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Flash Airlines 604

Accident Case Study

Though you wouldn't get this from a first look at the Egyptian Ministry of Civil Aviation Report, a few things are clear:

  • The captain was a retired Egyptian Air Force general, a war hero, fighter pilot. Military pilots in Egypt were revered.
  • The copilot was very inexperienced by comparison.
  • A third pilot was on the flight deck, as an observer. This pilot was also senior to the copilot.
  • The cockpit voice recorder shows the captain joking with the observer about the first officer's inexperience.
  • It was a clear, moonless night.
  • The aircraft was cleared immediately after takeoff to turn a sweeping 280° to the left.
  • The captain did roll left to about 20° bank but then shallowed the bank and called for the autopilot.
  • The autopilot was engaged but then the roll mode "transition to CWS-R mode," resulting in the loss of heading select mode, followed by an autopilot disconnect warning.
  • The flight data recorder noted an increase in pitch and momentary right aileron input.
  • As the aircraft banked further right the captain said, "See what the aircraft did?"
  • The first officer said "Aircraft turning right."
  • The captain responded, "How turning right?"
  • The bank continued to increase through 40° at which time the first officer said, "overbank."
  • The aircraft continued to increase its bank to which the captain commanded "autopilot," but it would not engage.
  • The flight data recorder noted increased right aileron inputs as the bank increased through 111° and pitch 43° nose down.
  • The aircraft impacted the water at 416 knots.

The report says no conclusive evidence was possible. I think they were reluctant to denigrate the captain's reputation, which was indeed considerable. But I think in the interest of flight safety, one can conclude the following::

  • The captain experienced vertigo, a type of spatial disorientation, and expressed a degree of confusion when the first officer announced he was in a right turn.
  • The first officer did not make any assertive moves to take control of the aircraft or forcefully correct the captain's actions.
  • An earlier inspection noted the airline did not have a Crew Resource Management training program and there was no evidence of either pilot having any such training.
  • Had the captain been more open to first officer input and had the first officer been more assertive and willing to take control of the aircraft, the captain's case of vertigo could have been overcome and the mishap need not have happened.

 

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Figure: Map, from May Day.

Accident Report

  • Date: 3 January 2004
  • Time: 04:45
  • Type: Boeing 737-3Q8
  • Operator: Flash Airlines
  • Registration: SU-ZCF
  • Fatalities: 13 of 13 crew, 135 of 135 passengers
  • Aircraft Fate: Destroyed
  • Phase: Initial Climb
  • Airports: (Departure) Sharm el Sheikh-Ophira Airport (SSH), Egypt; (Destination) Cairo International Airport (CAI/HECA), Egypt

Narrative

Weather was perfect (excellent visibility, 17 degrees C and a light breeze) when Flash Air flight 604 departed the Red Sea resort of Sharm el Sheikh for a flight to Paris-CDG with an intermediate stop at Cairo. On board were 135, mostly French, holiday makers who were heading home.

At 04:38 the flight was cleared to taxi to runway 22R for departure. After takeoff, at 04:42, the plane climbed and maneuvered for a procedural left turn to intercept the 306 radial from the Sharm el-Sheikh VOR station. When the autopilot was engaged the captain made an exclamation and the autopilot was immediately switched off again. The captain then requested Heading Select to be engaged. The plane then began to bank to the right. The copilot then warned the captain a few times about the fact that the bank angle was increasing. At a bank angle of 40 degrees to the right the captain stated "OK come out". The ailerons returned briefly to neutral before additional aileron movements commanded an increase in the right bank.

The aircraft had reached a maximum altitude of 5460 feet with a 50 degrees bank when the copilot stated: "Overbank". Repeating himself as the bank angle kept increasing. The maximum bank angle recorded was 111 degrees right. Pitch attitude at that time was 43 degrees nose down and altitude was 3470 feet.

The observer on the flight deck, a trainee copilot, called "Retard power, retard power, retard power". Both throttles were moved to idle and the airplane gently seemed to recover from the nose-down, right bank attitude. Speed however increased, causing an overspeed warning. At 04:45 the airplane struck the surface of the water in a 24 degrees right bank, 24 degrees nose-down, at a speed of 416 kts and with a 3,9 G load.

The wreckage sank to a depth of approx. 900 metres.

Probable Cause

No conclusive evidence could be found from the findings gathered through this investigation to determine the probable cause. However, based on the work done, it could be concluded that any combination of these findings could have caused or contributed to the accident.

Although the crew at the last stage of this accident attempted to correctly recover, the gravity upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.

See Also:

Spatial Disorientation

Crew Resource Management

References

Aviation Safety Network

Egyptian Ministry of Civil Aviation, Factual Report of Investigation of Accident, Flash Airlines flight 604, January 3, 2004, Boeing 737-300 SU-ZCF, Red Sea off Sharm El-Sheikh, Egypt

May Day: Vertigo, Cineflix, Episode 32, Season 4, 10 June 2007 (Flash Airlines 604)

Revision: 20120101
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