Flash Airlines flight FSH604 - Boeing B737-300 (SU-ZCF)

Flash Airlines – Boeing B737-300 (SU-ZCF) flight FSH604

On January 3, 2004, about 02:45:06 UTC, 04:45:06 Local time, Flash Airlines flight FSH604 , a Boeing 737-300, Egyptian registration SU-ZCF, crashed into the Red Sea shortly after takeoff from Sharm el-Sheikh International Airport (SSH) in South Sinai, Egypt. The flight was a passenger charter flight to Charles de Gaulle Airport (CDG), France with a stopover in Cairo international Airport (CAI) for refueling.

Flash Airlines flight FSH604 - Boeing B737-300 (SU-ZCF)
Flash Airlines flight FSH604 – Boeing B737-300 (SU-ZCF)

Flash Airlines flight FSH604 departed from Sharm el-Sheikh airport with 2 pilots (Captain and First Officer), 1 observer, 4 cabin crew, 6 off-duty crew members and 135 passengers on board. The airplane was destroyed due to impact forces with the Red Sea with no survivals. The airplane had departed from Sharm el-Sheikh runway 22R and was airborn at 02:42:33 UTC, approximately 2½ minutes prior to the crash, and had been cleared for a climbing left turn intercept the 306 radial from the Sharm el-Sheikh VOR station located just north of runway 22R.

This climbing turn allows departing flights to gain sufficient altitude before proceeding over higher terrain located along the flight path to Cairo.

  • 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.
  • 02 h 39 min 54 s, A/T engaged (through the whole flight),
  • The Take Off checklist was completed at 02:40:05.
  • 02 h 40 min 38 s, F/O : “Flash 604 ready for departure”,
  • 02 h 40 min 46 s, TWR : “Flash 604 surface wind 280/13 kts left turn to intercept radial 306 clear for take off 22R”, • 02 h 40 min 55 s, F/O : “Clear for take off runway 22R with left turn to establish 306 Sharm VOR, our Flash 604 clear for take off”,
  • 02 h 41 min 19 s, F/O : “Left turn to establish radial 306”, • 02 h 41 min 30 s, Captain : “Initially 140”,
  • 02 h 41 min 34 s, Captain : “Confirm initially 140”,
  • 02 h 41 min 35 s, F/O : “And Flash 604 confirm to the left to establish 306”,
  • 02 h 41 min 40 s, Captain : “Initial 140”,
  • 02 h 41 min 43 s, TWR : “Inch Allah”,
  • 02 h 41 min 44 s, F/O : “And initially 140”,
  • 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.
  • 02 h 42 min 10 s, F/O : “Take off power set speed building up 80 kts throttle hold”,
  • 02 h 42 min 26 s to 02 h 42 min 33 s, Take off phase, Co-pilot : “V1 rotate, positive rate”,
  • 02 h 42 min 36 s, Captain : “Gears up”,
  • 02 h 42 min 38 s, gears are up (FDR), CAS 169,5 kts
  • 02 h 42 min 43 s, Captain : “400 heading select”,
  • 02 h 42 min 44 s, F/O : “400 heading select” (FDR heading select 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 of Flash Airlines flight FSH604 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.
  • 02 h 43 min 00 s, Captain : “N1 speed 210 flaps 1”,
  • 02 h 43 min 04 s, Captain : “Left turn”,
  • 02 h 43 min 05 s, TWR : “Flash 604 airborne time 44 when you ready to the left to intercept 306 radial report on course”, (Aircraft at 1268 ft),
  • 02 h 43 min 11 s, Captain : “Left turn”, (1528 ft, beft)
  • 02 h 43 min 12 s, F/O : “Roger when ready inch Allah”,
  • 02 h 43 min 18 s, F/O : “left turn to establish 306 Sharm VOR”, (maximum recorded left roll is 21,8° within that phase at 02:43:21),
  • 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 inbound to Sharm el-Sheikh called ATC. Conversations between ATC and MSR 227 continue for approximately 60 seconds.
  • 02 h 43 min 21 s, MCP selected speed recorded 219 kts,
  • 02 h 43 min 23 s, Captain : “Flaps up”,
  • 02 h 43 min 33 s, Selected heading recorded 106,8°,
  • 02 h 43 min 35 s, Co-pilot : “Flaps up no light”, (2196 ft, CAS 209 kts, Hdg 168, Pitch 10.9°, Roll 20,74° left),
  • At time 02:43:37, the Captain of Flash Airlines flight FSH604 called for the After Takeoff checklist. There was not audible response from the F/O.
  • 02 h 43 min 53 s, CAS 216,5 kts decreasing (reached a minimum value of 184.5 Kts at 2:44:23 and then started increasing),
  • At time 02:43:55, the Captain called “Autopilot”. There was no immediate response from any crew member. (3124 ft, CAS 216 kts, Hdg 142.7, Pitch 15.3°, Roll 7.7° left)
  • At time 02:43:58, the Captain stated “Not yet”.(3320 ft, CAS 213.5 kts, Hdg 141.3°, Pitch 16.3°, Roll 6.6° left)
  • 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 (3392 ft, CAS 212 kts, Hdg 140.6°, Pitch 17.5°, Roll 6.6° left)
  • At time 02:44:00, the F/O stated “Autopilot in command sir”. (3468 ft, CAS 209.5 kts, Hdg 140.2°, Pitch 18.4°, Roll 6.6° left)
  • 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. (3624 ft, CAS 207 kts, Hdg 139.9°, Pitch 19.3°, Roll 5.6° left)
  • During this time, an increase in pitch and decay in airspeed were observed
  • At time 02:44:05, the Captain requested heading select. (3880 ft, CAS 203 kts, Hdg 139.5°, Pitch 20.5°, Roll 0.0° left)
  • 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. (4056 ft, CAS 199 kts, Hdg 139.5°, Pitch 19.8°, Roll 0.35° right)

Beginning at this time, the FDR of Flash Airlines flight FSH604 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. (4824 ft, CAS 186.5 kts, Hdg 149.4°, Pitch 15.4°, Roll 12.6° right)
  • 02 h 44 min 23 s, CAS 184,5 kts and will increase to the end of the flight,
  • 02 h 44 min 25 s, last recorded speed selected 220 kts,
  • 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 (5172 ft, CAS 186 kts, Hdg 160.6°, Pitch 13.3°, Roll 16.8° right)
  • 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 (5396 ft, CAS 192 kts, Hdg 174.7°, Pitch 11,7° Roll 23,5° right), last selected heading 84,9°)
Flash Airlines flight FSH604 - Boeing B737-300 (SU-ZCF)
Flash Airlines flight FSH604 – Boeing B737-300 (SU-ZCF)
  • At time 02:44:37, the Captain states – “how turning right” (5436 ft, CAS 195 kts, Hdg 179.6, Pitch 10.7°, Roll 27.7°)
  • At time 02:44:41, the Captain states “OK come out”. (5468 ft, CAS 202.5 kts, Hdg 194.7°, Pitch 6.5°, Roll 41.8° right) 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 43.2° at 2:44:40 to 41.8° at 2:44:41 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. (5432 ft, CAS 209.5 kts, Hdg 210.5°, Pitch 3.5°, Roll 53.0° right)

  • At time 02:44:46, the Captain again states “Autopilot”.
  • At time 02:44:48, the F/O states “Overbank, Overbank, Overbank”.(5276 ft, CAS 222 kts, Hdg 235.9°, Pitch 3.5° nose down, Roll 68.9° right).
  • 02 h 44 min 51 s, Master caution recorded,
  • At time 02:44:52.8, the F/O again states “Overbank”. (At 02:44:53, 4628 ft, CAS 254 kts, Hdg 265°, Pitch 25.14° nose down, Roll 91.4° right)
  • At time 02:44:53.4, the Captain responds “OK, come out”. • 02 h 44 min 54 s, aileron motion to the left during 9 s (4388 ft, CAS 264.5 kts, Hdg 270°, Pitch 29.7° nose down, Roll 95.2° right)
  • At time 02:44:56, the F/O states “No autopilot commander”.(3820 ft, CAS 289.5 kts, Hdg 277°, Pitch 37° nose down, Roll 103.0° right)
Flash Airlines flight FSH604 - Boeing B737-300 (SU-ZCF)
Flash Airlines flight FSH604 – Boeing B737-300 (SU-ZCF)
  • 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.(3068 ft, CAS 317.5 kts, Hdg 281°, Pitch 43.2° nose down, Roll 111° right)
  • 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.(Pitch 42.4° nose down, Roll 39.2° right)
  • At time 02:45:02, the CVR records the sound of the overspeed warning.(1320 ft, CAS 382.5 kts, Hdg 306.9°, Pitch 40.6° nose down, Roll 30.2° right)
  • Recovery from severe Right Bank and nose down pitch continued
  • At time 02:45:04.3, the captain states “Come out”. Bank angle was 15.6° right, pitch attitude was 30.5° nose down, altitude was 421 ft, and airspeed was 411.8 KIAS
  • At time 02:45:05, the CVR records a sound similar to ground proximity warning (180 ft, CAS 416 kts, heading 315.7°, pitch 25.4° nose down, right roll 19.3°),

A/C impacted the water at about 02:45:06 with last recorded data: – Bank Angle 19.3 to the right – Pitch Angle 25.4 Nose down – Vertical G. Load 3.96 (2.7) – Speed 416 Kts


Possible causes :

  • Trim/ Feel Unit Fault (Aileron Trim Runaway)
  • Temporarily, Spoiler wing cable jam (Spoiler offset of the neutral position)
  • Temporarily, F/O wheel jam (spoilers offset of the neutral position)
  • Autopilot Actuator Hardover Fault

Possible contributing factors :

  • A distraction developing to Spatial Disorientation (SD) until the time the F/O announced “A/C turning right“with acknowledgement of the captain.
  • Technical Log copies were kept on board with no copy left at departure station.
  • Operator write up of defects was not accurately performed and resulting in unclear knowledge of actual technical status
  • There are conflicting signals which make unclear whether the captain remained in SD or was the crew unable to perceive the cause that was creating an upset condition until the time when the F/O announced that there was no A/P in action.
  • After the time when the F/O announced “no A/P commander” the crew behavior suggests the recovery attempt was consistent with expected crew reaction, evidences show that the corrective action was initiated in full, however the gravity of the upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.

Additional findings:

  • The ECAA authorization for RAM B737 simulator was issued at a date later than the date of training for the accident crew although the inspection and acceptance test were carried out at an earlier date.
  • Several recorded FDR parameters were unreliable and could not be used for the investigation.

CONCLUSION

No conclusive evidence could be found from the findings gathered through this investigation to determine a 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 of the upset condition with regards to attitude, altitude and speed made this attempt insufficient to achieve a successful recovery.

 

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accident date: 03/01/2004
operator: Flash Airlines
make: Boeing
model: B737-300
registration: SU-ZCF
msn: 26283
location: Red Sea, Sharm El Sheik, Egypt
flight number: FSH604

Category: Aviation Accident

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