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Helios Airways Flight 522

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

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

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

(International Civil Aviation Organisation)

I C A O SHEL Model

Has any one heard of this model before?


A conceptual model using 4 blocks to represent interaction between the different components of Human Factors.

S H E L

Software Hardware Environment Livewire


CRM-NTS Ad Hoc Trainer Presentation

11/1/2013

So what do each of these categories mean?


1. Software

Interaction with technology, system rules and SOPs

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

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

Interface between categories: Any ideas as to why the Ragged interface between categories?
Essentially it suggests that any interaction involving human beings is always less than perfect Hence the importance of;

HUMAN FACTORS

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

So now to Helios 522

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

Background

14AUG05 crashed north of Marathon & Varnavas, Greece.

Wreckage located near Grammatiko community 40 km from Athens

All 121 on board were killed

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

Sequence of Events

Before take-off, crew failed to correctly set pressurisation system. Result, gradual decompression. All on board suffering Hypoxia. Captains 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.

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

Lets now look at how SHEL relates to:

Human Factors

Poor decision making

Poor Communication

11/1/2013

CRM-NTS Ad Hoc Trainer Presentation

SHEL / Human Factors relationship:


Liveware - Software

(The interface between people and software)

In this instance, none of significance


(The interface between people and hardware)

Liveware - Hardware

Pressurisation set to Manual instead of Auto - Importance of SOPs! 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 (the interface between people and other people)

Liveware - Liveware

Cultural differences, East German Captain, Cypriot First Officer, lack of common language Engineer during discussion identified Hypoxia. Didnt really press point to the Captain

11/1/2013

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 dont know, - Its what we know for sure that just aint so !
(Mark Twain)
11/1/2013 CRM-NTS Ad Hoc Trainer Presentation 11

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