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aircraft accident report helios airways flight hcy522 boeing ..., Exercises of Aviation

Fairleigh Dickinson University - College at FlorhamAviation

Accident of the a/c 5B-DBY of Helios Airways,. Flight HCY522 on August 14, 2005, in the area of Grammatiko, Attikis,.

Typology: Exercises

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HELLENIC REPUBLIC
MINISTRY OF TRANSPORT & COMMUNICATIONS
AIR ACCIDENT INVESTIGATION
& AVIATION SAFETY BOARD
(AAIASB)
AIRCRAFT ACCIDENT REPORT
HELIOS AIRWAYS FLIGHT HCY522
BOEING 737-31S
AT GRAMMATIKO, HELLAS
ON 14 AUGUST 2005
11 / 2006
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Download aircraft accident report helios airways flight hcy522 boeing ... and more Exercises Aviation in PDF only on Docsity!

HELLENIC REPUBLIC

MINISTRY OF TRANSPORT & COMMUNICATIONS

AIR ACCIDENT INVESTIGATION

& AVIATION SAFETY BOARD

(AAIASB)

AIRCRAFT ACCIDENT REPORT

HELIOS AIRWAYS FLIGHT HCY

BOEING 737-31S

AT GRAMMATIKO, HELLAS

ON 14 AUGUST 2005

ii

ACCIDENT INVESTIGATION REPORT

Accident of the a/c 5B-DBY of Helios Airways,

Flight HCY522 on August 14, 2005,

in the area of Grammatiko, Attikis,

33 km Northwest Of Athens International Airport

The accident investigation was carried out by the Accident Investigation and

Aviation Safety Board in accordance with:

x ǹȃȃǼȋ 13

x Hellenic Republic Law 2912/

x E.U. Directive 94/

The sole objective of the investigation is the prevention of similar accidents

in the future.

The Accident Investigation and Aviation Safety Board

Chairman

Captain Akrivos D. Tsolakis

Members

A. Katsifas

Supreme Court Judge ret.

G. Kassavetis

Captain

Ȁ. Alexopoulos

Mechanical & Electrical Engineer

G. Georgas

Hellenic Air Force Brigadier ret. (Meteorologist)

Secretary

J. Papadopoulos

  • SYNOPSIS DECLARATION............................................................................................................. xii
    1. FACTUAL INFORMATION.................................................................................
    • 1.1 History of Flight
    • 1.2 Injuries to Persons
    • 1.3 Damage to Aircraft
    • 1.4 Other Damage
    • 1.5 Personnel Information..............................................................................
      • 1.5.1 Captain
      • 1.5.2 First Officer...............................................................................................
      • 1.5.3 Cabin Attendants.......................................................................................
        • 1.5.3.1 Chief Cabin Attendant
        • 1.5.3.2 Cabin Attendant number two
        • 1.5.3.3 Cabin Attendant number three
        • 1.5.3.4 Cabin Attendant number four
      • 1.5.4 Ground Engineers
        • 1.5.4.1 Ground Engineer number one...............................................................
        • 1.5.4.2 Ground Engineer number two...............................................................
        • 1.5.4.3 Ground Engineer number three.............................................................
      • 1.5.5 Air Traffic Controllers
        • 1.5.5.1 Nicosia ACC
        • 1.5.5.2 Athinai ACC
    • 1.6 Aircraft Information...............................................................................
      • 1.6.1 General......................................................................................................
      • 1.6.2 Maintenance History..................................................................................
        • 1.6.2.1 Maintenance Program
        • 1.6.2.2 Scheduled Maintenance
        • 1.6.2.3 Unscheduled Maintenance
          • 1.6.2.3.1 Decompression Occurrence on 16 December 2004..........................
          • 1.6.2.3.2 Aft Service Door Occurrence on 13 August
      • 1.6.3 Systems Descriptions
        • 1.6.3.1 Bleed Air System
        • 1.6.3.2 Air Conditioning
        • 1.6.3.3 Pressurization System
          • 1.6.3.3.1 Outflow Valves
          • 1.6.3.3.2 Pressurization Outflow......................................................................
          • 1.6.3.3.3 Flow Control Valve...........................................................................
          • 1.6.3.3.4 Outflow Valves (two units)...............................................................
        • 1.6.3.4 Equipment Cooling System
        • 1.6.3.5 Oxygen Systems....................................................................................
          • 1.6.3.5.1 Cockpit Oxygen System
        • 1.6.3.5.2 Passenger Cabin Oxygen Systems iv
        • 1.6.3.5.2.1 Passenger Oxygen.............................................................................
        • 1.6.3.5.2.2 Passenger Portable Oxygen...............................................................
    • 1.6.4 Cabin and Flight Deck Doors
      • 1.6.4.1 Cabin Doors
      • 1.6.4.2 Flight Deck Door
  • 1.7 Meteorological Information
  • 1.8 Aids to Navigation...................................................................................
  • 1.9 Communications
    • 1.9.1 Radio Communication Failure..................................................................
    • 1.9.2 Handover from Nicosia ACC to Athinai ACC
  • 1.10 Airport Information................................................................................
    • 1.10.1 Larnaca Airport.........................................................................................
    • 1.10.2 Athens International Airport “El. Venizelos”...........................................
  • 1.11 Flight Recorders......................................................................................
    • 1.11.1 Cockpit Voice Recorder (CVR)................................................................
    • 1.11.2 Flight Data Recorder (FDR)
  • 1.12 Wreckage and Impact Information.......................................................
    • 1.12.1 Wreckage Distribution
    • 1.12.2 Aircraft System Components....................................................................
      • 1.12.2.1 Overhead Cockpit P5 Panel
      • 1.12.2.2 P5 Air Conditioning Panel
      • 1.12.2.3 P5 Cabin Pressurization Panel
      • 1.12.2.4 Cabin Pressure Controllers
      • 1.12.2.5 Forward Outflow Valve
      • 1.12.2.6 Aft Outflow Valve
      • 1.12.2.7 Pneumatic System Components........................................................
      • 1.12.2.8 Flight Deck Oxygen Cylinder...........................................................
      • 1.12.2.9 Flight Crew Oxygen Masks
      • 1.12.2.10 Portable Oxygen Bottles
    • 1.12.3 Engines......................................................................................................
    • 1.12.4 Landing Gear
    • 1.12.5 Doors.........................................................................................................
  • 1.13 Medical and Pathological Information
    • 1.13.1 Medical Information
    • 1.13.2 Physiological and Psychological Effects of Low Cabin Pressure
    • 1.13.3 Hypoxia.....................................................................................................
      • 1.13.3.1 Symptomatology
      • 1.13.3.2 Time of Useful Consciousness..........................................................
  • 1.14 Fire
  • 1.15 Survival Aspects.......................................................................................
    • 1.15.1 General......................................................................................................
    • 1.15.2 Emergency Response
  • 1.16 Tests and Research
    • 1.16.1 Cabin Pressure Controllers
    • 1.16.2 The NVM Chip from the No. 2 Controller
    • 1.16.3 The NVM Chip from the No. 1 Controller v
    • 1.16.4 Cabin Altitude Calculation
    • 1.16.5 Previous Pressurization Leakages
    • 1.16.6 Examinations at Boeing Equipment Analysis Laboratory........................
    • 1.16.7 Flight Deck Oxygen Masks
    • 1.16.8 Accident Flight Simulation
    • 1.16.9 Re-enactment of the Accident Flight..........................................................
    • 1.16.10 Mobile Telephones
  • 1.17 Organizational and Management Information
    • 1.17.1 Operator
      • 1.17.1.1 General Information..........................................................................
      • 1.17.1.2 Air Operator Certificate
      • 1.17.1.3 Operator Management
      • 1.17.1.4 Accountable Manager
      • 1.17.1.5 Chief Operating Officer
      • 1.17.1.6 Commercial Manager........................................................................
      • 1.17.1.7 Nominated Postholders
      • 1.17.1.8 Flight Operations Manager
      • 1.17.1.9 Chief Pilot
      • 1.17.1.10 Flight Safety Officer
      • 1.17.1.11 Quality Manager
      • 1.17.1.12 Technical Manager............................................................................
      • 1.17.1.13 Maintenance Manager.......................................................................
      • 1.17.1.14 Maintenance......................................................................................
    • 1.17.2 Operator’s Procedures...............................................................................
      • 1.17.2.1 Flight Safety Manual...........................................................................
      • 1.17.2.2 Flight Crew Procedures.....................................................................
        • 1.17.2.2.1 Normal Procedures............................................................................
      • 1.17.2.2.1.1 First Officer....................................................................................
      • 1.17.2.2.1.2 Captain
      • 1.17.2.2.1.3 Duties after Takeoff
        • 1.17.2.2.2 Non-normal Procedures
      • 1.17.2.3 Cabin Crew Procedures.....................................................................
        • 1.17.2.3.1 Normal Procedures............................................................................
        • 1.17.2.3.2 Non-normal procedures
    • 1.17.3 Audits of the Operator
      • 1.17.3.1 Background
      • 1.17.3.2 2003 Audit Information
      • 1.17.3.3 2004 Audit Information
      • 1.17.3.4 2005 Audit Information
    • 1.17.4 ATC Lasham.............................................................................................
    • 1.17.5 Department of Civil Aviation in the Republic of Cyprus
    • 1.17.6 The Role of the UK CAA
    • 1.17.7 Audits of Cyprus DCA..............................................................................
      • 1.17.7.1 Audits by ICAO
      • 1.17.7.2 Audits by JAA...................................................................................
        • 1.17.7.3 Evaluation by the European Commission....................................... vi
        • 1.17.7.4 Assessment by a Private Firm.........................................................
    • 1.18 Additional Information
      • 1.18.1 Previous Incidents with the Accident Aircraft........................................
        • 1.18.1.1 Pressurization Incident....................................................................
        • 1.18.1.2 Equipment Cooling Problems
      • 1.18.2 Previous Pressurization Incidents with other Aircraft
        • 1.18.2.1 Irish Air Accident Investigation Unit Reports
          • 1.18.2.1.1 Boeing 737-548, Irish Registration EI-CDB
          • 1.18.2.1.2 Boeing 737-204, Irish Registration EI-CJE
          • 1.18.2.1.3 Boeing 737-204, Irish Registration EI-CJC....................................
          • 1.18.2.1.4 Boeing 737-800, Irish Registration EI-CSC
        • 1.18.2.2 Boeing 737-700 Incident in Norway on 15 February
        • 1.18.2.3 NASA Aviation Safety Reporting System......................................
        • 1.18.2.4 Other Incident Databases
      • 1.18.3 Previous Accidents involving Pressurization..........................................
        • 1.18.3.1 LearJet 35 in Aberdeen, South Dakota, USA
        • 1.18.3.2 Beech King Air 200 in Burketown, Australia.................................
  • 2 ANALYSIS...........................................................................................................
    • 2.1 General...................................................................................................
    • 2.2 Sequence of Events................................................................................
      • 2.2.1 Pre-Departure Unscheduled Maintenance
      • 2.2.2 Preflight...................................................................................................
      • 2.2.3 Takeoff....................................................................................................
      • 2.2.4 Climb.......................................................................................................
      • 2.2.5 Pilot Incapacitation
      • 2.2.6 Cruise
      • 2.2.7 Descent....................................................................................................
    • 2.3 Cabin Crew Performance.....................................................................
      • 2.3.1 Preflight, Taxi, and Takeoff....................................................................
      • 2.3.2 Climb.......................................................................................................
    • 2.4 Crew Resource Management
    • 2.5 Cabin Altitude
    • 2.6 Operator.................................................................................................
      • 2.6.1 Maintenance
      • 2.6.2 Crew scheduling......................................................................................
      • 2.6.3 Crew Training
    • 2.7 Organizational Issues..............................................................................
      • 2.7.1 Operator Management
      • 2.7.2 Operator Staffing
      • 2.7.3 Operator Safety Culture
      • 2.7.4 Operator Quality Assurance....................................................................
    • 2.8 Air Traffic Control
      • 2.8.1 Nicosia ACC
      • 2.8.2 Athinai ACC
    • 2.9 Department of Civil Aviation in the Republic of Cyprus..................
      • 2.9.1 Organization and personnel vii
      • 2.9.2 Safety oversight capability......................................................................
      • 2.9.3 ICAO, EASA, JAA Audits
    • Pressurization Problems 2.10 Actions Taken as a Result of Previous Incidents/Accidents involving
      • 2.10.1 Safety Recommendations following Incidents
      • 2.10.2 Safety Recommendations following Accidents
      • 2.10.3 Alert Bulletins.........................................................................................
      • 2.10.4 Actions Taken by Boeing.........................................................................
      • 2.10.5 Chain of Events in Pressurization Incidents and Accidents....................
  • 3 CONCLUSIONS..................................................................................................
    • 3.1 Findings
      • 3.1.1 Flight Crew
      • 3.1.2 Cabin Crew
      • 3.1.3 Aircraft....................................................................................................
      • 3.1.4 Manufacturer...........................................................................................
      • 3.1.5 ATC.........................................................................................................
      • 3.1.6 EASA, JAA and ICAO
      • 3.1.7 Flight HCY522........................................................................................
      • 3.1.8 Operator
      • 3.1.9 Cyprus DCA............................................................................................
    • 3.2 Causes.....................................................................................................
      • 3.2.1 Direct Causes
      • 3.2.2 Latent causes...........................................................................................
      • 3.2.3 Contributing Factors to the Accident......................................................
  • 4 RECOMMENDATIONS
    • 4.1 Safety Actions Taken or in Progress
      • 4.1.1 To NTSB.................................................................................................
      • 4.1.2 To Cyprus AAIǿB
      • 4.1.3 To Hellenic ACC
      • 4.1.4 Actions by the FAA
    • 4.2 Recommended Safety Actions..............................................................
      • 4.2.1 ȉȠ EASA/JAA
      • 4.2.2 ȉȠ EASA/JAA and ICAO.......................................................................
      • 4.2.3 ȉȠ The Republic of Cyprus.....................................................................
  • APPENDICES

viii

ABBREVIATIONS

AAIB Air Accident Investigation Board (in the United Kingdom)

A/C Aircraft

AC Alternate Current

ACC Area Control Center

AFM Aeroplane Flight Manual

AFTN Aeronautical Fixed Telecommunication Network

AFS Automatic Flight System

A/IR Class A – Instrument Rating (pilot license)

AMM Aeroplane Maintenance Manual

AOC Air Operators Certificate

APP Approach Control

APU Auxiliary Power Unit

ATC Air Traffic Control

ATPL Airline Transport Pilot License

AWY Airway

BITE Built In Test Equipment

CAA Civil Aviation Authority

CAS Calibrated Airspeed

CAVOK Ceiling and visibility OK (No clouds and unlimited visibility)

CG Center of Gravity

CoA Certificate of Airworthiness

CoM Certificate of Maintenance

CoR Certificate of Registration

CPL Commercial Pilot License

CPS Cabin Pressure Controller

CRM Crew Resource Management

CRS Certificate of Release to Service

CVR Cockpit Voice Recorder

CWS Control Wheel Steering

x

ICAO International Civil Aviation Organization

JAA Joint Aviation Authorities

JAR Joint Aviation Requirements

JRCC Joint Rescue Coordination Center

km kilometers

kt knots

LBA Luftfahrt-Bundesamt (Civil Aviation Authority in Germany)

LED Light Emission Diode

LoA Letter of Agreement

LPC License Proficiency Check

LVO Low Visibility Operation

MAC Mean Aerodynamic Cord

METAR Meteorological Aerodrome Report

MHz Mega Hertz

MM Maintenance Manual

N North

NCO National Operations Center

NM nautical miles

NTSB National Transportation Safety Board (Accident Investigation Authority in

the United States)

NVM Non Volatile Memory

NOSIG No Significant Change

OFV Outflow Valve

OLDI On Line Data Interchange

OM Operations Manual

OPC Operator Proficiency Check

PALLAS Phased Automation of the Hellenic ACC System

PAX Passengers

PIC Pilot in Command

PRSOV Pressure Regulating Shut-Off Valve

psi Pounds Per Square Inch

xi

psia Pounds Per Square Inch Absolute

QRH Quick Reference Handbook

RCF Radio Communication Failure

ROC Rate of Climb

RVSM Reduced Vertical Separation Minima

SFO Senior First Officer

SLfpm Sea Level feet per minute

SMC Stall Management Computer

SOP Standard Operation Procedures

SSR Secondary Surveillance Radar

STAR Standard Instrument Arrival

TRE Type Rating Examiner

TUC Time of Useful Consciousness

UTC Coordinated Universal Time

VHF Very High Frequency

VMC Visual Meteorological Conditions

VOR Very High Frequency Omnidirectional Radio Range

ǻp Differential Pressure

1

OPERATOR : HELIOS AIRWAYS

OWNER : DEUTSCHE STRUCTURED FINANCE & LEASING

GMBH & CO

MANUFACTURER : BOEING CO

AIRCRAFT TYPE : B 737 – 31S

NATIONALITY : CYPRUS

REGISTRATION : 5B-DBY

PLACE OF ACCIDENT : (^) Hilly terrain in the vicinity of Grammatiko village,

approximately 33 km northwest of Athens International Airport 38 Ƞ^ 13.894’ N, 23 Ƞ^ 58.214’ E

DATE AND TIME : 14 AUGUST 2005 - 09:03:32 h

Notes: 1. All times in the report are Coordinated Universal Time (UTC) (Local time in Hellas was UTC + 3 h)

  1. Correlation of the times used in the radar and radio communication recordings, and the FDR and CVR showed differences of less than 12 seconds. The FDR time was used as the master time in this report.

SYNOPSIS

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 16 000 ft, 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 leveled 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:

x 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.

x 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).

x 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:

x Operator’s deficiencies in the organization, quality management, and safety culture.

x Regulatory Authority’s diachronic inadequate execution of its safety oversight responsibilities.

x Inadequate application of Crew Resource Management principles.

x 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.

4

performed a visual inspection of the aft service door and he carried out a cabin pressurization leak check. In response to the write-up in the Aircraft Technical Log, the Ground Engineer documented his actions as follows:

“Door and local area inspected. NIL defects. Pressure run carried out to max diff. Safety valve operates at 8.25 ǻpsi. No leaks or abnormal noises (IAW MM 21 – 32 – 21 – 725 – 001)”.

The aircraft was released for the next flight at 03:15 h on 14 August 2005.

The aircraft was scheduled for flight HCY522, departing Larnaca at 06:00 h on 14 August 2005, via Athens, Greece to Prague, Czech Republic. The crew arrived at the company Operations Centre in Larnaca before 05:00 h and held a briefing for the flight. The aircraft took off from Larnaca airport at 06:07:13 h. At 06:11:21 h, the flight crew contacted Nicosia Area Control Centre (ACC) at reporting point LOSOS, climbing through flight level (FL) 100 for FL200. At 06:11:35 h, Nicosia ACC identified the flight and asked for the requested final cruising level. The Captain requested cruising level 340. At 06:11:45 h, flight HCY522 was cleared to climb to FL340 and to proceed direct to the RDS (Rodos) VOR. The Captain acknowledged the clearance. This was the last recorded communication between the flight crew and Nicosia ACC.

At 06:12 h, Nicosia ACC called the Planner Controller in Athinai ACC with data on flight HCY522: FL340 and 06:37 h estimated time at reporting point EVENO between the Athinai and Nicosia FIRs. The Planner Controller verified the data, which had been received earlier, as an “estimated message” via Aeronautical Fixed Telecommunication Network (AFTN).

According to the Flight Data Recorder (FDR), at 06:12:38 h and at an aircraft altitude of 12 040 ft and climbing, the cabin altitude warning horn sounded. At 06:14:11 h, at an aircraft altitude of 15 966 ft, the Captain contacted the company Operations Centre on the company radio frequency, 131.2 MHz. According to the Operator’s Dispatcher, the Captain reported “Take-off configuration warning on” and “Cooling equipment normal and alternate off line.” The Dispatcher requested an on-duty company Ground Engineer to communicate with the Captain. According to a written statement by the Ground Engineer (number one), written immediately after the accident at the Technical Manager’s instruction, the Captain reported that “the ventilation cooling fan lights were off.” Due to the lack of clarity in the message, the Ground Engineer asked him to repeat. Then, the Captain replied “where are the cooling fan circuit breakers?” The Ground Engineer replied “behind the Captain’s seat.” According to another statement given by the Ground Engineer to the Cyprus Police on 19 August 2005, the Captain reported “ both my equipment cooling lights are off.” The Ground Engineer replied “ this is normal ” and asked the Captain to confirm the problem “ because it did not make sense, as the lights are normally off when the system is serviceable ” [i.e. operating properly]. The Captain replied “ they are not switched off .” Since the message from the Captain did not make any sense to the Ground Engineer and “ given the close proximity of the pressure control panel and the fact that he [the Ground Engineer] had used the pressure panel prior to the flight and the pressure panel

5

has four lights” , the Ground Engineer asked the Captain to “confirm that the pressurization panel was selected to AUTO.” The Captain replied “where are my equipment cooling circuit breakers?” The Ground Engineer replied “behind the Captain’s seat”.

During the communication between the flight crew and the company Operations Centre, the passenger oxygen masks deployed in the cabin as they were designed to do when the cabin altitude exceeded 14 000 ft. It was determined that the passenger oxygen masks deployed at 06:14 h at an aircraft altitude of approximately 18 000 ft (extrapolation of the data from the NVM in the cabin pressure controller).

According to the FDR, the microphone keying (communication between the Captain and the Ground Engineer) ended at 06:20:21 h as flight HCY522 was passing through 28 900 ft. Shortly afterwards, the Operator’s Dispatcher called the flight crew again but there was no response.

At 06:23:32 h, the aircraft leveled off at FL340.

At 06:29 h, the Operator’s Dispatcher called Nicosia ACC and asked the Air Traffic Controller to contact flight HCY522.

From 06:30:40 to 06:34:44 h, Nicosia ACC called flight HCY522 without receiving any response. At 06:35:10 h, Nicosia ACC tried to make contact with the flight via another aircraft without any response. At 06:35:49 h, Nicosia ACC called the flight requesting it to “Squawk STAND-BY.”

At 06:36:00 h, one minute before flight HCY522 entered the Athinai FIR, the color of its radar track and the corresponding label on the radar display in the Athinai ACC, changed automatically from green to salmon color. The color of the target and the label then changed to blue when the Athinai Controller “clicked” on the radar target, which meant that he was aware of the incoming flight and that automatic coupling of track and Flight Plan had occurred.

At 06:36:12 h, Nicosia ACC contacted the Planner Controller at Athinai ACC with the information that flight HCY522 was “over point EVENO [entry point for the Athinai FIR] and does not answer, if he calls you, let us know.” At 06:37:27 h, the flight entered the Athinai FIR, about 10 NM south of point EVENO without calling Athinai ACC. The flight continued at FL340 towards Athens according to its Flight Plan route direct to RDS VOR, then via UL995 – RIPLI – VARIX – KEA VOR.

A further radio call was made by Nicosia ACC at 06:39:30 h on the emergency frequency (121.5 MHz) but there was no response from flight HCY522. At 06:40:15 h, Nicosia ACC called the Planner Controller in Athinai ACC asking “Did Helios call you?” The latter answered “not yet.”

At 07:12:05 h, the Athinai ACC Radar Controller called flight HCY522 in order to issue a descent clearance. There was no response from HCY522. Further attempts to call the flight were made on the emergency frequency and by other aircraft. At 07:12:32 h, the Planner Controller in Athinai ACC called Athinai Approach Control (APP) and informed them that he had no radio contact with flight HCY522. Between 07:12:38 h and 07:12: h, the Athinai ACC Radar Controller called flight HCY522 three times on the frequency in use (124.475 MHz).

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mask removal from its stowage box and oxygen flow during donning of the mask were recorded.

Approximately 08:49 h, during the tenth holding pattern, the F-16 pilot observed a person wearing a light blue shirt and dark vest, but not wearing an oxygen mask, enter the cockpit and sit down in the Captain’s seat. He put on a set of headphones and appeared to place his hands on the panel directly in front of him.

According to the FDR, at 08:49:50 h, the left engine flamed out. At this time, the F- pilot observed what he assumed was fuel coming out of the left engine. The aircraft turned steeply to the left and headed in a northerly direction. The person in the Captain’s seat did not respond to any of the attempts of the F-16 pilot to attract his attention. He appeared to be bending forward every now and then. Flight HCY522 began a descent on a northwesterly heading. The two F-16s followed at a distance due to the maneuvering by the Boeing 737.

When the F-16 pilot next came close to the Boeing 737, he saw the upper body of the person in the First Officer’s seat lean backwards as if he was sitting up. It became evident that this person was not wearing an oxygen mask and remained motionless.

At 08:54:18 h, the following distress was recorded by the CVR “MAYDAY, MAYDAY, MAYDAY, Helios Airways Flight 522 Athens … (unintelligible word) ”. A few seconds later, another “ MAYDAY, MAYDAY ” with a very weak voice was recorded.

When the Boeing 737 was at about 7 000 ft, the person in the Captain’s seat for the first time appeared to acknowledge the presence of the F-16s and he made a hand motion. The F-16 pilot responded with a hand signal for the person to follow him on down towards the airport. The person in the Captain’s seat only pointed downwards but did not follow the F-16.

At 08:59:20 h, the heading of the Boeing 737 changed to a southwesterly direction. The aircraft continued to descend. At 08:59:47 h, according to the FDR, the right engine flamed out at an altitude of 7 084 ft.

The aircraft continued to descend rapidly and collided with rolling hilly terrain in the vicinity of Grammatiko village, approximately 33 km northwest of the Athens International Airport at 09:03:32 h. (See the next page for a map of the sequence of events).

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