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B733, en-route, Grammatiko Greece, 2005 (HF LOC FIRE AW)
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|On 14 August 2005, a B737-300 aircraft belonging to Helios Airways, crashed near Grammatiko, Greece following the incapacitation of the crew due to Hypoxia.|
|Event Type||AW, FIRE, HF, LOC|
|Type of Flight||Public Transport (Passenger)|
|ICL / ENR|
|Approx.||near, Grammatiko, Greece|
|Tag(s)|| Inadequate Aircraft Operator Procedures|
Ineffective Regulatory Oversight
|Tag(s)||Loss of Comms|
|Tag(s)||Post Crash Fire|
|Tag(s)|| Ineffective Monitoring|
Flight / Cabin Crew Co-operation
Procedural non compliance
Inappropriate crew response - skills deficiency
Flight Crew Visual Inspection
Maintenance Visual Inspection
Flight Crew Incapacitation
|Tag(s)|| Loss of Engine Power|
Flight Management Error
|Tag(s)||Pax oxygen mask drop|
|System(s)||Air Conditioning and Pressurisation|
|Contributor(s)||Maintenance Error (valid guidance available)|
|Damage or injury||Yes|
|Aircraft damage||Hull loss|
|Injuries||Nonewarning.png"None" is not in the list of possible values (Few occupants, Many occupants, Most or all occupants) for this property.|
|Fatalities||Most or all occupants|
|Causal Factor Group(s)|
|Group(s)|| Aircraft Operation|
Air Traffic Management
Crew Incapacitation Accident
This is an extract from the synopsis of the official report into the accident published by the Hellenic republic Ministry of Transport & Communications (Greece):
“On 14 August 2005, a Boeing 737-300 aircraft, registration number 5B-DBY, operated by Helios Airways, departed Larnaca, Cyprus at 06:07 h for Prague, Czech Republic, via Athens, Hellas.
The aircraft was cleared to climb to FL340 and to proceed direct to RDS VOR. As the aircraft climbed through 16000 ft4,876.8 m, 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 concerning the above problems and ended as the aircraft climbed through 28 900 ft. Thereafter, there was no response to radio calls to the aircraft. During the climb, at an aircraft altitude of 18 200 ft, the passenger oxygen masks deployed in the cabin. The aircraft levelled off at FL340 and continued on its programmed route.
At 07:21 h, the aircraft flew over the KEA VOR, then over the Athens International Airport, and subsequently entered the KEA VOR holding pattern at 07:38 h. At 08:24 h, during the sixth holding pattern, 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 at 08:32 h that the Captain’s seat was vacant, the First Officer’s seat was occupied by someone who 2 was slumped over the controls, the passenger oxygen masks were seen 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 08:49 h, he reported a person not wearing an oxygen mask entering the cockpit and occupying the Captain’s seat. The F-16 pilot tried to attract his attention without success. At 08:50 h, the left engine flamed out due to fuel depletion and the aircraft started descending. At 08:54 h, two MAYDAY messages were recorded on the CVR. At 09:00 h, the right engine also flamed out at an altitude of approximately 7 100 ft. The aircraft continued descending rapidly and impacted hilly terrain at 09:03 h in the vicinity of Grammatiko village, Hellas, approximately 33 km northwest of the Athens International Airport. The 115 passengers and 6 crew members on board were fatally injured. The aircraft was destroyed.
The Air Accident Investigation and Aviation Safety Board (AAIASB) of the Hellenic Ministry of Transport & Communications investigated the accident following ICAO practices and determined that the accident resulted from direct and latent causes.
The direct causes were:
- Non-recognition that the cabin pressurization mode selector was in the MAN (manual) position during the performance of the Preflight procedure, the Before Start checklist and the After Takeoff checklist.
- Non-identification of the warnings and the reasons for the activation of the warnings (Cabin Altitude Warning Horn, Passenger Oxygen Masks Deployment indication, Master Caution).
- Incapacitation of the flight crew due to hypoxia, resulting in the continuation of the flight via the flight management computer and the autopilot, depletion of the fuel and engine flameout, and the impact of the aircraft with the ground.
The latent causes were:
- Operator’s deficiencies in the organization, quality management, and safety culture.
- Regulatory Authority’s diachronic inadequate execution of its safety oversight responsibilities.
- Inadequate application of Crew Resource Management principles.
- Ineffectiveness of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft.
The AAIASB further concluded that the following factors could have contributed to the accident:
- Omission of returning the cabin pressurization 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 pressurization 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…"
Loss of Control