One of my family friends works as an engineer at Boeing. We were having a family dinner back in 2019, and I asked him about the recent crash of a Boeing 737 Max in Ethiopia. He said Boeing 737 Max’s are usually very safe or secure, but a malfunction of one small part led to the crash.
It wasn’t quite the most reassuring endorsement of his company or the most confidence-inducing message for riding on Boeing 737 Max planes. I later found out this was a software problem where Boeing made an alarm feature optional instead of mandatory, which later led to two fatal plane crashes in 2018 and 2019.
One particularly tragic airplane crash was that of Helios Flight 522. In 2005, Helios Airways, a low-cost airline from Cyprus, flew a Boeing 737 from Larnaca, Cyprus to Athens, Greece. The plane would eventually crash into a mountain outside Athens, killing all 115 passengers and six crew on board.
It would be the worst aviation accident in Greek history, and the plane would be known as the “ghost plane” in the international press— almost everyone on the plane had been passed out for hours by the time it crashed.
Boeing, of course, blamed the entire accident on “human error,” and the subsequent blame game almost completely absolved the company. Instead, a lawyer for Boeing, Stephen Preston, said the ground engineers for Helios did not follow correct procedures, as did the flight deck crew and passenger cabin crew.
So what happened to Helios Flight 522? And what lessons does it have for aviation safety in the present and the future?
The events on the plane
Journalist Christine Negroni documents the events on Helios Flight 522 that eventually led to the death of 121 people. She does so in the context of what may have happened to the greatest aviation mystery today: what happened to Malaysia Flight 370?
The plane was scheduled to fly from Larnaca, Cyprus to Athens, Greece (for a layover on the way to Prague). It took off at 9:07 a.m. local time in Larnaca and warning signs were there very soon after departure.
Jake Hardiman at Simply Flying says that only five minutes after takeoff, the cabin altitude warning horn sounded, just as the aircraft crossed 10,000 feet in altitude. The crew ignored the alarm since it sounded similar to an innocuous takeoff configuration warning, which did not make sense since the plane was not in its takeoff stage.
What was actually happening was a loss of cabin pressure, and once the airplane reached 18,000 feet, oxygen masks were deployed for the crew and the passengers. While the pilots reported an air conditioning problem a few minutes later, further communication would be incoherent and difficult.
The operations center on the ground made its last contact with the crew 13 minutes into the flight. The captain of the plane, Hans-Jürgen Merten, was asked by engineer Alan Irwin if the pressurization panel was selected to auto. Mergen did not address the question and asked “where are my equipment cooling circuit breakers?”
A subsequent investigation by an accident investigator at Boeing found the crew had been incapacitated by hypoxia, a lack of oxygen to the brain. The loss of cabin pressure was the main reason for this, and the plane climbed to 34,000 feet before stopping 16 minutes into the flight. Breathing masks supplying emergency oxygen on the plane only sustained oxygen for about 12 minutes.
The accident report said that once the plane entered Greek airspace, the pilots stopped responding to air traffic control messages. At 9:37, the plane was circling Athens on autopilot, and shortly after, the Hellenic Air Force sent two F-16 fighter jets to intercept the plane and possibly shoot it down if needed.
The first thought of the two fighter pilots was terrorism. After all, this was in early 2005, only four years after 9/11.
But they found the pilot seat empty, and the first officer unconscious in the cabin. They also found oxygen masks dangling in the passenger cabin.
A flight attendant attempts to control the plane
Hope was not completely lost — one flight attendant, 25-year-old Andreas Prodromou, was one of the only people on the plane not completely passed out from hypoxia. He found a portable supply of oxygen and made his way to the cockpit shortly before the plane crashed.
Prodromou would have had to get the plane to a lower altitude so the pilots could regain consciousness. And Prodromou saving the plane, its crew, and all its passengers was a possibility — he was a commercial pilot, so even though he did not have experience flying an airline or Boeing 737, there was a chance he could have gotten the plane to safety.
Prodromou’s girlfriend, Haris Charalambous, also was conscious and identified as helping him try to control the plane. Prodromou waved to one of the F-16 fighters, and could not control the plane, but succeeded in steering it away from Athens and towards the countryside. The accident report says that while the two tried to control the plane, it was too late: the engine flamed out due to fuel exhaustion.
While Prodromou was unable to control the plane, he radioed five maydays as a final call for support. However, no one heard the maydays— the radio was set to the incorrect frequency to Larnaca rather than Athens.
The plane then crashed into a hillside outside Athens.
The blame game
After the crash, the Hellenic Air Accident Investigation and Aviation Safety Board listed three direct causes of the crash. The first was a non-recognition that the cabin pressurization mode selector was in the manual position during the preflight inspection, Before Start checklist, and After Takeoff checklist.
The second was a non-identification of warnings of the plane’s depressurization, including the deployment of oxygen masks for passengers and the cabin altitude warning horn. The third was the incapacitation of the crew due to hypoxia, the subsequent continuation of the flight on autopilot, and the depletion of fuel which led to its impact on the ground.
Since the pressurization selector switch was set to manual, the plane did not automatically calibrate the pressure inside the plane.
According to Sally Williams at The Guardian, the engineer who was blamed for not putting the pressurization selector switch on auto was named Alan Irwin. Irwin was a freelance licensed engineer who had worked for 15 years, and he was the engineer who inspected the plane prior to its takeoff.
He was hired for six months by Helios Airways, in charge of making sure three Boeing 737s were safe for takeoff. He was called in on August 14, 2005, to address the operations room losing contact with the plane and the suspected terrorism of everyone on the plane being passed out and motionless.
The subsequent investigation said “human error” was the cause of the crash, particularly the human error of Irwin. Irwin insisted he turned the switch back to auto, but he would be blamed for putting the switch to manual.
Irwin was the person who bore the brunt of the blame for the plane crash in the investigation report. Irwin would lose his job, pay a lot of money in legal fees, and lose his long-term relationship of 20 years.
In the international press, the plane would be called a “ghost plane” since passengers and crew members had been passed out for over two hours, and alive on impact. One lawyer for a crisis management company Helios Airways hired said the investigation led to a “blame mentality” when the job of an accident investigation is to “find the causes.”
When the cabin pressure control switch was found at the crash site, the switch was put on manual. This was used as evidence for Irwin’s responsibility in the crash since he put the switch on manual when he was inspecting a problem with the aircraft. However, Irwin says the “distorting effects of impact,” in Williams’s words, led to a change in the switch’s position.
Regardless, almost everyone in power thought Irwin was guilty. Investigators in Larnaca told Irwin “you left the switch in manual and you caused the accident.” He would be vilified across the British press and he would have trouble getting another job due to the negative publicity.
On April 7, 2008, Irwin was charged with manslaughter. He and his wife separated the next year. On April 20, 2012, Irwin was found guilty of manslaughter, along with three officials from Helios Airways — the chief pilot, CEO, and flight operations manager. That same year, his ex-wife died.
Irwin appealed the verdict, and in 2013, he won his appeal. The three other Helios Airways officials lost their appeals.
The case for blaming Boeing
The truth is a plane crash is caused by much more than the human error of one person. Maybe it can be caused by the human error of several people, but what safeguards should airplanes have against that kind of human error?
Maybe it was a more systemic problem, Williams insinuates. Boeing had a very confusing warning horn — it would sound for problems with takeoff configuration as well as altitude warnings, which caused the pilots on Helios Airways Flight 522 to misidentify the alarm as the takeoff configuration warning. The year before the crash, in 2004, the director of NASA’s Aviation Safety Reporting System raised concern about this confusion.
It wasn’t the first time a Boeing 737 almost had a cabin pressure-related emergency. In 2001, a Boeing 737 flying in Norway had the takeoff configuration/altitude warning horn go off, and pilots did not think it was a pressurization problem until oxygen masks dropped in the cabin.
Four other serious pressurization incidents that almost resulted in tragedies were reported to an air accident investigation unit between 2000 to 2005.
Boeing did nothing about the warning horn.
This was a common source of confusion on Boeing 737s, and in 2011, the Federal Aviation Administration (FAA) required Boeing to install two additional warning lights to differentiate the takeoff configuration and cabin altitude warnings.
The accident report did not completely absolve Boeing, and said the company was cited for “ineffectiveness of measures taken in response to previous pressurization incidents in the particular type of aircraft.”
In late 2006, the FAA conducted a Boeing safety assessment summary. This report effectively blamed Boeing for the accident. It said the warning horn and its confusion were “likely a significant contributing factor” that would likely happen again because it was “not likely to be detected by the ground crew.” Every Boeing 737 was “within one foreseeable failure of a catastrophic event.”
It’s important to note Boeing was also sued by families of the dead. In July 2007, families of eight Cypriots sued Boeing for 76 million euros. The families were paid out of court in a settlement.
The blame game was convenient, particularly for Boeing. Obviously few sides want to take responsibility for such an accident because of the tremendous financial and legal repercussions that would result, but for years, Boeing did not have to address concerns about the warning horn by relying on the “human error” narrative of what happened to Helios Flight 522.
This “human error” justification does not age well in light of other fatal Boeing 737 Max crashes in recent history. But it is the default and possibly necessary defense in Boeing’s perspective to shield the company from liability. And this does not mean individual pilots and engineers have no responsibility, but if the problem was a pattern rather than an isolated incident, it needed to be addressed.
Of course, it is important to differentiate the earlier model of the Boeing 737, which Helios Airways Flight 522 was, and the Boeing 737 Max. The Boeing 737 Max was recently put back in service after being grounded for more than a year.
As for the hypoxia-induced crash of Helios Airways Flight 522, many airplanes had suffered depressurization in the past but narrowly avoided tragedy. Helios Airways tried rebranding itself soon after the crash, but it did not last long as a company.
Christine Negroni believes the same hypoxia-induced crash happened in the case of Malaysia Airlines Flight 370. Of course, we might never know in that case.
Today, Irwin believes he was the fall guy for the tragedy. He has moved on: he no longer works with planes, but now works as a property developer.
Unfortunately, it still took Boeing six years after the tragedy to change its warning horn, and only after pressure from the FAA. That, as well as more recent developments, does not paint a favorable picture for how much Boeing prioritizes aviation safety.
This post was previously published on CrimeBeat.
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