors. But that is NO excuse for this level of confusion. If it's a "Takeoff Warning" the intermittent horn is trying to alert, that kind of problem will *only* occur on the ground. At which time, the pilots are supposed to do certain things. But if it's a "cabin altitude" problem, (which is to say a pressurization fault) they are supposed to do different things. Pressurization problems can only take place while airborne and will *never* take place on the ground. BUT you'd have to be a complete IDIOT to confuse the two, different, possible meanings that one horn is trying to tell you (as the article points out.)

 

But I still find it impossible to believe that the pilots would be able to continue climbing to such an altitude to where they'd lose consciousness (somewhat above 20,000' I assume, which would take several minutes to reach) AFTER their first warning, when the plane climbed through 10,000 feet. Doing a 'Wild Goose Chase' around the cockpit, pursuing bogus 'faults' and pulling circuit breakers should certainly stop, if not sooner, at least at 14,000! I'll tell you why.

 

The pilots can *command* the passenger oxygen masks to drop at any time they choose; even while on the ground! Just throw one switch and it'll happen. Regardless of that, if the cabin altitude gets to 14,000 feet, the masks will drop *automatically* in the passenger cabin, due to an automatic, built-in pressure sensor set to trigger then. (Nothing extra happens in the cockpit as they pass that altitude.) The very next thing that will happen in the Real World is that the flight attendant/stewardess is going to be wildly dinging the cockpit crew with the interphone chime to find out just what the hell is going on and why did the masks all dropped, and what the pilots are doing about it, and do they want their coffee now? When the F/A tells the Captain that the masks have all dumped in the back of the aircraft, even a MONGOLOID Captain would then know he's got a serious pressurization problem, not some 'takeoff warning' that won't shut off!

 

For that matter, the Captain could have easily trouble-shot the probem to confirm which reason the horning was going off - by pressing one button. The 'Altitude Warning' horn *can be silenced* by pressing a 'cutoff' button on the overhead panel. But that button has no effect on a 'takeoff warning'. The only way to silence a 'takeoff warning' horn is by fixing the source of the problem.

 

I never believed a crew could be SO ignorant as to ignore a RED 'Cabin Altitude' emergency annunciator light, assume a cabin altitude horn is malfunctioning, and to ignore or fail to check the Pressure Differential, Cabin Altitude, AND the altitude Rate-of-Change gauges, which are pneumatic, direct-reading, and bona fide 'no shit' gauges that ALWAYS work, and always tell the truth, even without electrical power!

 

This German (an ethnic group with a well-deserved reputation for engineering and scientific intelligence) and his ESL Co-Star hit a new cumulative low on the I.Q. scale. I'm just sorry that all those people had to be with them when the pilots left their brains at home that day.

[britgliderpilot]

:(

[iceden]

odd, nav lights on only in some pics, and tail numbers from F16's differ in dif shots...can someone clarify?

[Ice]

With all the things that should have stopped this catastrophe from happening. Isn't it conceivable that something else went wrong that wasnt the fault of the pilots?

 

There is something missing. Has to be.

[GGTharos]

Yeah, something's definitely wrong with these pictures ... check the armaments on the F-16's.

 

It -is- possible that two different pairs of F-16's joined on the 737 ...

[Ice]

Well considering it would have been flying until it ran out of fuel it's not surprising ther was more than 1 pair of f16's

[Pilotasso]

With all the things that should have stopped this catastrophe from happening. Isn't it conceivable that something else went wrong that wasnt the fault of the pilots?

 

There is something missing. Has to be.

 

One should check the background of that airline. Some airlines are notorious for strange incidents. This crash sure is strange, its badly told. There were 2 versions of it avaiable on the news at the time.

1) everybody got intoxicated on carbon monoxide.

2)Air climatization malfuntioned letting freeze everybody on board by startospheric temperatures.

 

In any of the 2 situations the problem could have been simply solved by dropping to an altitude below 10000 feet and just let the pressure equalize, even if they had to open doors if anything else failed. No one would die of poisening or freez with the new air circulation.

 

Being this a cyprus plane I also dont know wich political cause it could favour for some sort of deliberate action. The story is at least incomplete. On the other hand I also have no Idea why it would the facts be hidden away.

[Roman G]

OK, it does sound like pilots were extremely poorly trained - which is quite against all popular believes and shocking.

 

Other thing hard to believe is that in this century an commercial airliner alarm system is communicating information to pilots by buzzers and lights. How expensive it would be that instead of siren sound the alarm system would SAY "Cabin Pressure Low, take oxygen mask NOW !" and suggest what else is the pilot is supposed to do ? This could also help scenario where for whatever reason an amateur is flying the plane (in the event where both pilots just died of heart-attack or whatever else). And why autopilot takes plane to 35 thousand feet (even if it is programmed so) if cabin pressure is low ? Why opening main oxygen valve is manual procedure and why there is no warning when valve is closed and the airplane is in the air ?

[Ice]

There's been a few of these incidents over the last few years. i wonder how difficult or expensive it would be to have some sort of remote autopilot landing activation system or ("RALAS", hehe I'll patent it)that could be transmitted by a control tower. For example a modern day jetliner can land itself if it needs to but needs someone onboard to intiate it. What if a Control tower with the right activation codes being able to initiate an autopilot to land at an airfield.

 

If someone is capable onboard the plane they could override it. But if all unconcious then it could save hundreds of lives.

[Roman G]

There's been a few of these incidents over the last few years. i wonder how difficult or expensive it would be to have some sort of remote autopilot landing activation system or ("RALAS", hehe I'll patent it)that could be transmitted by a control tower. For example a modern day jetliner can land itself if it needs to but needs someone onboard to intiate it. What if a Control tower with the right activation codes being able to initiate an autopilot to land at an airfield.

 

If someone is capable onboard the plane they could override it. But if all unconcious then it could save hundreds of lives.

 

I didn't want to go that far - but, yes - why this is not part of every larger passanger plane ?

[Ice]

It could also be a great weapon against terorists. Forcing the aircraft to land. Would have to rethink the override option. Inputting a code that the pilots dont know could work. It would have to be requested over the radio.

[ARM505]

I believe the pressurisation mode controller was left in the 'manual' mode, with the outflow valve only partially closed. Horrendous memory actions and troubleshooting though, and the company can certainly be faulted for pairing incompatible (language-wise) crewmembers.

[169th_Dredd]

Interesting... saw these pictures before.

Photoshop wizzes.. spot the touchups.

 

http://www.briandunning.com/helios.shtml

 

<insert twilight zone music here>

[Guest EVIL-SCOTSMAN]

the f18 got it, and thats only 2 people, so i agree that for huge passenger jets that it should be mandatory, to have an automated remote landing capability, if they can get an f18 to land on a carrier remotely then i cant see the problem why they cant have it on passanger jets.

[Force_Feedback]

the f18 got it, and thats only 2 people, so i agree that for huge passenger jets that it should be mandatory, to have an automated remote landing capability, if they can get an f18 to land on a carrier remotely then i cant see the problem why they cant have it on passanger jets.

 

Why don't the pilots got ejection seats on passenger jets? Why don't the passengers and crew have parachutes on pass jets? Why are there no bombproof baggage containers?

 

That brings me to a famous song made by ABBA; "Money, Money, Money"

[jpm1]

The two pilots ignored the cabin altitude warning siren, MASTER WARNING, cabin pressurization RED Light and the Oxygen masks dropped and they thought it was the Takeoff Configuration Warning (Were you on the runway, you IDIOT!!) and the Capt called Maintenance Control and was out of his seat busily trying to pull the C/B to silence the horn. The FO didn't speak his language (German) and neither of them spoke English enough to communicate with each other; but, hey, I'll bet they worked CHEAP !!!

 

year i ve seen that . just unbelievable ..!

[hitman]

Id like to know what the GPS coordinates were between these sets of photos. They do look like they were in different geographical locations.

[Pilotasso]

There's been a few of these incidents over the last few years. i wonder how difficult or expensive it would be to have some sort of remote autopilot landing activation system or ("RALAS", hehe I'll patent it)that could be transmitted by a control tower. For example a modern day jetliner can land itself if it needs to but needs someone onboard to intiate it. What if a Control tower with the right activation codes being able to initiate an autopilot to land at an airfield.

 

If someone is capable onboard the plane they could override it. But if all unconcious then it could save hundreds of lives.

 

your plan has only 1 problem. If the pilots were incompetent as this case apears to indicate, then they would probably fail to press initiate button anyway!

Even more: pressing it would a formal declaration of incompetence and none on board would want to bruise his ego.

[169th_Crusty]

Interesting... saw these pictures before.

Photoshop wizzes.. spot the touchups.

 

http://www.briandunning.com/helios.shtml

 

<insert twilight zone music here>

 

Good find Dredd...

[169th_Crusty]

Why don't the pilots got ejection seats on passenger jets? Why don't the passengers and crew have parachutes on pass jets? Why are there no bombproof baggage containers?

 

That brings me to a famous song made by ABBA; "Money, Money, Money"

 

Same song applies to: Why were these "pilots" hired and/or so poorly trained

by this "airline". ...but let`s wait for more details, if ever.

[169th_Crusty]

your plan has only 1 problem. If the pilots were incompetent as this case apears to indicate, then they would probably fail to press initiate button anyway!

Even more: pressing it would a formal declaration of incompetence and none on board would want to bruise his ego.

 

Anybody heard a term PIC (pilot in command)?

 

Oh, someone mentioned mentioned Hornet`s ACLS. I don`t think a system

modification to allow the CATTC (boat`s air traffic) to take over the controll

of a fighter in trouble will be adopted anytime soon.

Hehe, I just imagined Strike Controll calling some lonely Bug: "All right, we`re

bringing you in!!!" That`ll be the day...

[Ice]

We get a few more cases like this and it will be on the cards. Pilots egos arent enough if it means saving lives or stopping an aircraft from slamming into the white house.

[169th_Crusty]

We get a few more cases like this and it will be on the cards. Pilots egos arent enough if it means saving lives or stopping an aircraft from slamming into the white house.

 

Certainly in the future the systems will change. Who knows how? Hopefully

the Pilot will still be in the picture (as an observer/backup ;))