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?

04/08/23 CRM-NTS Ad Hoc Trainer Presentation

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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?

04/08/23 CRM-NTS Ad Hoc Trainer Presentation

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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?

04/08/23 CRM-NTS Ad Hoc Trainer Presentation

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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

04/08/23 CRM-NTS Ad Hoc Trainer Presentation

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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.

04/08/23 CRM-NTS Ad Hoc Trainer Presentation

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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:

04/08/23 CRM-NTS Ad Hoc Trainer Presentation

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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)