Lessons from Athens

The crew members of a Cypriot airliner that crashed Aug. 14 near Athens became confused by a series of alarms as the plane climbed, failing to recognize that the cabin was not pressurizing until they grew mentally disoriented because of lack of oxygen and passed out, according to several people connected with the investigation.

Dan alterted me to this International Herald Tribune article on last month’s Boeing 737 crash in Greece.

While the article has to be taken with a grain of salt — after all, when it comes to aviation the media get the story wrong more often than they get it right — it’s still quite disturbing. I hope the article turns out to be wrong. But it can’t be, can it? Something caused both members of the flight crew to continue the climb above ten thousand without pressurization.

I’m hesitant to write about this at all, because it irks me to see ‘experts’ delivering a verdict before trained investigators have had time to prepare their report. On the other hand, the issues it presents are a constant thorn in the side of aviators everywhere. I see them at work every day, so it bears discussing as a variation which has certainly taken place in many cockpits over the years.

If what’s printed in that article is accurate (and again, that’s a BIG ‘if’), there were two major problems: first, the crew couldn’t communicate. And second, they didn’t understand how the airplane worked.

Complicating the cockpit confusion, neither the German pilot nor the young, inexperienced Cypriot co-pilot could speak the same language fluently, and each had difficulty understanding how the other spoke English, the worldwide language of air traffic control.

The airlines make a big deal about CRM (crew resource management). In fact, it’s the hub around which the flight training revolves. CRM evolved from a long line of broken airplanes. In the old days, the captain was God. The copilot kept his mouth shut, filled out the paperwork, and never questioned The Man. Crew resource management is aimed at ensuring cockpit duties are efficiently and effectively shared by both pilots. If the copilot sees something amiss, he will speak up. Obviously this kind of thing doesn’t work if the two guys up front can’t communicate.

So is it possible that they put two people in the cockpit who don’t speak the same language? The Cypriot crash aside, are there airlines out there that do this sort of thing? It’s not a problem here in the U.S. where everyone speaks English, so it’s one of those issues I’ve never even considered.

References to the copilots youth don’t mean anything. The guys who fly F16s are young. But “inexperienced” is another story. Only time will tell just how experienced he was. The authorities already know. I’m sure they had obtained his numbers from the airline within hours of the crash. Was he too inexperienced to confront the captain when it counted? Provide all the training you want, the young guy is still going to be somewhat intimidated by the 40,000 hour captain who’s been on the airplane since it was designed.

Human factors aside, the timbre of the article leads one to conclude that the pilots didn’t understand the systems on the airplane they were flying. It’s bad enough when this happens in a general aviation cockpit. I see that every day. Is it possible this could have happened — and to this degree — on a major commercial airliner?

At 10,000 feet, or 3,000 meters, as designed, an alarm went off to warn the crew that the plane would not pressurize. However, the crew members mistakenly thought that the alarm horn was a warning to tell them that their controls were not set properly for takeoff, the officials said.

The same horn is used for both conditions, although it will sound for takeoff configuration only while the plane is still on the ground.

That’s a pretty important piece of information not to have in your noggin. It begs the question of how this was covered in the simulator. Certainly they had numerous cabin pressurization emergencies thrown at them during intial and recurrent training. The warnings must have been familiar to them.

The crew continued the climb on autopilot. At 14,000 feet, oxygen masks deployed as designed and a master caution light illuminated in the cockpit. Another alarm sounded at about the same time on an unrelated matter, warning that there was insufficient cooling air in the compartment housing avionics equipment.

The radio tapes showed that this created tremendous confusion in the cockpit. Normally an aircraft cabin is held at 8,000 feet pressure, so the crew at over 14,000 feet would already be experiencing some disorientation because of a lack of oxygen.

During this time, the German captain and the Cypriot co-pilot discovered they had no common language and that their English, while good enough for normal air traffic control purposes, was not good enough for complicated technical conversation in fixing the problem.

So they were continuing to climb with a pressurization problem. Every airline I’ve ever heard of has the same drill for this situation: the crew puts on their quick-donning O2 masks and descends to 10,000 feet.

The article mentions disorientation setting in at 14,000 feet, but that’s probably not the case. Here in the U.S., it’s perfectly legal (14CFR 91.211) to fly as high as 14,00 feet without using supplemental oxygen. It’s unlikely that the pilots would have become disoriented by the time they reached 14,000, especially considering the climb rates of a 737. They were only a few minutes removed from 10,000 feet.

It’s almost beyond comprehension that the crew could have acted this way. Either the training was criminally deficient or there’s still a piece of this puzzle missing.

As pilots, we evaluate accidents like this in order to examine our own flying for similar patterns. As I previously mentioned, there are two here. First, a lack of systems knowledge. Needless to say, this can bite you in the ass in all sorts of ways. GA pilots are notorious for poor knowledge of constant speed propellers, hydraulic and electrical systems, and advanced avionics. When an emergent situation occurrs, the pilot doesn’t detect the problem, or can’t correct it, or doesn’t know how to deal with it. They get distracted, fixated, and bad things happen.

The second issue is poor communication and a willingness to accept what you’re told whether it makes sense or not. In the general aviation world, this manifests itself when pilots accept whatever ATC tells them. They’ll read back instructions they don’t understand, won’t insist on clarification, and use confusing and/or nonstandard phraseology. For all intents and purposes, you might as well be speaking German while the controller is speaking Greek.

Nothing can be done for the 121 people who perished in Athens, but it can serve as a powerful reminder for those of us who fly: know your aircraft’s systems. Communicate clearly. It doesn’t have to happen to you.

  1 comment for “Lessons from Athens

  1. max.ab
    September 8, 2005 at 1:23 pm

    One thing is for sure: in critical technical situations on the air, there is always a flight engineer needed. Just think how many of the recent air disasters could be avoided if there was in the cockpit a specialist on the aircraft type, as it was in the past. I think it’s time, ICAO & FAA to reconsider about “minimum flight crew” and to put aside the issue of “cost and manhours per flight”.

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