3 January 2004 - Flash Airlines 604

Flash Airlines Flight 604 was a charter flight operated by Egyptian charter company Flash Airlines. On 3 January 2004, the Boeing 737-300 crashed into the Red Sea shortly after takeoff from Sharm el-Sheikh International Airport, killing all 142 passengers, many of them French tourists, and all 6 crew members. The findings of the crash investigation are controversial, with accident investigators from the different countries involved not agreeing on the cause.

The flight took off at 04:44 Eastern European Time (0244 GMT) from runway 22R at the Egyptian resort en route to Paris via Cairo. The captain was one of Egypt's most experienced pilots, with over 7,000 hours flying experience that included a highly decorated career in the Egyptian Air Force.

After taking off, the aircraft should have climbed and initiated a left turn to follow the air corridor to Cairo designated by the Sharm el-Sheikh VOR station. The captain appeared surprised when the autopilot was engaged, which he immediately switched off again. The copilot warned the captain that the bank angle was increasing. At a bank angle of 40 degrees to the right, the captain said "OK come out". The ailerons were briefly returned to a neutral before being commanded to increase the bank to the right. The aircraft reached an altitude of 5,460 feet (1,660 m) with a 50 degrees bank when the copilot exclaimed "Overbank" repeatedly when the bank angle kept increasing. The bank angle was 111 degrees right, while the pitch attitude was 43 degrees nose down at an altitude of 3,470 feet (1,060 m). The observer on the flight deck, also a pilot, but a trainee on this type of aircraft, shouted "Retard power, retard power, retard power". Both throttles were moved to idle; the captain appeared to regain control of the airplane from the nose-down, right bank attitude. However the speed increased, causing an overspeed warning. At 04:45, the aircraft impacted the water about 9.4 statute miles (15.2 km; 8.2 nmi) south of the airport. The impact occurred while the aircraft was in a 24 degree right bank, 24 degree nose-down attitude, travelling at 416 knots (770 km/h)(478 mi/h) and pulling 3.9g (38 m/s²). All passengers and crew were killed on impact.

Charles de Gaulle Airport initially indicated the Flash Airlines flight as delayed; authorities began notifying relatives and friends of the deaths of the passengers two hours after the scheduled arrival time. Authorities took relatives and friends to a hotel, where they received a list of passengers confirmed to be on the flight. Marc Chernet, president of the victims' families association of Flight 604, described the disaster as the "biggest air disaster involving French nationals" in civil aviation.

Initially, it was thought that terrorists might have been involved, as fear of aviation terrorism was high (with several major airlines in previous days cancelling flights on short notice). Former British Prime Minister Tony Blair was also holidaying in the Sharm el-Sheikh area. A group in Yemen said that it destroyed the aircraft as a protest against a new law in France banning headscarves in schools. Accident investigators dismissed terrorism when they discovered that the wreckage was in a tight debris field, indicating that the aircraft crashed in one piece; a bombed aircraft would disintegrate and leave a large debris field.

The wreckage sank to a depth of 1,000 m (3,300 ft), making recovery of the flight data recorder and cockpit voice recorder difficult. However two weeks after the accident, both devices were located by a French salvage vessel and recovered by a ROV. The accident investigators examined the recorders while in Cairo. The maintenance records of the aircraft had not been duplicated; they were destroyed in the crash and no backup copies existed.

The American National Transportation Safety Board (NTSB) and the French Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA) investigated and concluded that the pilot suffered spatial disorientation, and the copilot was unwilling to challenge his more experienced superior. Furthermore, according to the NTSB and BEA, both pilots were insufficiently trained. The NTSB stated that the cockpit voice recorder showed that 24 seconds passed after the airliner banked before the pilot began correcting maneuvers. Egyptian authorities disagree with this assessment, as does the Egyptian public, who both tend to attribute the cause to mechanical issues. Shaker Kelada, the lead Egyptian investigator, said that if Hamid, who had more experience than the copilot, detected any problems with the flight, he would have raised objections. Some media reports suggest that the plane crashed due to technical problems, possibly a result of the apparently questionable safety record of the airline. This attitude was shown in a press briefing given by the BEA chief, who was berated by the first officer's mother during a press conference, and demanded that the crew be absolved of fault prior to the completion of the investigation. Two months after the crash Flash Airlines went bankrupt.

U.S. Summary Comments on Draft Final Report of Aircraft Accident Flash Airlines flight 604, Boeing 737-300, SU-ZCF January 3, 2004, Red Sea near Sharm El-Sheikh, Egypt. Quote from page 5 of 7:

"Distraction. A few seconds before the captain called for the autopilot to be engaged, the airplane’s pitch began increasing and airspeed began decreasing. These deviations continued during and after the autopilot engagement/disengagement sequence. The captain ultimately allowed the airspeed to decrease to 35 knots below his commanded target airspeed of 220 knots and the climb pitch to reach 22°, which is 10° more than the standard climb pitch of about 12°. During this time, the captain also allowed the airplane to enter a gradually steepening right bank, which was inconsistent with the flight crew’s departure clearance to perform a climbing left turn. These pitch, airspeed and bank angle deviations indicated that the captain directed his attention away from monitoring the attitude indications during and after the autopilot disengagement process. Changes in the autoflight system’s mode status offer the best explanation for the captain’s distraction. The following changes occurred in the autoflight system’s mode status shortly before the initiation of the right roll: (1) manual engagement of the autopilot, (2) automatic transition of roll guidance from heading select to control wheel steering-roll (CWS-R), (3) manual disengagement of the autopilot, and (4) manual reengagement of heading select for roll guidance. The transition to the CWS-R mode occurred in accordance with nominal system operation because the captain was not closely following the flight director guidance at the time of the autopilot engagement. The captain might not have expected the transition, and he might not have understood why it occurred. The captain was probably referring to the mode change from command mode to CWS-R when he stated, “see what the aircraft did?,” shortly after it occurred. The available evidence indicates that the unexpected mode change and the flight crew’s subsequent focus of attention on reestablishing roll guidance for the autoflight system were the most likely reasons for the captain’s distraction from monitoring the attitude".

Problems associated with the complexity of autopilot systems are well known. Before the completion of the investigation, Avonics writer David Evans suggested that differences in instrumentation between the MiG-21, which the captain had experience on, and the Boeing 737, may have contributed to the crash.

Flight 604 has the highest death toll of any aviation accident in Egypt since EgyptAir Flight 990 and the highest death toll of any accident involving a Boeing 737-300.

Download the full investigation report

Transcript of the Cockpit Voice Recorder (CVR)

Legenda:

FO= First Officer
CA= Captain
ATT= Attendant
ATC= Air Traffic Control
EC1= Extra crew 1
EC3= Extra crew 3
MSR227= Egyptair 227, other aircraft communicating whith ATC during the event
SV= Synthetic Voice

Note: Transcription is picked up just after engine start.

02:32:31 FO: Before start check list completed down to the after start
02:32:58 EC3: Come on fellows
02:33:00 ATT: Close two L please
02:33:07 : (Thump)
02:33:16 CA: We rely on God, thank God, in the name of God
02:33:20 : Sounds
02:33:25 ATT: Attention cabin crew doors in armed position and crosscheck
02:33:30 :Sounds for 47 seconds (may be cockpit door, jump seat and unknown ratcheting sounds)
02:34:08 CA: What is this
02:34:09 FO: In the name of God, we rely on God
02:34:11 FO: Duct pressure decrease start valve open
02:34:14 CA: N two
02:34:25 ATT: Ladies and gentlemen, good morning on behalf of Captain Kheder and his crew members welcome you on board Flas Airlines Boeing seven three seven three hundred proceeding to cairo, during our flight to Cairo we shall cover the distance at fifty minutes and altitude twenty seven thousand feet, you are kindly requested to fasten your seat belts and put back of your seats in full up right position, and observe the no smoking sign during all the flight, thank you
02:34:31 FO: Oil pressure
02:34:48 FO: Approaching forty six
02:34:50 FO: Duct pressure normal start valve closed
02:34:51 ATT: Cabin crew stand by for demo
02:35:06 CA: Number one, we rely on God
02:35:08 FO: Duct pressure decrease start valve open
02:35:10 CA: N two
02:35:16 CA: EGT thirteen, nineteen when it starts again
02:35:21 FO: Approach*
02:35:22 CA: N one EGT ok normal
02:35:27 FO: Max motoring
02:35:30 FO: Oil pressure
02:35:48 CA: Approach forty six start cut out pressure normal start valve closed start cut out
02:36:04 CA: Stabilized
02:36:13 CA: To the line
02:36:14 FO: Electrical
02:36:16 CA: On bus
02:36:17 FO: Pitot heat
02:36:17 CA: On
02:36:18 FO: Anti-ice
02:36:19 CA: On
02:36:19 FO: Air conditioning and pressurization
02:36:21 CA: Packs on, flight
02:36:23 FO: Isolation valve
02:36:24 CA: Auto
02:36:25 FO: APU
02:36:29 CA: Start there in flight no problem whith God's help
02:36:30 FO: Start levers
02:36:32 : *
02:36:33 CA: Idle detent
02:36:34 FO: Ground equipment
02:36:36 CA: Clear
02:36:36 FO: After start checklist completed
02:36:37 CA: Taxiing
02:36:39 FO: Sharm El Sheikh Flash six zero four ready to taxi out
02:36:48 ATC: Six zero four taxi right delta alpha hold short runway two two right
02:36:53 FO: Roger to the right via delta alpha to holding point runway two two right Flash six zero four
02:36:59 FO: Commander delta alpha god willing to the right
02:37:02 CA: God willing
02:37:03 FO: Holding point runway two two right and right side is clear
02:37:06 : Sound
02:37:07 CA: We rely on God
02:37:08 FO: Shocks off zero two three *
02:37:09 : Sound
02:37:09 CA:Is this not operating normally
02:37:10 : Sound
02:37:11 :Sound maybe parcking brake release
02:37:14 FO: One minute past for APU
02:37:16 CA: Off
02:37:18 FO: APU off sir
02:37:18 : (six clicks)
02:37:23 : (engine acceleration sound)
02:37:26 CA: Flaps five
02:37:28 : Thrre sounds similar to flap handle
02:37:30 CA: Rudder right neutral left
02:37:28 : (high thump)
02:37:35 CA: Neutral
02:37:37 FO: Flight control checked
02:37:40 : Two consecutive sounds
02:37:41 CA: Turning to the right
02:37:43 FO: God willing via delta commander
02:37:44 CA: Is this delta
02:37:45 FO: God willing
02:37:49 FO: Straight ahead
02:37:52 : Sound maybe landing light
02:38:01 ATC: Flash six zero four ready to copy
02:38:03 FO: Go ahead sir
02:38:05 ATC: Flas six zero four destination cairo as filed, climb initially flight level one four zero, one six seven three on the squawk
02:38:15 FO:Our clear destination Cairo via flight plan route one four zero initially, one six seven three on the squawk, Flas six zero four and we have total passengers one three five, God willing
02:38:25 ATC: Continue taxi via Alpha line up two two right advice ready for departure
02:38:34 FO: Roger, next vall ready God willing
02:38:37 FO: One four zero initially, one six seven three
02:38:44 CA: Before takeoff
02:38:45 FO: Recall
02:38:46 CA: Checked
02:38:47: FO: Flight controls
02:38:48 CA: Checked
02:38:48 FO: Flaps
02:38:49 CA: Five green light
02:38:49 FO: Stabilizer trim
02:38:51 CA: Five units
02:38:52 FO: Cockpit doors
02:38:54 CA: Ok closed because this door opens
02:38:57 EC1: What do you want
02:38:57 CA: yes because *give why*
02:38:58 CA: No really
02:39:01 FO: Take off briefing
02:39:03 CA: Standard briefing god willing
02:39:04 FO: before check list is completed down to the line God willing
02:39:12 : (Series of sounds)
02:39:55 CA: To the line
02:40:01 FO: Engine start switches
02:40:02 CA: On
02:40:02 FO: Transponder
02:40:04 CA: On
02:40:05 FO: Before takeoff checklist completed down to strobe lights
02:40:07 CA: Completed god willing
02:40:36 CA: Set it on take off ninety and half ...ready for departure
02:40:38: FO: Flash six zero four ready for departure
02:40:46 ATC: Flash six zero four surface wind two eight zero one three knots left turn to intercept radial three zero six, cleared for takeoff two two right
02:40:55 FO: Clear for takeoff runway two two right whith left turn to establisk three zero six Sharm VOR our Flash six zero four clear for takeoff
02:41:01 : one thump (door knock)
02:41:02 CA: It is left turn open the door
02:41:04 FO: God willing
02:41:09 ATT: Cabin is clear
02:41:12 CA: Thank you
02:41:12 FO: Final is clear
02:41:13 : One thump
02:41:15 : Four similar thumps, maybe landing lights
02:41:19 FO: Left turn to establish radial three zero six
02:41:29 CA: Initially one four zero?
02:41:30 FO: God willing
02:41:34 CA: Confirm initially one four zero
02:41:35 FO: And Flash six zero four confirm to the left to establish three zero six
02:41:40 CA: Initial one four zero
02:41:43 ATC: God willing
02:41:44 FO: and initially one four zero
02:41:46 ATC: God willing
02:41:48 CA: We rely on God
02:41:59 : Sound similar to increase of engine r.p.m.
02:42:00 FO: Stabilized sir N one
02:42:10 FO: Takeoff power set speed building up, eighty knots, throttle hold
02:42:11 CA: Eighty knots (one thump sound)
02:42:26 FO: V one, rotate
02:42:33 : One thump similar to gear retraction
02:42:33 FO: ** positive rate
02:42:34 CA: Heading select
02:42:36 CA: Gear up
02:42:36 FO: Ok
02:42:43 CA: Four hundred heading select
02:42:44 FO: Four hundred heading select sir
02:42:48 CA: Level change
02:42:49 FO: Level change, MCP speed, N1 armed sir
02:42:59 FO: One thousand
02:43:00 CA: N one speed two twenty flaps one
02:43:04 CA: Left turn
02:43:05 ATC: Flas six zero four airborne time four four when you ready to the left to intercept three zero six radial report on course, God willing
02:43:11 CA: Left turn
02:43:12 FO: Roger when ready God willing
02:43:18 FO: Left turn to establish three zero six Sharm VOR
02:43:19 MSR227: Sharm Egypt air two two seven greeting
02:43:22 FO: Speed available
02:43:23 CA: Flaps up
02:43:27 ATC: Egypt air two two seven go ahead, greeting
02:43:26 MSR227: Mantaining Flight level one two zero four three DME inbound to Sharm el Sheikh and request descent
02:43:34 ATC: Egypt air double two seven clear sierra hotel mike VOR, visual approach runway two two right pilot discretion descend four thousand feet QNH one zero one one
02:43:35 FO: Flaps up no light
02:43:37 CA: After takeoff checklist
02:43:35 MSR227: How much is the wind sir
02:43:48 ATC: Indicated two eight zero one zero knots
02:43:53 MSR227: Can we use runway zero four sir
02:43:55 CA: Autopilot
02:43:56 MSR227: Right zero four
02:43:58 CA: Not yet
02:43:59 ATC: There is no problem Straight in ILS approach runway zero four left god willing report fuel establish QNH one zero one
02:44:00 FO Autopilot in command sir
02:44:01 CA: Exclamation remark
02:44:02 : Sound of A/P disengage warning
02:44:05 CA: Heading select
02:44:05 MSR227: Straight in approach runway zero four lrft, one zero one, next call full establish Egypt air two two seven
02:44:07 FO: Heading select
02:44:18 CA: See what the aircraft did!
02:44:27 FO: Turning right sir
02:44:30 CA: What?
02:44:31 FO: Aircraft is turning right
02:44:32 CA: AH
02:44:35 CA: Turning right?
02:44:37 CA: How turning right
02:44:41 CA: Ok come out
02:44:41 FO: Over bank
02:44:41 CA: Autopilot
02:44:43 CA: Autopilot
02:44:44 FO: Autopilot in command
02:44:46 CA: Autopilot
02:44:48 FO Over bank, over bank, over bank
02:44:50 CA: OK
02:44:52 FO: Over bank
02:44:53 CA: OK, come out
02:44:56 FO: No autopilot commander
02:44:58 CA: Autopilot
02:44:58 EC1: Retard power, retard power, retard power
02:45:01 CA: Retard power
02:45:02 : Sound similar to overspeed clacker
02:45:04 CA: Come out
02:35:05 FO: No god except...
02:35:05 SV: "whoop" sound similar to ground proximity warning
02:45:06 END OF RECORDING