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Accident / Incident Review: FG Offr A Saxena Paraspears'

The crew of a Helios Airways Boeing 737 crashed in Greece after running out of fuel. The flight crew had become unconscious due to improper cockpit air conditioning settings. A student pilot in the passenger cabin attempted to land the plane but could not. An investigation found a lack of crew resource management and improper flight planning contributed to the accident.

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Prashant Verma
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33 views11 pages

Accident / Incident Review: FG Offr A Saxena Paraspears'

The crew of a Helios Airways Boeing 737 crashed in Greece after running out of fuel. The flight crew had become unconscious due to improper cockpit air conditioning settings. A student pilot in the passenger cabin attempted to land the plane but could not. An investigation found a lack of crew resource management and improper flight planning contributed to the accident.

Uploaded by

Prashant Verma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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ACCIDENT / INCIDENT

REVIEW

FG OFFR A SAXENA
‘PARASPEARS’
BRIEF
• A HELIOS AIRWAYS BOEING 737-300 WITH A
CREW OF 6 AND 115 PASSENGERS ON
BOARD CRASHED IN GREECE ON 14 AUG
2005.
• IT RAN OUT OF FUEL AS A STUDENT
PRIVATE PILOT ATTEMPTED TO FLY THE
AIRCRAFT TOWARDS ATHENS AIRPORT
BECAUSE THE FLIGHT CREW WAS
UNCONSCIOUS.
SEQUENCE OF EVENTS
• ATS AT BACAU AVAILABLE ONLY FOR UN
AC, INFO INCLUDED IN THE NOTAMS BUT
NOT NOTICED BY CREW.

• CREW CONTACTED BACAU TWR


REPEATEDLY, NO RESPONSE RECEIVED.
SEQUENCE OF EVENTS
• OFF-DUTY CONTROLLER INFORMED THE
CREW THAT ATS N/A, LDG AT THE
DISCRETION OF THE CREW.

• WEATHER & TRAFFIC INFO NOT OBTAINED


BY THE CREW.

• PILOT DESCENDED BELOW THE MSA AND


THE COMMENCEMENT ALTITUDE FOR THE
NON-PRECISION APPROACH.
SEQUENCE OF EVENTS
• INSTRUMENT APPROACH CHARTS WERE
AVAILABLE FROM CAD, CREW USED
JEPPESEN.

• NAVIGATOR PROVIDED THE INFO TO PILOT


BASED ON THE THRESHOLD INFO
DEPICTED ON THE JEPPESEN CHARTS
AND THUS INACCURATE.

• DURING THE FIRST APPROACH CREW


REALISED THAT R/W IS DISPLACED AS
COMPARED TO JEPPESEN.
SEQUENCE OF EVENTS
• APPROACH DISCONTINUED, NAV APPLIED
THE CORRECTION WHICH POSITIONED AC
0.88 nm NW OF THRESHOLD.

• ON SECOND APPROACH NAV ASKED PILOT


TO INCREASE ROD, PILOT INCREASED TO
18 m/s AND STATED ‘INCREASED’.

• FLT ENGR MISTOOK PILOT’S STATEMENT


‘INCREASED’ TO BE A COMMAND TO
INCREASE THRUST & ADVANCED THRUST
LEVERS.
SEQUENCE OF EVENTS
• CREW’S ATTENTION DIVERTED DUE TO
FE’S INCORRECT ACTION, AT THE SAME
TIME AC DESCENDED THROUGH THE MDH.

• NONE OF THE CREW NOTICED THE AC


DESCENDING THROUGH MDH, WERE
PROBABLY TOO DISTRACTED.

• HIGH ROD CONTINUED UNTILL 2 SEC


BEFORE THE IMPACT.
CAUSES
• LACK OF CRM.

• CREW’S ATTENTION DIVERSION.

• INCORRECT FLIGHT PLANNING & DESTN


BFG.

• DESCENDING THROUGH MDH WITHOUT


HAVING ESTABLISHED THE REQD. VISUAL
REFERENCE FOR LDG.
MATO CH 5 ORDER NO.13
• BEFORE COMMENCEMENT OF EACH FLIGHT, THE
CAPTAIN IS TO BRIEF THE CREWMEMBERS. THE
CONTENTS OF THE CREW BFG MAY VARY
DEPENDING UPON THE EXPERIENCE OF THE
CREW AND THE NATURE OF THE FLIGHTS.
HOWEVER, THE FOLLOWING POINTS ARE TO BE
COVERED.
(A) WEATHER: THE OVERALL SYNOPTIC
SITUATION OVER THE ROUTE/AREA AND THE
WEATHER AT DEPARTURE, DESTINATION AND
DIVERSIONARY A/F.
MATO CH 5 ORDER NO.13
(B) ATC: THE LATEST INFORMATION ON THE
STATE AND SERVICEABILITY OF RUNWAYS,A/F
FACILITIES, NAVIGATIONAL AND
COMMUNICATION AIDS AT DEPARTURE,
DESTINATION AND DIVERSIONARY A/F.

(C) CREW AND AC LIMITATIONS: THE DETAILS OF


THE MISSION AND LIMITATIONS ARE TO BE
WORKED CORRECTLY BY THE CREW.
MATO CH 5 ORDER NO.13

(D) AC DRILLS, PROCEDURES AND


EMERGENCIES.

(E) ADDITIONAL DUTIES ALLOTTED TO THE


CREW.

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