Helios Flight 522 Aircraft accident - SHEL factors
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Transcript of Helios Flight 522 Aircraft accident - SHEL factors
04/08/23 CRM-NTS Ad Hoc Trainer Presentation
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Helios Airways Flight 522
04/08/23 CRM-NTS Ad Hoc Trainer Presentation
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Introduction
International Civil Aviation Organisation “SHEL” Model- Quick explanation
Helios Airways Flight 522 - Back ground
Sequence of Events
Relate the “Human Factors” to “SHEL”
Summary
04/08/23 CRM-NTS Ad Hoc Trainer Presentation
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I C A O “SHEL” Model(International Civil Aviation Organisation)
A conceptual model using 4 blocks to represent interaction between the different components of“Human Factors”.
S - SoftwareH - HardwareE - Environment
L - Livewire
Has any one heard of this model before?
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1. Software Interaction with technology, system rules and
SOP’s
2. Hardware Controls / Surfaces, Displays and functional systems
3. Environment The “Climate”; Social / Economic, as well as Natural
v “Operating” Environments
4. Liveware Human interaction; Flight crew -> Cabin Crew ->
Engineers etc.
Note the “Less than perfect” Interface between categories
So what do each of these categories mean?
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Interface between categories:
Essentially it suggests that anyinteraction involving human
beingsis always less than “perfect”
- Hence the importance of;
“HUMAN FACTORS”
Any ideas as to why the “Ragged” interface between categories?
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So now to Helios 522
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14AUG05 crashed north of Marathon & Varnavas, Greece.
Wreckage located near Grammatiko community 40 km from Athens
All 121 on board were killed
Background
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Sequence of Events
Before take-off, crew failed to correctly set pressurisation system.
Result, gradual decompression. All on board suffering Hypoxia.
Captain’s conversation with engineer, confirmed he was suffering hypoxia.
When Greek air space entered, ATC not contacted. 2 Hellenic Air Force F-16 fighters scrambled.
F-16 pilots saw F/A Andreas Prodromou at controls, (trainee pilot), attempting control of aircraft, (consciousness due to portable oxygen).
Aircraft crashed due to lack of fuel. Engines failed in quick succession.
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Lets now look at how “SHEL” relates to:
“Human Factors”
Poor decision making
Poor Communication
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Liveware - Software (The interface between people and software)
In this instance, none of significance
Liveware - Hardware (The interface between people and hardware)
Pressurisation set to “Manual” instead of “Auto” - Importance of SOP’s! “Cabin altitude” horn misidentified as a take-off configuration warning An “Oxy ON” warning light misinterpreted as “systems” were overheating.
Liveware - Environment (The interface between people and the environment)
Attempt at cogitative thought in a “Hypoxic” environment, (loss of cabin pressure) Re-enforces vital importance of recognition of symptoms and adherence to drills
Liveware - Liveware (the interface between people and other people) Cultural differences, East German Captain, Cypriot First Officer, “lack of common language” Engineer during discussion identified Hypoxia. Didn’t really “press point” to the Captain
“SHEL” / Human Factors relationship:
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Summary
International Civil Aviation Organisation “SHEL” Model
Case Study: Helios Airways Flight 522 - Back ground / Sequence of Events
Related the “Human Factors” of this accident to the “SHEL” model
“What gets us in trouble is not what we don’t know, - It’s what we know for sure that just aint so !”
(Mark Twain)