Human factors experts like to talk about the "authority gradient" in the cockpit as a potential source of Crew Resource Management problems. No matter what you call it, a first officer's primary duty is backing up the captain and sometimes that means challenging the captain.
— James Albright
- 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
- Flash Airlines flight 604 Boeing 737-300 scheduling to depart Sharm El Sheikh at 0230 GMT 0430 local time.
- From Cockpit Voice Recorder information the first officer and observer were in the Cockpit at 02:14:30 the Captain was in the cockpit at 02:18:14.
- Load information and flight information were exchanged between the Flight Deck and Cabin Attendants.
- At 02:18:58 before start check list was requested by the Captain and was read by the F/O and responded by Captain and F/O completed at 02:20:17.
- The Cleared to Start checklist was carried out at 02:32:19, the After Start checklist at 02:35:36, and the Taxi checklist at 02:39:55.
- The ATC clearance was delivered at 02:38:15 and read back by F/O as follows:
- ATC Flash 604 destination Cairo as filed climb initially flight level 140 1673 on the squawk.
- F/O Our clear to destination via flight plan route 140 initially 1673 on the squawk Flash 604 we have total pax 135 God willing.
- The Take Off checklist was completed at 02:40:05.
- Take off was initiated at 02:41:59 with standard call outs.
- At time 02:42:02 TOGA mode engaged and then disengaged at 02:42:04.
- Aileron movements during T/O roll and lift off were consistent with crosswind.
- At time 02:42:43, as the airplane was climbing through 440 feet the Captain requested Heading Select. The F/O confirmed the command and the FDR records that heading select mode was engaged.
- At time 02:42:48, Captain requested "Level Change"
- At time 02:42:49 the F/O announced "Level Change, MCP speed, N1 armed Sir".
- At time 02:42:59 the F/O announced "one thousand". At the same time, ATC reported the departure time and confirmed left turn clearance. The clearance was acknowledged by the F/O. This was the last ATC transmission from the flight crew. The aircraft rolled to 20 left bank and began a climbing turn.
- The turn continued as the magnetic heading approached 140 (at an altitude of 3600 ft), at which point the bank angle decreased to approximately 5 left bank.
- At time 02:43:19, EgyptAir Flight (MSR 227), a flight from Hurgada inbounds to Sharm el-Sheikh called ATC. Conversations between ATC and MSR 227 continue for approximately 60 seconds.
- At time 02:43:37, the Captain called for the After Takeoff checklist. There was not audible response from the F/O.
- At time 02:43:55, the Captain called "Autopilot". There was no immediate response from the F/O or mode changes recorded on the FDR
- At time 02:43:58, the Captain stated "Not yet". At time 02:43:59, the FDR recorded the autopilot was engaged, and that the roll mode transition to CWS-R mode. This transition would have resulted in loss of Heading Select Mode
- At time 02:44:00, the F/O stated "Autopilot in command sir".
- At time 02:44:01, the captain stated "EDEELO", (an Arabic exclamation expressing a sharp response of some kind). At the same time, the FDR records momentary aileron surfaces movements. The right aileron deflected to 7.2 degree TEU for one second
- At time 02:44:02, the CVR records the autopilot disconnect warning and the FDR recorded the autopilot disengaged. The aural warning lasted for 2.136 seconds.
- During this time, an increase in pitch and decay in airspeed were observed
- At time 02:44:05, the Captain requested heading select.
- At time 02:44:07, the F/O states "heading select" and the FDR records heading select mode engaging. This mode transition would have resulted in the reappearance of the flight director roll command bar. During this sequence, the aircraft’ left-bank continued to decrease at a slow rate until the airplane was briefly wings level.
- Beginning at this time, the FDR records a series of aileron motions that command a right bank and subsequent right turn.
- At time 02:44:18, the captain states "See what the aircraft did". At this point the aircraft bank angle was approximately 12° to the right.
- At time 02:44:27, the F/O states "Turning right, sir". Three seconds later, the captain responses "What". At the same time, bank angle is 17° to the right and the FDR records the aileron motions to increase the right bank.
- At time 02:44:31, the F/O states "Aircraft is turning right". One second later, the captain response "Ah"
- At time 02:44:35, the Captain states "Turning right”, at this point, the bank angle was 23.6° to the right
- At time 02:44:37, the Captain states – “how turning right” , bank angle was 29.7
- At time 02:44:41, the Captain states "OK come out". At this point, the bank angle was slightly more than 40° right bank and the FDR records the ailerons returning to just beyond neutral, the high right roll rate stopped and a momentary left roll rate occurred resulting in a slight decrease in the right bank from 43° to 42° before additional aileron movements command an increase in the right bank.
- At time 02:44:41.5, the F/O states "Overbank". The bank angle at this time was just beyond 50° right bank. The airplane reaches its maximum altitude of just over 5460 feet.
- At time 02:44:41.7, the Captain states "Autopilot". He repeats the statement at 02:44:43.4.
- At time 02:44:44, the F/O states "Autopilot in command". No autopilot engagement was recorded on the FDR. The bank angle was approaching 60° right bank. Pitch angle was zero and altitude was 5390 feet.
- At time 02:44:46, the Captain again states "Autopilot".
- At time 02:44:48, the F/O states "Overbank, Overbank, Overbank". The bank angle was approaching through 70° right bank, pitch angle was 3° nose down FDR continues to record aileron motions that increase the right bank.
- At time 02:44:52.8, the F/O again states "Overbank". Bank angle was approaching 90°, pitch attitude was 23° nose down, and the altitude was 4860 ft.
- At time 02:44:53.4, the Captain responds "OK, come out". The FDR records aileron motions to increase the right bank.
- At time 02:44:56, the F/O states "No autopilot commander". Bank angle was 102°, pitch attitude was 37° nose down, and the altitude was 4100 ft.
- At time 02:44:58, the captain states "Autopilot". At the same time, the FDR records a large aileron motion to the left and the airplane begins rolling back towards wings level. The maximum bank angle recorded was 111° right. Pitch attitude at that time was 43° nose down and altitude was 3470 feet.
- At time 02:44:58.8, the observer states "Retard power, retard power, retard power".
- At time 02:45.01.5, the captain states "Retard power", and the FDR records both engine throttles being moved to idle. The bank angle was 51° right bank, pitch attitude was 40° nose down and altitude was 2470 ft.
- At time 02:45:02, the CVR records the sound of the overspeed warning. The FDR records the airspeed as 360 KIAS.
- Recovery from severe Right Bank and nose down pitch continued
- At time 02:45:04.3, the captain states "Come out". Bank angle was 14° right, pitch attitude was 31° nose down, altitude was 760 ft, and airspeed was 407 KIAS.
- At time 02:45:05, the CVR records a sound similar to ground proximity warning.
- A/C impacted the water at 02:45:06.
Source: Factual Report, ¶1.1
The captain was born in 1950 and had been with the airline for one year. He had 7,443 hours total flight time, including nearly 2,000 hours as a military instructor.
The first officer was born in 1979 and has been with the airline a few months short of a year. He had 788 hours total flight time.
Source: Factual Report, Exhibit F, ¶3.2
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.
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)