Professional Documents
Culture Documents
11/1/2013
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
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I C A O SHEL Model
S H E L
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2. Hardware
3. Environment
4. Liveware
Human interaction; Flight crew -> Cabin Crew -> Engineers etc.
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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
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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. 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.
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Human Factors
Poor Communication
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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
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
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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