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Hypoxia: The Crash of Helios Airways Flight 522

Hypoxia: The Crash of Helios Airways Flight 522

Hypoxia: The Crash of Helios Airways Flight 522

Helios Airways Flight 522 was a Boeing 737 that crashed into a mountain on August 14, 2005 north of Marathon and Varnavas, Greece while flying from Larnaca, Cyprus. Rescue teams located wreckage near the community of Grammatiko (25 mi) from Athens. All 121 on board perished, making this crash the deadliest aviation disaster in Greek history. The investigation concluded that the accident was caused by Hypoxia.
When the aircraft arrived at Larnaca earlier that morning, the previous flight crew reported a frozen door seal and abnormal noises coming from the right aft service door and requested a full inspection.[1][2] The inspection was carried out by a ground engineer who then performed a pressurization test. In order to carry out this test without requiring the aircraft's engines, the pressurization system was set to manual, and was not set back to auto upon completion of the test.[3]
After the aircraft was returned into service, the flight crew overlooked the fact that the pressurization system was set to manual on three separate occasions: during the pre-flight procedure, the after-start check, and then after take-off check. The aircraft took-off around 9:07 with the pressurization system still set to manual, and the aft outflow valve partially open.[4]
As the aircraft climbed, the pressure inside the cabin gradually decreased. As it passed through an altitude of 12,040 feet, the cabin altitude warning horn sounded.[5] The warning should have prompted the crew to stop climbing, [6] but it was misidentified by the crew as a take-off configuration warning, which signals that the aircraft is not ready for take-off, and can only sound on the ground.[6]
In the next few minutes, a number of warning lights on the overhead panel in the cockpit illuminated. One of the equipment cooling warning lights came on to indicate low airflow through the cooling fans (a result of the decreased air density), accompanied by the master caution light. The passenger oxygen light illuminated when, at an altitude of approximately 18,000 feet, the oxygen masks in the passenger cabin automatically deployed.[7][8]
Shortly after the cabin altitude warning sounded, the captain radioed the Helios operations center and reported "the take-off configuration warning on" and "cooling equipment normal and alternate off line".[5] He then spoke to the ground engineer and repeatedly stated that the "cooling ventilation fan lights were off".[5] The engineer (whom had conducted the pressurization leak test) asked "Can you confirm that the pressurization panel is set to AUTO?" The captain, however, disregarded the question and instead asked in reply, "Where are my equipment cooling circuit breakers?”[8] This was the last communication with the aircraft.[9]
The aircraft continued to climb until it leveled off at 34,000 feet.[8] Between 09:30 and 09:40, Nicosia ATC repeatedly attempted to contact the aircraft, without success.[8] At 09:37, the aircraft passed from Cyprus Flight Information Region into Athens Flight Information Region, without making contact with Athens ATC.[8] Nineteen attempts to contact the aircraft between 10:12 and 10:50 were unsuccessful, [10] and at 10:40 the aircraft entered the holding pattern for Athens Airport, still at 34,000 feet.[11] It would remain in this holding pattern, under control of the auto-pilot, for the next seventy minutes.[11]
Two F-16 fighter aircraft from the Hellenic Air Force 111th Combat Wing were scrambled from Nea Anchialos Air Base to establish visual contact.[12] They intercepted the passenger jet at 11:24 and observed that the first officer was slumped over at the controls and the captain's seat was empty.[13] They also reported that oxygen masks had deployed in the passenger cabin.[11]
At 11:49, flight attendant Andreas Prodromou entered the cockpit and sat down in the captain's seat.[14] Prodromou held a UK Commercial Pilot License, [15] but was not qualified to fly a Boeing 737. Crash investigators concluded that Prodromou's experience was insufficient for him to gain control of the aircraft under the circumstances.[14]
Almost as soon as he entered the cockpit, the left engine flamed out due to the lack of fuel, [14] and the plane left the holding pattern and started to descend.[16] Ten minutes after the loss of power from the left engine, the right engine also flamed out, [16] and just before 12:04 the aircraft crashed into hills near Grammatiko.[16]
Pilots are trained and understand the dangers of hypoxia which makes it difficult to understand why highly trained, capable pilots would chose to disregard a basic safety system. The popular 737 aircraft’s warning horn is confusing to pilots. The warning system serves two purposes. It warns the pilots that there is a problem with the configuration of the aircraft before the take-off. After the pilot trouble shoots the pre- takeoff problem, they assume there are no more issues and dismiss the warnings, when in reality, potential problems of pressurization can occur in flight.
Other problems that pilots deal with are false alarms. Faulty pressurization equipment cause alarms to sound when they shouldn't be. Because of the false positive altitude and pressure warnings, pilots have been known to ignore the safety signals.
The FAA has been investigating numerous reports of pressurized problems in various types of aircraft. In the 737, they have recommended a warning light to accompany the warning horn, and have also focused on after take-off procedures to include safety checks of the pressurization switches.
The documented pilot errors and dismissal of warning systems have led to investigations and legal action, as was the case of the Helios Airways Flight 522. Helios executives were charged with man-slaughter. In addition, U.S. and Cyprus attorneys filed lawsuits in 2006 on behalf of the crash victims.
Boeing has built a new and improved altitude warning system in their new aircrafts and are retrofitting older aircraft with an improved safety altitude warning systems. More effective warning systems of pressure problems in flight should lead to less pilot hypoxia-related aircraft accidents, but pilots need to be aware the hypoxia can occur no matter what aircraft they are flying.

References

1. AAIASB final report, section 1.1, page 3. Retrieved on 21 July 2012 2. AAIASB final report, section 1.6.2.3.2, pages 21–22. Retrieved on 21 July 2012 3. AAIASB final report, section 3.2.3, page 159. Retrieved on 21 July 2012 4. AAIASB final report, section 1.16.2, page 66. Retrieved on 21 July 2012 5. AAIASB final report, section 1.1, page 4. Retrieved on 21 July 2012 6. AAIASB final report, section 2.2.4, page 121. Retrieved on 21 July 2012 7. AAIASB final report, section 2.2.4, page 122. Retrieved on 21 July 2012 8. AAIASB final report, section 1.1, page 5. Retrieved on 21 July 2012 9. AAIASB final report, section 2.2.5, page 125. Retrieved on 21 July 2012 10. AAIASB final report, section 1.1, pages 5–6. Retrieved on 21 July 2012 11. AAIASB final report, section 1.1, pages 5–6. Retrieved on 21 July 2012 12. "Helios Crash: Background information". Famagusta Gazette. http://famagusta-gazette.com/helios-crash-background-information-p237-69.htm. Retrieved 21 July 2012 13. Don Phillips (16 August 2005). "Crash inquiry focuses on oxygen mask use". New York Times. http://www.nytimes.com/2005/08/15/world/europe/15iht-crash.html. Retrieved via LexisNexis Database on 21 July 2012. 14. AAIASB final report, section 2.2.7, page 127. Retrieved on 21 July 2012 15. AAIASB final report, section 1.5.3.4, page 15. Retrieved on 21 July 2012 16. AAIASB final report, section 1.1, page 7. Retrieved on 21 July 2012

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