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| Written by Dimitrios Soukeras

ORGANISATIONAL

DIAGNOSIS LTD A TRIPOD VIEW OF HELIOS ACCIDENT

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HELIOS accident, a catastrophic event that claimed 121 souls

onboard a Boeing 737/300 heading to Athens, occurred back in time on

August 14th 2005 but still, from time to time, attracts International Media

interest, as the whole story is thought to be shrouded by a veil of mystery and

undisclosed details. According to the official final accident report, prepared

and released by the Greek AAIASB, this tragedy was directly attributed to

human error ; an estimation supported by the application of HFACS model for

the investigation of this accident. Nowadays, there might still be a call for

attempting to shed additional light to such a complex accident, as it is widely

thought that more discoveries are waiting to come into light.

While in prehistory years, in Greek Mythology only Ariadne was thought to

have been the expert in labyrinths, today many others, among them, air

accident investigators, might also encapsulate the art of “applying thread”, as

a means of finding their way out from a difficult to solve situation, like an

aviation accident. In this scenario perhaps, it is most important to share a new

viewpoint, by applying another form of methodology in order to interpret this

accident. In this occasion TRIPOD Beta is believed to have the credibility

into further submitting useful Analysis hints and opening pioneer paths in

Accident Analysis.

The intentions of this Marketing Edition for TRIPOD demonstration are to

abstain from disputes that may arise from the fact that this graph depiction

intentionally will deviate from the official (The Greek AAIASB’s opinion).It is

true that as it was being drawn up so much time after the disclosure of the

original accident report, the chances were in favor for this new attempt to also

have gained insight from other papers or the opinions as presented by other

experts, among them even those in opposition to the so called “Tsolakis

Report”.

A TRIPOD VIEW OF HELIOS ACCIDENT

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Prior to starting working with TRIPOD in sorting out valuable data of HELIOS

accident, it is worth mentioning that by applying this methodology there is the

option of disregarding the “relative position” of the pressure system’s control

switch (either in AUTO or in MAN) or who left it that way. TRIPOD BETA can

be applied without taking into account the comments, either in favor or

against, of the role of the pair of F-16s on the accident, or even of survivability

aspects for passengers, flight and cabin crew, after remaining for nearly 2 ½

hours in an altogether hypoxic and also extremely cold environment and its

consequences as they are thought to have been, which created the “Accident

Environment”, as the cabin undoubtedly “followed” the airplane in the height of

34000 ft.

Tripod Incident Analysis Methodology

Accidents or Incidents are unpleasant events of a kind that no one wishes to

continue speaking about after they have occurred. In High Risk Entities at

least, there is a growing tension of investigators struggling to uncover real

and latent “Causes” that had led to them. The primary reason for doing so had

always been the need of human nature to move further down rather than just

continuing picking up the easy option, that of casting blame upon the most

obvious victims instead of bringing over the catharsis, by letting fresh air

coming in, by new concepts and new investigation methodologies.

What is the TRIPOD Incident& Accident Analysis Methodology?

The birth of the “Safety Culture” era and its dominance over the previous

“Socio-technical Period” in accident causation had forever altered the

prevailing axioms that drive accident investigation. In Safety Culture Era, it is

profound that people form teams and carry common characteristics that play a

substantially important role into the way that accidents are created and thus

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investigation moves down to organisational issues rather than just

apportioning blame to certain humans.

Therefore Tripod methodology delves into the new advents and fresh tools

segment, which aim at pinpointing and analyzing the reasons for failure of a

Barrier, via the application of the Human Behavior model. That is why this

Analysis looks at what had caused the sequence of events in an incident, the

sequence of events themselves, how the incident happened and also of

which Barriers had failed, no matter if they had been in place or not.

The most important factor examined is the reason why those Barriers failed.

The construction of a “tree” diagram forms a graph representation of the

incident mechanism which describes the events and its relationships. The

event in a TRIPOD Beta Diagram is the result of the Hazard acting upon an

Object. A Barrier is something that was made to prevent the meeting of an

object and a hazard.

When such a Barrier fails, a causation path is made to explain how and why

this happened. The TRIPOD Beta method presumes that incidents are

caused by human error, which can be prevented by controlling the working

Environment. The Causation path displays this by starting with the Active

Failure of the Barrier, then investigating under what Precondition or in what

contextual state this happened and finishing up by identifying the Underlying

Causes that led to the Accident.

By delving into the “Preconditions” World , emanating after the accident,

investigators have the opportunity to deepen their knowledge about the Safety

Culture segment of the Organisations involved into the accident and reliably

identify both Behavior Norms and Shared Values that dictated the established

patterns of actions that have driven the Causes of Accident.

The aim of TRIPOD Beta is not only to uncover the hidden deficiencies in an

Organisation, the Latent Failures, but also to offer a solid starting point to

depict all subsequent changes in the Organisational Cultures suffered by the

accident. Those flaws are classified into eleven Basic Risk Factors (BRFs),

categories that represent distinctive areas of management activity, where the

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solution of the problem lies. All the items of the TRIPOD Diagram are shown

below:

Benefits from the Application of TRIPOD Methodology

Tripod Methodology assists investigators:

• To easily structure an investigation,

• To distinguish all relevant facts

• To make causes and effects explicit

• To encourage team discussion

• To reduce the report writing task

• To increase the quality of corrective actions

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• But most importantly to offer the Organisation the opportunity to create

a link between previous Risk Analysis and accident aftermaths that

profoundly assists the creation of a Learning Organisation Entity.

THE HELIOS ACCIDENT

From early noon on August 14th 2005, it was known that a flight of an aircraft

in a hypoxic and extremely cold Environment for quite some time would have

by all means led all HELIOS Crew & Passengers into an “Incapacitation”

status. Therefore, there was not much left to be done to protect “Our Object”,

into the Red-Green Box, (Crew & Passengers) from fatality , which was the

subsequent event after the action of the Change Agent (Fuel Starvation of the

Engines ) on the still intact hull of the aircraft.

In starting a TRIPOD Beta Investigation it is important to be able to create

“trios”, Tripods, which are formed by three elements. (a) The Object which

has the potential of “receiving” change -mostly unwanted- from (b) the

change agent and which, if the “Barriers” are not proved effective will lead to

an (c) outcome-event which will definitely be in favor of no one. The

Investigation that follows an accident aiming at Barriers identification, which

are afterwards categorized, either as “Failed” ,“Missing” or “Effective”, if they

did succeed in stopping the accident sequence.

Μissing Barriers require enormous changes and consume time, while Failed

Barriers are easier for mitigation.

The Fifth TRIPOD

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Failed Barriers owe their failure to stop the accident from happening to an

Active Failure that can easily be spotted. The important part of the

Investigation commences with the “hunting” after Preconditions,

environmental, situational, psychological ‘system states’ or ‘states of mind’

that promote Immediate Causes.

The necessity to distinguish Preconditions while investigating is the

“whistleblower” speaking up about the Organisational Cultures involved into

the accident. Therefore, not only can we reach the underlying Causes behind

the failure more efficiently but also we have enough hints and raw data about

corporate cultures that definitely need change.

Back to “HELIOS Accident”

The First TRIPOD

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While the formation of the first TRIPOD, from the maximum five that we can

manage in an Accident Analysis, might be easy, all the rest require effort and

a definite knowledge of who requested the investigation, since his array of

interests we need to take into account upon examining the accident’s data.

Soon after HELIOS take off, the flight crew faced a challenge as they had

found themselves faced with the task of dealing with multiple warnings, a

combination of at least two of the elements of the Warning System of the

aircraft (either OFF & Intermittent Horn or Aux Fail & Intermittent Horn) as

they had been active in short time intervals or almost simultaneously. That

challenge had been the change agent of this first in session TRIPOD while the

Object that had been chosen to be guarded is “The Boeing 737/300 integrity

of the design over time”.

According to Sidney Dekker (unknown), the EICAS (Engine Indication and

Crew Alerting System) technology was available at the time that Boeing

737/300 came out but still it is unknown why this system had never been

applied on the prototype. Sidney Dekker argues that for that reason “B737

lags behind the industry standard on warning and alerting systems”.

A thorough study of Boeing’s 737/300 model in 2005 reaches the conclusion

that the designer of the aircraft had decided not to follow the simple rule of

putting in place a unique warning per grave emergency. Additionally,

international aviation community had long ago been informed about the

necessity to also take human factors principles into account in the design of

flight checklists, Degani &Wiener (1990) state, but unfortunately a

mechanism, either driven by an International Regulatory Body or the

Manufacturer itself, failed to lead these changes.

While the Barriers that are identified as “Missing” were reported in good faith,

still there are also others that had failed to protect the Object and had led to

the unwanted event of “letting HELIOS Cabin Altitude cross the hypoxic

threshold with the aircraft operating in a non normal situation”.

Reality states that it is highly likely that nothing might have happened if the

flight crew had correctly interpreted and effectively applied the Boeing flight

checklists, before and after takeoff. Although many were found to apportion

blame on the professionalism and the capabilities of pilots, in general

experience has shown that during the past, in other relative accidents again,

in only two cases out of ten flights, crew had reacted effectively. That alone

shows that “evil” is always hiding behind the details and therefore it is worth

mentioning that “Soldiers in Battles should be sent equipped with the best

available weapons if later on we intend to cast blame upon them for any loss”.

TRIPOD investigation spotted several preconditions shown below that need to

be counterbalanced if the relative Barrier is to become effective:

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Organisational cultures in airlines unfortunately still carry some of the

characteristics which are presented by the statements above and indeed

those are the prevailing axioms around aviation professionals. For as long as

pilots insist on declaring that they think of checklists as the means of the

manufacturer to cast blame upon them, in case of an accident and

international community fails to root out the evil, we should expect more

occasion where pilots will be the scapegoats and latent failures will remain in

dark.

On the other hand, there are signs that relative knowledge had been found far

beyond in time, before HELIOS accident occurred, but unfortunately till the

time of the accident it had remained on the shelf.

TRIPOD methodology had been designed to draw the attention away from

single failures of first line personnel (pilots, engineers, ATC controllers, etc)

and instead shed light on organisational issues, which are the breeding

mechanism for latent failures and far more complex issues to be dealt with.

Below are depicted the rest of the TRIPODS which are included into the

investigation:

Active Failure & Preconditions

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The Second TRIPOD

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The Third TRIPOD

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In the event of this accident investigation being transformed into a short

business oriented report, the fact that during this -demonstrative only- attempt

there were discovered nine Missing barriers that require immediate concern

and careful study and another eight Failed barriers indicates that for the

former we should expect time consuming solutions, while for the latter, things

might get better more easily.

On the other hand, the magnitude of the gaps found explains the safety

breaches that took place and in addition offers absolution for the pilots, at

least in the eyes of common people who initially might have thought that the

obvious is also the real.

FURTHER DETAILS CAN BE DISCUSSED VIA EMAIL AT:

info@o-diagnosis.com or directly reaching out Dimitris Soukeras at :

Mobile: +306947006664

The Fourth TRIPOD

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REFERENCES

1. AAIASB (2006), “Aircraft Accident Report Helios Airways Flight

HCY522 BOEING 737-31S AT Grammatiko, Hellas on August 14

2005”.

2. Asaf Degani & Earl Wiener (1990), “Human Factors of Flight-Deck

Checklists: The Normal Checklist”, NASA, Ames Research Center.

3. Asaf Degani & Earl Wiener (unknown), “Cockpit Checklists: Concepts,

Design, and use”,

4. Sidney Dekker (Unknown), “Expert Opinion-Human Factors”, retrieved

from the internet.

5. R. Key Dismukes & Ben Berman (2010), “Checklists and Monitoring in

the Cockpit: Why Crucial Defenses Sometimes Fail”, NASA/TM ,Ames

Research Center.

6. Jop Groeneweg (2002), “Controlling the Controllable Preventing

Business Upsets”, Global Safety Group, Fifth Edition.