by YFred » Tue Jan 13, 2009 2:12 am
This leaked report makes interesting reading of Aircraft and CAA.
‘Doomed from the outset’
By Elias Hazou
(archive article - Tuesday, March 21, 2006)
Greek paper says leaked report points to grave errors that led to crash
OVERSIGHTS ON the ground, slackness on the part of the crew during the flight, inadequate controls by the Civil Aviation Authority and faulty flightdeck consoles by Boeing – led to what has been dubbed the worst peacetime disaster in Cyprus’ recent history.
The above are the conclusions gleaned from a leaked draft of the accident report, published by Greek daily Kathimerini on Sunday. Citing its sources, the paper commented ominously that flight ZU-522, the August 14 crash of Helios Airways that claimed the lives of 121 people, was “doomed from the outset.”
According to Kathimerini, chief air investigator Akrivos Tsolakis and his team of experts have found that the confusion over the decompression warning alarm “could under no circumstances have been the cause on its own…there were dozens of other omissions in air safety that contributed to the crash.”
Now seven months in the making, Tsolakis’ voluminous probe should be ready sometime in April. It comprises 200 pages, divided into four chapters: the facts of the case; analysis of the facts; the findings/causes of the accident; and a list of safety recommendations. This is followed by thousands of pages of appendices with all the documents used in the investigation.
Kathimerini said the probe would apportion responsibility on all those involved with aviation in Cyprus, and would be particularly damning on civil aviation, for an “unparalleled absence of assessing air flight safety,” and on the airline for “criminal negligence”.
The inquiry contains some chilling details on the sequence of events. Problems began with mistakes on the ground that were subsequently not dealt with in the air. Shortly after takeoff at 9am on the fateful day, two warnings – one for the decompression system, the other for the cooling system – were sounded almost simultaneously.
The warning horn sounded after the aircraft reached an altitude of 10,000 feet. The cabin decompression switch had been left on manual by ground crew during pre-flight checks, while it should have been set to automatic.
Still, this lapse could have been detected in time by the pilots had they properly scanned their gauges and carried out a checklist of components before takeoff. The aviators apparently did not do that.
When the decompression alarm went off, the crew – who had assumed that the decompression switch was on auto – mistakenly took this for a glitch in the positioning of the flaps, because the sounds emitted in both cases are identical. As the aircraft climbed to 34,000 feet, both the pilots and passengers gradually suffered the effects of hypoxia, or low oxygen in the blood: giddiness, loss of consciousness and finally deep slumber.
Captain Hans-Juergen Merten, who had left his seat to check the cooling system, is believed to have fainted inside the cabin.
According to the paper, all the people on board suffered irreversible brain damage from the lack of oxygen, and even if anyone had actually survived the horrific crash they would have been left in a vegetative state.
That includes flight attendant Andreas Prodromou who managed to retain consciousness using a portable oxygen mask at 14,000 feet and vainly tried to fly the plane before it slammed into a ravine at Grammatikos, outside Athens.
Moving on, the probe hauls the Cypriot Civil Aviation Authority over the coals, reportedly suggesting that its system of controls was “full of holes”. Kathimerini’s sources say the agency did not carry out the necessary checks on planes and often ignored instructions from ICAO (International Civil Aviation Organisation). Moreover, it blew off recommendations periodically made by its two British consultants.
However, partial responsibility also lies with EASA (European Aviation Safety Agency) and JAA (Joint Aviation Authorities) for failing to place the local civil aviation authorities under surveillance and thus acting preventatively.
As far as Helios Airways is concerned, the probe reportedly notes the marked “lack of a safety culture” in the company. The airline’s employees were hired on six-month contracts, giving them no career prospects and thus no incentives. The same corporate policy extended to the pilots, as the airline tended to hire the “cheapest they could find”,
Aircraft manufacturers Boeing also had its share of blame. In his probe, Tsolakis notes the confusion generated over the decompression warning signal and that Boeing should have taken steps to rectify this.
What is more, the company’s 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,” i.e. from manual to auto.
The manual setting is used in pre-flight checks to simulate decompression situations, but needs to revert to automatic for takeoff.
According to procedure, when completed the probe will be communicated to the US’s National Transportation Safety Board and to Helios, who then need to respond to the observations within 60 days. Once their answers are in, the report will be published, opening the way for any legal proceedings by the victims’ relatives, who for months now have been agonisingly waiting for the truth to come out.
In a related development, ICAO is considering enforcing stricter controls on the civil aviation authorities of countries that are deemed to be problematic. One proposal is to appoint a “guardian” who would monitor the authorities and ensure they comply with all safety standards.
At the ICAO summit in Montreal, Canada, the heads of civil aviation authorities around the world are being asked to authorise the publication of the results of checks on the organisation’s website.
Really?
