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11/1/2013 CRM-NTS Ad Hoc TrainerPresentation

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Helios Airways Flight 522


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Introduction

International Civil Aviation OrganisationSHEL 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(International Civil Aviation Organisation)

A conceptual model using 4 blocks

to represent interaction betweenthe different components ofHuman Factors.

S - Software

H - HardwareE - EnvironmentL - Livewire

Has any one heard of thismodel before?


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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 Interfacebetween categories

So what do each of these categories mean?


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Interface between categories:

Essentially it suggests that any

interaction involving human beingsis always less than perfect

- Hence the importance of;

HUMAN FACTORS

Any ideas as to why theRagged interface betweencategories?


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So now to Helios 522


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14AUG05 crashed north of Marathon& Varnavas, Greece.

Wreckage located near Grammatikocommunity 40 km from Athens

All 121 on board were killed

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 sufferinghypoxia.

When Greek air space entered, ATC not contacted. 2 Hellenic AirForce F-16 fighters scrambled.

F-16 pilots saw F/A Andreas Prodromou at controls, (traineepilot), attempting control of aircraft, (consciousness due to

portable oxygen).

Aircraft crashed due to lack of fuel. Engines failed in quicksuccession.


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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 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

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. Didnt really press point to the Captain

SHEL / Human Factors relationship:


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11/1/2013CRM-NTS Ad Hoc Trainer

Presentation11

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)

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