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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.
notice: This paper is a demonstration only edition prepared by consultants of
Organisational Diagnosis also available for
download from: www.o-diagnosis.com based on the investigation of HELIOS accident with the application of TRIPOD Beta
methodology.
A more extended version of the paper had been presented by Mr Dimitrios Soukeras in the last 3rd Aviation Conference under the
title “Air Transport of Today and Tomorrow” which was organized and taken place in Athens International Airport (Building 17th),
by the Hellenic Aviation Society, on May 12-13 2014.
FURTHER DETAILS CAN BE DISCUSSED VIA EMAIL AT:
[email protected] or directly reaching out Dimitris Soukeras at
Mobile: +306947006664
:
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.
Dimitrios Soukeras was born in Athens in 1968.In 1986 he entered the Greek Military Academy and from 1994 till 2007 he
served in Army Aviation as a helicopter pilot. He honourably retired at the end of 2007 as Lieutenant Colonel and then he
dedicated himself to end up his MBA studies with Leicester University. He holds an MBA(ER) since 2010. His thesis that was
entitled: “Developing a Safety Culture or Implementing a Safety Management System: The case of Organisations operating
helicopters” was dealing with “Safety Culture Mapping” within high risk entities and it is considered to be a valuable paper by
the IHST (International Helicopter Safety Team), which gained a permission by the author and simultaneously the right to also
posting the paper, in early 2013, on their website.
Dimitrios fulfilled the prerequisites to become a full member ISASI (International Society of Air Safety Investigators), as from
time to time investigates helicopter accidents for the Greek AAIASB. The European branch of ISASI (ESASI) had already
accepted Dimitrios twice to presenting papers in the annual Seminars they offer.
Dimitrios endorses and utilises all modern tools in Incident Analysis and Risk Assessment, submitted the first final accident
report to the Greek AAIASB with the application of TRIPOD Beta methodology two years ago and he offers training and
consultation for accident prevention.
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