Crash of a Boeing 737-31S near Grammatiko: 121 killed

Date & Time: Aug 14, 2005 at 1203 LT
Type of aircraft:
Operator:
Registration:
5B-DBY
Flight Phase:
Survivors:
No
Site:
Schedule:
Larnaca – Athens – Prague
MSN:
29099
YOM:
1998
Flight number:
ZU522
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
115
Pax fatalities:
Other fatalities:
Total fatalities:
121
Captain / Total flying hours:
16900
Captain / Total hours on type:
5500.00
Copilot / Total flying hours:
7549
Copilot / Total hours on type:
3991
Aircraft flight hours:
17900
Aircraft flight cycles:
16085
Circumstances:
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.
Probable cause:
Direct Causes:
1. Non-recognition that the cabin pressurization mode selector was in the MAN (manual) position during the performance of the:
a) Preflight procedure;
b) Before Start checklist; and
c) After Takeoff checklist.
2. 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), and continuation of the climb.
3. Incapacitation of the flight crew due to hypoxia, resulting in continuation of the flight via the flight management computer and the autopilot, depletion of the fuel and engine flameout, and impact of the aircraft with the ground.
Latent causes
1. The Operator’s deficiencies in organization, quality management and safety culture, documented diachronically as findings in numerous audits.
2. The Regulatory Authority’s diachronic inadequate execution of its oversight responsibilities to ensure the safety of operations of the airlines under its supervision and its inadequate responses to findings of deficiencies documented in numerous audits.
3. Inadequate application of Crew Resource Management (CRM) principles by the flight crew.
4. Ineffectiveness and inadequacy of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft, both with regard to modifications to aircraft systems as well as to guidance to the crews.
Contributing Factors to the Accident:
1. Omission of returning the pressurization mode selector to AUTO after unscheduled maintenance on the aircraft.
2. Lack of specific procedures (on an international basis) for cabin crew procedures to address the situation of loss of pressurization, passenger oxygen masks deployment, and continuation of the aircraft ascent (climb).
3. Ineffectiveness of international aviation authorities to enforce implementation of corrective action plans after relevant audits.
Final Report:

Crash of a Cessna 421C Golden Eagle III off Rhodes

Date & Time: May 3, 2003 at 1235 LT
Operator:
Registration:
D-IWWW
Flight Phase:
Flight Type:
Survivors:
Yes
MSN:
421C-0042
YOM:
1976
Country:
Region:
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The aircraft suffered a double engine failure and the pilot attempted to ditch the aircraft off Rhodes. All occupants were rescued while the aircraft sank and was lost.
Probable cause:
Double engine failure for unknown reasons.

Crash of a Canadair CL-215-1A10 near Volos: 2 killed

Date & Time: Jul 15, 2000
Type of aircraft:
Operator:
Registration:
1048
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Volos - Volos
MSN:
1048
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
The crew departed Volos-Nea Anchialos Airport on a fire fighting mission over Mt Pelion, about 10 km northeast of Volos. While flying at low height, the crew was preparing to drop water when the right wing struck the ground. The aircraft crashed and exploded, killing both pilots.

Crash of a Tupolev TU-154B-2 in Thessaloniki

Date & Time: Jul 4, 2000 at 1657 LT
Type of aircraft:
Operator:
Registration:
HA-LCR
Survivors:
Yes
Schedule:
Budapest - Thessaloniki
MSN:
82A543
YOM:
1982
Flight number:
MA262
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
86
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7420
Captain / Total hours on type:
7000.00
Copilot / Total flying hours:
566
Copilot / Total hours on type:
566
Aircraft flight hours:
22409
Aircraft flight cycles:
13583
Circumstances:
Originally, flight MA262 from Budapest to Thessaloniki should be performed by a Boeing 737-300 HA-LES but due to technical problems, a Tupolev TU-154B-2 was dispatched. Following an uneventful flight, the crew was cleared for a VOR/DME approach to runway 34 followed by a visual circle to land on runway 28 as the runway 34 was closed to traffic due to construction works. Because a Boeing 757 slowed to vacate the runway after landing, ATC instructed the crew to extend the downwind leg for runway 28. For unknown reasons, the crew failed to comply with this instructions and performed 'S'. On final approach, the tower controller informed the crew that he forgot to lower the undercarriage. The captain increased engine power and initiated a go-around procedure but this decision was too late. The aircraft continued to descend and struck the runway surface in a gear-up configuration at 1657LT. The aircraft suffered substantial damages but the crew managed to go-around and to follow a holding pattern. A safe landing was completed at 1715LT. All 94 occupants evacuated safely while the aircraft was damaged beyond repair.
Probable cause:
Despite repeated instructions of the control tower the crew did not carried out a short turn for landing, resulting in:
- The aircraft was not aligned with the runway in time (unstabilized approach).
- Attention of the cockpit crew was to exclusively dedicated to performing sudden maneuvers at low altitude, in order to align the plane with the runway.
- Failure to lower the undercarriage in accordance with the applicable procedures for this flight phase.
Contributing Factors:
- The apparent inactivation of the audible warning when the undercarriage was not deployed.
- Lack of Cockpit Resources Management.
Final Report:

Crash of a Swearingen SA227AC Metro III off Rhodes

Date & Time: Jul 28, 1999
Type of aircraft:
Operator:
Registration:
SX-BGG
Flight Type:
Survivors:
Yes
Schedule:
Athens - Rhodes
MSN:
AC-656
YOM:
1986
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
On final approach to Rhodes-Diagoras Airport, while on a cargo flight from Athens, both engines failed simultaneously. The aircraft stalled and crashed in the sea one km short of runway. Both pilots were rescued while the aircraft was damaged beyond repair.
Probable cause:
Double engine failure for unknown reasons.

Crash of an Airbus A300C4-620 in Rhodes

Date & Time: Mar 24, 1999 at 1210 LT
Type of aircraft:
Operator:
Registration:
A6-PFD
Survivors:
Yes
Schedule:
Dubai - Rhodes
MSN:
374
YOM:
1985
Country:
Region:
Crew on board:
19
Crew fatalities:
Pax on board:
252
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Following an uneventful flight from Dubai, the crew completed the approach to Rhodes-Diagoras Airport in rain falls and strong winds. The aircraft landed at a speed of 166 knots, about 22 knots above Vref. After touchdown, the ground spoilers did not deploy automatically because they had not been armed. Consequently the auto brake system, which operates by the deployment of spoilers, did not activate. The crew attempted manual braking but this operation was too late and the aircraft was unable to stop within the remaining distance. It overran, lost its undercarriage and came to rest few dozen metres further. All 271 occupants evacuated safely while the aircraft was damaged beyond repair.

Crash of a Lockheed C-130H Hercules on Mt Pastra: 5 killed

Date & Time: Dec 20, 1997 at 0930 LT
Type of aircraft:
Operator:
Registration:
750
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Elefsis - Tanagra
MSN:
4729
YOM:
1977
Country:
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
5
Circumstances:
The four engine aircraft departed Elefsis AFB near Athens on a short flight to Tanagra AFB, carrying five crew members. The aircraft was dispatched at Tanagra AFB to pick up a contingent of 80 soldiers who should take part to the SAR operations following the crash of an Ukrainian Yak-42 on December 17 in the region of Katerini, Central Macedonia. While cruising in a limited visibility due to foggy conditions, the aircraft struck the slope of Mt Pastra located about 24 km southwest of Tanagra Airbase. The wreckage was found few km southeast of the village of Erythres. All five crew members were killed.
Probable cause:
Controlled flight into terrain.

Crash of a Yakovlev Yak-42 near Katerini: 70 killed

Date & Time: Dec 17, 1997 at 2112 LT
Type of aircraft:
Operator:
Registration:
UR-42334
Flight Phase:
Survivors:
No
Site:
Schedule:
Lvov - Odessa - Thessaloniki
MSN:
26 06 164
YOM:
1986
Flight number:
AEW241
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
62
Pax fatalities:
Other fatalities:
Total fatalities:
70
Captain / Total flying hours:
9850
Captain / Total hours on type:
2300.00
Copilot / Total flying hours:
16210
Copilot / Total hours on type:
5350
Aircraft flight hours:
12008
Aircraft flight cycles:
6836
Circumstances:
AeroSvit Airlines Flight 241 was a scheduled service from Kiev, Ukraine to Thessaloniki, Greece with an en route stop at Odessa, Ukraine. The first leg of the flight was operated by a Boeing 737. Because of engine problems, an aircraft change had to be made at Odessa. The last leg of the flight was carried out using a Yakovlev 42 (UR-42334), which was being chartered from Lvovskie Avialinii. The flight crew had no previous experience in flying to Thessaloniki. The flight was dispatched from Odessa with the No 1 VHF/NAV receiver inoperative, which was contrary to the minimum equipment list (MEL), and took off at 17:23 hours UTC. The weather conditions at Thessaloniki Airport were above required approach and landing minima, however, darkness and an overcast cloud layer obscured awareness of mountainous terrain in the area. The flight was instructed by the approach controller to conduct the LAMBI1F standard arrival procedure and was cleared to execute a VOR-DME-ILS approach to runway 16. The aircraft did not follow the "19 DME arc" as required by the approach procedure, but proceeded directly to the THS NDB. It overshot the localizer course at least twice and the flight crew were unable to establish a stabilized approach. According to the CVR cockpit conversations, the flight crew was confused and uncertain with respect to the navigation aids and the information that was presented. During the approach there were no standard callouts made by the flight crew related to the glide slope, outer marker or minima. At 18:54 UTC the Thessaloniki Tower controller reported that they had passed the airport. The flight crew was unaware that they overflew the runway until they were informed by the controller. The flight crew then initiated a go-around but did not follow the published missed approach procedure, nor did they follow the instructions given by the ATC. Although instructed by ATC to proceed to, and enter the south holding pattern, the flight continued on a flight path to the west. The flight crew remained confused, disorganized, and disoriented during the missed approach and the subsequent clearances issued by ATC. They had lost situational and terrain awareness, and they were uncertain with respect to the radio navigation aids and the information that was presented. They also requested "route vectors" and "heading" twice although Thessaloniki Airport was a non-radar facility. The flight crew occasionally was confused in reading and reporting the correct distances on their DME equipment (miles to kilometers and vice versa) as their instruments displayed distances in kilometers. The flight crew in their effort to solve the navigational problem, often switched their focus from VOR/DME information to ADF, and vice versa. This, in conjunction with the VHF/NAV receiver malfunction, contributed greatly to the confusion in the cockpit and to the loss of orientation. At 19:12 UTC the GPWS sounded for 4 seconds. At the same time the approach controller radioed: "AEW number one, continue VOR-DME/ILS approach minima, continue and report approaching the outer marker". The crew replied: "Outer marker will be report`. After a while the approach controller asked: "AEW-241, do you have the field in sight?". At that time the GPWS sounded again. Shortly afterwards the aircraft impacted the side of Mount Pente Pigadia at 3300 feet. The wreckage was found at 10:30 hours, December 20. At the same date a Greek Air Force Lockheed Hercules, which was being used in the search, crashed, killing all 5 on board. On October 6, 2000 a trial began with two air traffic controllers being accused of many counts of manslaughter and of violating the transportation regulations. They were sentenced to five years imprisonment. In December 2002 a Thessaloniki appeals court reduced the sentences of two air traffic controllers to four years and four months each.
Probable cause:
Causes:
1. The failure of the flight crew to adequately plan and execute the approach and missed approach procedure for runway 16 at Makedonia airport.
2. The failure of the flight crew to properly utilize the Makedonia airport radio navigational aids and aircraft radio equipment / instruments and to interpret the information that was presented.
3. The failure of the flight crew to declare an emergency when they lost their orientation following the missed approach, despite numerous cues alerting them for the aforementioned situation.
4. The captain's failure to achieve maximum performance climb in response to the GPWS alarm signal, 30" prior to impact.
5. The lack of command presence, cockpit discipline and resource management which resulted in a disorganized, confused and ultimately dysfunctional flight crew.
6. The company's inadequate oversight, over their flight operations, that allowed for and resulted in scheduling one inadequately prepared and marginally qualified flight crew and an aircraft which did not comply with national and international airworthiness regulations (it had not been issued the Type Certificate with the corresponding Amendment for the international flights), to execute a regular passenger flight with No 1 VHF/NAV receiver inoperative.
Contributing Factors:
1. The inadequate training provided to the flight crew for cockpit resource management and international flight operations.
2. The dispatch of the aircraft with No 1 VHF/NAV receiver, inoperative, despite the restrictions provided in M.E.L. (Appendix 28, pages 14, 16).
3. The assignment of a marginally qualified instructor pilot to this specific flight who disrupted and substantially reduced the coordination and effectiveness of the flight crew.
4. The inaccurate display of the symbol (R) on the Jeppesen Sanderson Inc. chart 11-1, for runway 16, from which the flight crew, most probably, have formed the wrong impression that radar service was available in Makedonia airport.
5. The insufficient evaluation by the Approach Control, under the aforementioned circumstances, of the difficulties encountered by the flight crew in following procedures and clearances, which prevented the Controllers to offer any available assistance, by their own initiative, in order to prevent, probably, the accident.
Final Report:

Crash of a Lockheed EP-3E Orion in Chania

Date & Time: Sep 23, 1997
Type of aircraft:
Operator:
Registration:
157320
Survivors:
Yes
MSN:
185-5535
YOM:
1968
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
22
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After touchdown at Chania-Souda Airport, the four engine aircraft went out of control, veered off runway, lost its undercarriage and came to rest. All 26 occupants escaped uninjured while the aircraft was written off.
Probable cause:
Loss of control upon landing following a wrong approach configuration and an excessive speed.

Crash of a Boeing 727-230A in Thessaloniki

Date & Time: Aug 12, 1997 at 1741 LT
Type of aircraft:
Operator:
Registration:
SX-CBI
Survivors:
Yes
Schedule:
Athens - Thessaloniki - Frankfurt
MSN:
20791
YOM:
1974
Flight number:
OA171
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
26
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The approach to Thessaloniki Airport was completed in poor weather conditions. The aircraft landed too far down the runway and after touchdown, the crew realized he could not stop the aircraft within the remaining distance so he decided to veer off runway to the right. While contacting soft ground, the undercarriage were torn off and the aircraft came to rest. All 35 occupants escaped uninjured and the aircraft was damaged beyond repair. At the time of the accident, the wind was from 360° at 18 knots gusting to 28 knots with thunderstorm activity, rain falls and a visibility of 5 km.
Probable cause:
The following findings were reported:
- Poor weather conditions,
- The runway surface was wet and the braking action was considered as moderate to low,
- The flying crew consisted of two highly experienced captains,
- The crew was under stress during the final approach due to poor weather conditions,
- Wrong approach configuration as the aircraft was too high on the glide,
- The crew failed to follow the approach checklist,
- The aircraft landed too far down the runway, about a third past its threshold, reducing the landing distance available,
- Lack of crew coordination,
- The crew failed to initiate a go-around procedure.