Republic of the Philippines

PHILIPPINE STATE COLLEGE OF AERONAUTICS

Institute of Engineering and Technology

The Crash of Helios Airways Flight 522 on account of Loss in Cabin

Pressurization: A case study

Angelo G. Divino

Mary Angelika Grace A. Quiroz

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 Republic of the Philippines
PHILIPPINE STATE COLLEGE OF AERONAUTICS
Institute of Engineering and Technology

Angelo G. Divino

Mary Angelika Grace A. Quiroz

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 Republic of the Philippines
PHILIPPINE STATE COLLEGE OF AERONAUTICS
Institute of Engineering and Technology
Executive Summary

The aviation business initially served the military to help them fight their
conflicts, but there was a surplus of planes once the war was over. The
abundance of planes allowed individuals to travel longer distances more
quickly. Since then, aviation safety has been created to safeguard the public
from dangers associated with airplanes. In the twenty-first century, aviation
safety regulations are among the tightest in the transportation industry, and
non-compliance might have disastrous implications. It is common for a ground
employee to overlook parts of maintenance procedures, but it is expected for
other flight employees to be able to notice these errors. The errors should
always be addressed one way or another, before taking flight.

Findings

In 14 August 2005, 121 people which were in Helios Airways Flight 522
in a Boeing 737, died due to its crash. Human error is suspected as the reason
of the crash, service, and other areas. Under the ground staff’s turnaround
inspection, the flight deck crew’s inability to spot errors within the switches and
unawareness of the situation, the flight was named “ghost plane” and a “flying
tomb” as passengers as well as the flight deck crew were either passed out or
motionless.

The initial report two hours since Flight 522’s takeoff indicated that when
the Hellenic air force was trying to intercept the flight, they noticed that there
was no one in the captain’s seat, the first officer had fallen over the controls
and there were no movement seen with the only 3 passengers that were seen.
The passengers were either wearing oxygen masks or had them dangling
above their heads.

There had been a previous instance where Boeing 737s had confusing
alert systems. The same warning horn is used for takeoff configuration and as
an altitude of warning. The latter was the problem in Flight 522, there was a
pressure loss that consequently resulted in less oxygen supply inside the
aircraft.

Discussion

As early as five minutes within takeoff, the cabin’s warning horn went off,
signaling the flight deck crew to stop the climb. During this event, the aircraft
was already at over 12000 feet above the ground. What made them ignore the
warning horn was the crew’s misunderstanding of the reason behind why it went
off—it was identical to the warning horn that indicates a takeoff configuration

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PHILIPPINE STATE COLLEGE OF AERONAUTICS
Institute of Engineering and Technology
warning. The decrease in cabin pressure resulted to the difficulty in
communicating with the pilots as they are already experiencing symptoms of
hypoxia. The aircraft eventually reached its peak of 34000 feet just a little over
15 minutes after takeoff.

From Larnaca, Cyprus to Prague, Czech Republic, the plane had a stop
over in Athens, Greece. When the aircraft entered the Athens flight information
region, it started to be on autopilot as a result of the incapability of the crew to
control the plane. It was circling around when two Greek F-15 fighter jets were
deployed to intercept the plane. When they have located the aircraft, they
reported that there was no one in the captain’s seat and the first officer was
unconscious. They then noticed that there were flight attendants that were
trying to control the aircraft by entering the cockpit while being equipped with a
portable oxygen supply. As the rescuers had just been recognized by the crew,
the plane’s left engine was put into flames because of fuel exhaustion that
caused the aircraft to descend.

The flight attendant recognized by the pilots of the two Greek F-15s was
able to turn the plane away from Athens that prevented ground casualties.
However, he was unable to regain enough control of the aircraft, causing them
to inevitably crash into the hillside near the village of Grammatiko, Greece just
25 miles away from Athens.

The investigation of Flight 522’s crash determined that the reason behind
it was the improper pressurization of the aircraft. Aircraft engineer Alan Irwin
was attributed with a huge portion of the blame. He is ground staff that assessed
the plane’s ability to get back and have a turnaround, implying that it was his
call to begin with. The theory focused on the fact that the pressurization selector
switch was not switch back to “auto”, but rather left in “manual”. It was said that
the person responsible was Irwin who allegedly was not able to return the
switch correctly after conducting his safety check. Aside from Irwin, the crash
was also attributed to the incompetence of the captain and the first officer who
were both incapable of spotting the error left by Irwin—the misunderstanding of
the warning horn sounded for the pressure warning instead of takeoff
configuration. According to the lawyer hired by Boeing, Helios’s ground staff did
not properly observe the procedures provided by the manufacturer. There were
16 mistakes identified that were done by the ground staff, and both of the flight
deck crew and passenger cabin crew of Flight 522.

Aside from these employee-centered faults, there were previous

instances that involved incidents caused by the confusing warning horn
systems on Boeing 737s. Two different problems, namely one for takeoff

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PHILIPPINE STATE COLLEGE OF AERONAUTICS
Institute of Engineering and Technology
configuration and pressure loss, use the same warning horn sounds to signal
their presence within the aircraft. The director of NASA’s Aviation Safety
Reporting System has already called Boeing’s attention regarding this situation
a year before the crash, calling it as a safety concern. This chain of events
started with Boeing being unable to address this concern as per aircraft
engineer Alan Irwin, who is second in line on the blame.

The train of blame started with how the flight deck crew and the
passenger cabin crew being unable to notice the real reason behind the
warnings which resulted in the manufacturer’s blame on their incompetence.
However, a big part of the blame was pointed to Alan Irwin, the ground engineer
who allegedly, wasn’t able to switch back the plane’s pressurization selector
switch from manual to auto, after conducting a cabin pressurization leak check
that tested the integrity of the cabin door after being reported by the cabin crew.
An even bigger and wider-reaching fault was that of Boeing’s itself. The
manufacturer straight-out disregarded ASRS’s calling of their attention
regarding their similar warning horn systems for two distinct errors within the
aircraft.

The Hellenic Ministry of Transport and Communication’s Air Accident

Investigation & Aviation Safety Board looked into the accident through ICAO’s
practices and was able to identify that the crash resulted from direct and latent
causes presented in the document as:

“The direct causes were:

• Non-recognition that the cabin pressurization mode selector was in the

manual position during the performance of the:
o Preflight procedure;
o Before Start checklist; and
o 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), and continuation of the climb.
• Incapacitation of the flight crew due to hypoxia, resulting in continuation
of the flight via the flight management computer and the autopilot,
depletion of the fuel and engine flameout, and impact of the aircraft with
the ground.

The latent causes were:

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PHILIPPINE STATE COLLEGE OF AERONAUTICS
Institute of Engineering and Technology
• 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.”

In this document, the flight crew’s incompetence and irresponsibility

were identified as the direct causes. While Boeing’s inability to recognize
adequate quality management and safety culture was identified as contributing
factors.

As stated by Akrivos Tsolakis, head of Greece’s National Aviation Safety

Board, human error was the main cause of the crash, who these persons are
were also stated. The first ones mentioned were the two pilots who failed to
regulate the cabin pressure, followed by the maintenance officials who were
unable to switch the pressure controls to its correct setting, and the
manufacturer’s “ineffectiveness of measures taken in response to previous
pressurization incidents in the particular type of aircraft.” There was no single
person held accountable, each and everyone that was involved and either
turned a blind eye to the situation or was not competent enough to ensure the
passenger’s safety are to be blamed.

Conclusion

In conclusion, Boeing should not have ignored NASA’s ASRS’s warnings

about the threat that their warning horns had posed to the aircraft's functioning.
With an issue like this, persons in positions of responsibility at both Boeing and
the NASA’s ASRS should be held accountable for the failure to properly ensure
the compliance of the manufacturer. Instead of maximizing profits and ignoring
the issues raised by persons inside and outside the company, Boeing should
have prioritized the safety of passengers and crew flying the aircrafts with faulty
warning horn systems.

In line with Irwin’s incompetence, Boeing should also have included

enough redundancy within its procedures to ensure that the pressurization
system would always be properly configured after every safety and
maintenance check. Both the ground staff and flight staff should be able to
countercheck what each of them had done before, during, and after every
takeoff as it is both their responsibilities to assure that the aircraft is in its best
condition to safely transport human lives.

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PHILIPPINE STATE COLLEGE OF AERONAUTICS
Institute of Engineering and Technology
Recommendations

The situation could’ve been handled better if there were operator

evaluation that integrates the country’s civil aviation authority and Boeing. The
dual use of the warning horn system for both warnings in takeoff configuration
and cabin altitude as well as the lack of warning lights were integral in the safety
of everyone in the flight. The revision of their procedures and guidelines should
also include the effects of inadequately pressurized cockpits and cabins, one
of which was identified as hypoxia.

Moreover, the cabin crew should also be provided with access to the
flight deck with the use of the cockpit door and should undergo training and
orientation regarding its operations. It is also needed for cabin crew procedures
to be amended that the Cabin Chief to be required to be alert and notify the
flight crew in case of a loss of cabin pressure or its insufficiency.

With the execution of these improvements, the Boeing 737 will be safe
to fly, and the deadly crashes of Helios Airways Flight 522 will never happen
again. Aircraft makers should have always prioritized passenger safety as their
first concern.

Implementation

To ensure the safe functioning of aircrafts and the safety of their

passengers, everyone in the airline manufacturing industry and administration
should execute their highest safety standards. In the case of the Helios Airways
Flight 737, Boeing and its corresponding aviation authorities in its
corresponding countries of operation should adhere to tight compliance and
safety requirements in order to avoid overlooking any future problems or
warnings.

Instead of saving costs by asking no additional training in the

development of the Boeing 737, airline firms should have prioritized competent
flight deck crew, passenger cabin crew, and ground staff training as well as
adhering and addressing the recommendations and issues raised to them by
authorities.

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 Republic of the Philippines
PHILIPPINE STATE COLLEGE OF AERONAUTICS
Institute of Engineering and Technology
References

The Associated Press. (2006, October 10). Human error blamed for 2005 Greek
air crash. NBC News.

Duque, L. V. (2017, September 8). The numerous safety deficiencies behind

Helios Airways HCY 522 accident. Living Safely with Human Error.
Retrieved June 11, 2022, from
https://livingsafelywithhumanerror.wordpress.com/2017/09/08/the-
numerous-safety-deficiencies-behind-helios-airways-hcy-522-accident/

Hardiman, J. (2021, April 30). What Caused The Crash Of Helios Airways Flight
522 In 2005? Simple Flying. Retrieved June 12, 2022, from
https://simpleflying.com/helios-airways-flight-522/

Hellenic Republic Ministry of Transport & Communications. (2006, November).

HELIOS AIRWAYS FLIGHT HCY522 BOEING 737-31S AT
GRAMMATIKO, HELLAS ON 14 AUGUST 2005. Retrieved June 11,
2022, from https://reports.aviation-safety.net/2005/20050814-
0_B733_5B-DBY.pdf

Williams, S. (2020, September 19). In 2005, Helios flight 522 crashed into a
Greek hillside. Was it because one man forgot to flip a switch? The
Guardian. Retrieved June 12, 2022, from
https://www.theguardian.com/world/2020/sep/19/in-2005-helios-flight-
522-crashed-into-a-greek-hillside-was-it-because-one-man-forgot-to-
flip-a-switch