Extract Watts Book Re CVRs | Aviation Safety | Aviation

17

The Historyof FlightSA2s5
On 27 November1987Flight SA295was scheduled deparifrom to T ; i o e i s C h i " n g K a . S h p k A i r f n r t " t t J : 0 0l o r P l a i . a n c ;A i r p o r t . Maudtius,on a scheduled international flight.Adverseweatherand l l - pl . r t p r r i v d o ' a c o n n p u t i n g ' r rd " lta y p d " p a , r u r"e d t h p" i r " . "h n crafttook off an hour and 23minuLes late.On boardwere149 000 ka n ' ' U e l . 4 1 2 " l q n f o " g g " g e n dc a r g o . 4 0 " r . o n g o . 'a n d " c r " r ^ 2 a 1 p of five flight crew membersand 14 cabin crew members. The calculated flight time was 10hours:14 minutes. Take off was normalin all respects for thefirst few hoursof theflight routinecommuniand cationswere madewith Hong Kong radar and flight information c€niresat Hong Kong, Bangkok,Kuala Lumpur, Colonbo, Cocos l. anrls nd M"uritrus. r At 15:5 5:18 roulinereportwas madeto Springbok a fohannesburg RadioStationIcodename ZUR],the international radio commLrnicationscentre adjacent SAA'Sbaseai Ian SmutsAirport. The flight lo cre\,v confirm€d ZUR their take off from Taipeiat 14:23, to ihaLthe Heiderberg r,r'asflying at flight lev€l 310 and that arrival time at Maurilius r'las estimaiedat 00:35. ZUR's radio oDerator informed F r i ; n l A 2 q h h a l h es , l e r l i r , p , l i n g . 1 . . r nl S t L C A L l .. j ! \ h i ,h t 5 "l lhe radiostationcouldcall an individualaircraft, was unserviceable and requested flighl crew call at 18:00. a

THE MISSING ZURTAPE
ZUR cam€underheavyfire duringthe publicheafing the Board ot of lnquiry into the Helderbefg accideni. was qLrestioned its It on failurc to contactthe Heiderbergh'henth€ llighl crer'\'had made not th€ ZUR requ€sted at 18:00, the lossof ihe ZUR tapeh'hich call on rvould have recorded communicationbetween ZUR and the Helderberg alsoon log entries. and Evidencewas given bir Eliennedu Toil, Communications Offi.er purpose at ZUR, $'ho explained that ZUR'S was'. . . to assistour aircraft, including any otherjnternational aircraflon the domestic positionreporlsand and int€rnational routes,r\ith taking do\,\,n also1oassist iftherearean-vtechnical snags thai wecouldpossibl-v pass onlo engin€ering, anythineto assjstthesepeople.The and SELCAL syslem, t€stified Toit,hadbeen ol opefation two Du out tor

accidentA log bookas $e as rrceksat ihe lime of the Iieidr:rberg

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tu*t" 6a,l'gone HelLlerLerr sF!",:h-ou' ,q':" "'
conlronted Du Toit \'vilh '

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a

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ion that lhere \!as a

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c.oss.:xanlnairon rhe €nsuins ir"" *","-.""".i"J r'r""aisapPeafed

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i'l;., in ol ^ i,." il ^i it r'".r r-g" llumber eniries it e\cludinsrhe
r e t e f e n c el o L h i s r i o n v e r s a i i o n , !DuT'|'r 'r' rl r r p , l r ' r ' ,r| ' p r h ' 'n'it

sir' forser' n,, i";" o"" *-'ra l"!e rob{ian aNlullvsi'od

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Lr ihrt 0oNeci? '.' l)rLh C 'LrPct.

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"r'-'ta i r l i n e s i o u s l i r e r f v",,k r r s or,* a.*t""'*""e'r'hi''iJ;iiliii,:ii:;l; l: iher as
" 'l':rrr' , ' r ' " . " , ' i r ' ' . " t ' " ' r ' ' ' L o r r rl -

(-'hoifllrdriWhrl is vour ans\teri

1 q _

Dick Well I did not do that, sir. As I said I approached the Duly Offic€r. Soutlwoodj Thatis what you should havedone immedlalely. Dick: Yes, lrut I did not do that. Southwood: And someone-anda half to two hours later we have a repealof this scenario, thar no communicarion is In cross examinationAdvocate C.E.Puokdn. SC, appearingon behalf of SAA, madea clearer definition the drguments of which Ad vocate Southwood had beenaitemptins lead.Puckrinsaid that to Southwoodwas arguingthat the Hclde.berghad in facl calledZUR to enquire to the nalureofthe cargoin thEhold.ZLIR,saidPuckas fin, did not hold flight cargo lisis bul radio operatorDick did conlirm that the Dut)' Officercouldhavehad access those'.. . to a malterof metres. .'away. . The same log book of that particular night carried entries with intervals of far mor€ than two hours lrom other SAA flights. te fohannes Roux,Duty Otticerat ZUR who oameon duty aL17:00 on 28 November, thentestifi€d that h€removed bothrapes (Number '1. which recorded SA2S5's deparlure from Taipei,and Number2l for safestoragelapes are kepLlor 30 days beloferc usel.These tapes, said Le Roux,were handedoverto Connie Booysen. SAA'S Assistanr Manager:Flight Opefations and in chargeof Communicationson his request. The tapeswere eveniually impounded by DCA. Two weeks afterwardsBoovseniold Le Roux ihat iape Number 2 ion which the communicationbetween the Heiderberg and ZUR would have beenrecordedlwas ihe wrons tape and had beenplacedin lhe wrong numbered container and was therefore Iong sinceused for re recording.This happeneddespitea complex inlormation recofdinB card systematLached eachtapeand conto The protracted cfoss examination oam€ anendwhenAdvocaie to Soulhwood urgcdLhe Chairman andmembers ofthe Board'.. . thai this line of examination cometo an end . . .' and staiedthar anv possible link to ihe.ause of the accident was'tenuousio say rhe 1 " J " .1. . . l u . l : F C p r V . - r u g a r e h . s p r n m p p r m r \ . i n r . t ,

_20

At about 22:23Captain Uys calledMaLritius Air Traffic Control and advisedthat position the ofhis aircraftwouldbe070o EastandFlisht L p v e l3 5 0 \ 4 i l h i ns i x m i n u t e sH e q a v ea l u r r h e ri n d i L d t i o o l i h e . n flight's progress by informing Air lraffic Control that the Heiderberg would rcach position 0650East at 23::t2. confiroed that He positionprogress 23113t27,minute and 27 seconds at a bevondthe e s l i m " l e di m p .A s i t c a nb ea c c e p l etd a t t h ea i r c r a f w . s o n t r a c k . l h l givenas065o theposiiion Eastwould havebeen atlatitude15040,12,, South 6nd position 0600East at latitude 18057'54" South.

Fligit poth of ihe Helderberg,tie route whicfi S AA..rirctofrfly frcm"toipei, Republicol Ciina, to JonSmuts Airport. TheHetd€rbergirod compleiedthe Iorgestsiretci ol tie jou.ney wfien it plungcd inlo the Indion Oceonno.ih eostof Mouririus (Adapted from ihe Citizenl

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The Stena Workhorse, o lorge moto. vesseldesignedto support offshore o lield work, wos ihe mothership which suppo ed the ROV operoiion dnring the searci ond recove.yphose.Its largeo penfit wo*deck wos ideal for the temponry stowogeof debris brought to ,he deck by lour cronesAl

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'Jill

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IDCA]

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Routineradio transmissionsbetweenthe Helderbergand Mauritius ended at 23:-14. The nexi radio communicationwith plaisancewas " 1 , 2 ' l : 4 8 : \ \1- p nC a p t a i rU y s , a l l e dM d u r i t i u s i r T r a l i r rC o n . r o l , 5l A v \ h p r e i r l t d r l i r c o n l r o l l e\rd L o o bh n o d a b a , u s d \ o n d L l ! . T h e d w official Lranscriptionof the plaisance Air Traffic Controt Lipe as n r . s e n l p d y l h e D s p " 1 , m . r 'o l T r a n s p o , r o t h F B o a r d l l n o u i r \ b o M R U d e n o r i n gy ' a u r i t i La r d 2 9 5 d p n o t i n g h e H . i d p ; b n , ; [!\irh \ s t cockpitlreadsas follows: TIME

SPEAKERRECORDEDINFORMATION
Eh, Mauritius, Springbok Two Nine Five. Springbok Two Nine Five,eh,good morning, eh, go ahead. Eh,goodmorning,we have.eh,a snoke,ehp,eh,problemand we're doingemergency descenl level one to five, eh. one four zero. Confirm you wish to descendto flight teveloneI0ur zero. Ya, we havealreadycommenced, eh, due to a smokeproblemin the aeroplane, Eh, Roger, you are clearto descend immediately to flight level one four
zefo,

23148:51 295 23:49:00 MRU 23:491O7 295

23:49:18 MRU 23:49:00 295 23:49:25 MRU 23:49:30 295 23:49140 MRU 23.49148 23:49.51 23i49i54 23:49:56 295 MRU 255 MRU

23:50:00 295 23:5O:O2 MRU 23t'OiM 295

Roger,we will appreciateif you can aleri,eh,fire, ehp,ehp,eh, eh. . . Do you wish to, eh,do you requesta full emergencv? O k a yJ o ek a n 1 ' y .. . v i r o n s . . . , Springbok Two Nine Five, Plaisance. Sorry,go ahead. Do you, eh,requesta full emerqencv pleasea full emergencv? Allirmative.that'sCharlieCharlie. Roger,I declarea full emergency, Roger. Thank you.

-22

.| 23:50r40 MRU 23:50i44 295 23:50:46 MRU 23i50:51 295 2 3 : 5 0 : 5 5 MRU Eh, go ahead.

J

Tuu Nine five, Plai:am4 Springbok dcc i"q-,t""t fou" u.t""t Position
and your DME dlsianca

23i51r00 295 23r51:02 MRU 2 3 : 5 1 : 0 92 9 5 23i51:12 MRU 2 3 : 5 1 : 1 52 9 5 23i51:18 MRU 23:52:19 MRU 23:52:30 MRU 23152t32 295 23i52:33 MRU 23:52:3ti 2 S 5 23t52t4l MRU 2 3 : 5 2 r 5 0295 MRU 231-12:52 00r01:34 2S5 00:01:3ti 295 00:01:45 295 00:01:57 295 00i02::10 295 00r02:14 295 00i02:25 295 00:02:38 295 00:02:4'l MRU 00:02i43 2 S 5 00:02:45 MRU

Sh,'ie hav"nt gottheDMEYeL a"tt'"1 ih, nog"" "nd -vout please. Eh,sayagain?
Your actualPosjtioni we Now we'velosi a lot of electrics' got anything on the aircralt haven't Eh, Roger,I declarea lull immediatelY. Affirmative Roger. Two Nine Eh, Springbok EchoTangoAlla ha\e an please? Two Nine Springbok Ya, Plaisance Do vou havean EchoTango Alfa Ph please? sance eh,zerozero.eh tsben t €e Ya.
Roqer, zero zero three zero' tltilt He-v loe, shr.rtdown the oxYgen

Soiry saYagainPlease transmrssron'l lUnintelliEiblc transmrssron l lUnintelligible transmlsslon l lUnintelhgible l t ea n s m i s s i o n r lUninlelligjbl trdnsmrssLon l lUninlelligibl€ transmissionl iUnint€lligible """'9' [Carrierwave onty.]. - o Niaf

*, l::ii,*. i';1"::,\i:1''\i: I
s.]Y-dgarn againplease, . Were now si\l\ tive mlles' Confirm sixtYfive miles'

;"":'sp;i;cbok rrr

23

OO:02i47 295 00rLl2:5{l MRU

Ya, affirmativeCharlieCharlie. Eh, Roger, Splingbokeh Two Nine Five,eh re you'rerecleared fiight level live zero.Recleared llight levelfive Roger, live zero. And, SplingbokTrvo Nine Five copy aclualu,eather Plaisance copy actual r,vealher Plaisance. wind oneone The zelo degrees zerofive knots.The visibility aboveonezerokilometres. Ancl w-" havea precipitation sightto th€ in north.Clouds, five oclasone six z€ro zero,on€octafive thousand feet. 'I emp€rature lv,'enty is two. two t\,vo. And the QNH onezeroone eightheclopascals, zero0neeightover, one R0ger, one zerooneeight, Affirmative,€h and bolh runwavs available you wish. if And Tra'o Nine Five,I request pilot's lntenlr0n. Eh rve'dlike to track in eh,on eh one three. Confirmrunway on-"four. CharlieCharlie. Affirmative and you'recleared, eh dir'€ct FoxtrotFoxlrot.You report to approaching zero. five Ka-r. T$,o Nine Five,Plaisance. Springbok T!vo Nine Fiv€,Plaisance. Springbok Trvo Nin""Five,Plaisance.

00:02:58 2 9 5 {J{Ji03:Uu ]\,IRU

0{l:03:28 2 9 5 U0:0:l:ll1 MRU 00i03:43 N,IRL] 00:03:4ti 2 9 5 00:0ll:51 MRU 0{l:03:5,1 295 {10:0llr5fi N,1RL]

00r0,1r02 00r08r00 00:08r11 00r08:35

255 MRU MRU \IRU

Additionalhistoryof the llight tas r.etrie,.'ed the miraculously from .e(jovefed CockpitVoiceRecofder Onlv lhelast 1 minuteand lCVRl. 14seconds thc 30minuter-"cording of cycleof theCVRn'hichfe{rords cockpil (ionversation lr,as reasonablvclear.. Sullicient data '"vas recover""d duringthc analysis the CVR tapeto determin€ ol that ihe

-24

priorto the souldingofthe smokewarningbeli cockpitcolversation 'Joe', to referred in thetranscripiion' topicsonly. had 6eenon generai was the senlor flight-engineet Guiseppe Michele Bellagarda The by aspresented againtheolficialversion cript is once followingtrans the Boardof InquirY: DCA to

TIMEIN AND MINi]TES SECONDS FROM START OFTAPE ORIGIN
2813'I 28:35 28:36 28:37 28..40 28142 28145 28:46 28148 28149 28i52 28157 29:O1 291O2 29:05 29:08 29:09 29:11 29i12

CONVERSATION/REMARKS

Fire alarm a]mostimmediately.l bell IStopped lntercom chime What'sgoingon now? Ioe Huh? ! Cargo? Joe It cameon afierwards. loe IStrongclick sound.] And where is ihat? ? (Clicksound.l ? Iust to the right. Ioe Say again[?]. ! Main deckcargo. Ioe Then the otheronecameon as well. loe I've got two, the ShallI lget/push] [bottle/button] Ioe overthere? la, Leesvir ons die checklist daar hoor' Captain click sound.] IDouble Die buik [?] se lig is af [?]. ? Huh. [Two click sounds.) main deckcargolight Checkiist ? Captain Ja. can be heard Isoundsof movement with clicks and clunks.l

2i

2g:33 29r36 29:38 29:40 29t41 29tA 29146 29:5'I 29t52

Captain

[CURSE]dis die feit dat altweeaangekomhet - dit sleurmens.

Intercom chime [Whi]ecapiainis speakins.J ? Aag shit. ||I [800Hz Test Tonesigna] commences,l Captain Wat de donnergaannou aan? toneof voice.J {Saidin a surprised loud sound.l {Sudden (Largeand rapid changesin amplitude of test tonestarts.J (Endof test signal,very irregular nearend.l IEnd of recording.]

According ihe 30-minute to cyclecockpitvoicerecording which had no timecoding, muchof thefirst 28 minuteperiod was uninte)ligible. TwenLy-eight minutesand 30 seconds after commencement lhe of recording cycle,the smokewarning bell sounded. probSomebody, ably lhe piloi,inquiredwhereit was from and received replv that the i ' r . a m er o m i h p m a i r d c rl . , a r 8 o T h en i l o rt h e n s k e d o r t h r , h p 'k l . a f list to be read.Some30 seconds later somebodv the flipht deck on urlcrpd n o;th.Thisword was lolluv\"d \ th; LVR 800"H2 esl " b T Tone and endedin a warble at 29 minutes52 seconds after commencement the recording. is assumed of It that the recorded cockpit conversation had commenced very shortlv after communication with Plaisance 23:14:00 endedshortlv after the communica ai and l i o n w i l h M aLf i l i u sA i r T r al l i ' . C o rt r L ,d , 2 3 : 4 8 : 5 1 . l

THE'ALTERNATIVE' TAPETRANSCRIPTS
As had beenthe casewilh olher internaiional disasters, air lhe content andcorrectness oftransoripts ofthe Heldcfbcrg's CVRrape as well as the MauritiusAir'l'rallic Controltape wefe disputed. Olficial and non-otficial versionslvere debatedbeforc LheBoard of Inquiry.Readtogelher thoughpefhapsnot at all iimesvalid lhe transcripts in cfucialgapsin ihe historyof thedisasler fill flighi.

-

2Fj

formerlv with Dr Jansen, DCA contracted [Brigadier] l-eendert Lo privateconsultanl' and now a Laboratorl' S.ience lhe Forensic lapes He madeuse transcribeboih th€ CVR and Air Tfaffic Control 'machine' to of a self designe.l Ihis own modesi descriptionl] lt uses a computer-tvpememory to transcribe ihe CVR recording. ."ioin tn" lnfo.t"ation und is coupled to a tape recorderin such a go€s the the wav ihal lhe moment Stopbuttonis pressed, machine iranol mode of the past 4 seconds tape to faciLitat€ LepeaL into hiter exte.sive oompuier analysis synthesis m€thods an'i the filleringmethods computer lansenlinallv compl€ied transcrlpt ' as goodas one coLrl!l as th; .n.l;lescribed CVR transcripLion r n d ,I p r F o F d s o " n ' ' p l ' u l L h p o o s s i L 'e " r a "ur"'' "nd dtt" ' brn "o"", nern shi'h l'P o"'r'dl'o . p c o n . li n s h r \ n - u n d . r l i " . " ^ r o . " d ,rr "no " ..-..l ' " r o n r a , e s , h . ' o" . o s . o lw l ' r r h l ' " h a d r n d o u u r ' d b o u l l f o ' AirTfaffic Controltapehe madeuse ofthe Plaisance ihe transcripl \ o i o a L o m D u t p r. F r , ud h u m s . \ o ' o i n r o \ \ n h p l i r u r l l b P o f p n F B ' d r do l I n q L ' r \ t"n*n.:n,c,.'F\dmndr'on m i n i o n e o r l - "h e w a - , J - \ , n L F o nd " r e a n s d l " d . r | \ F d i l t P r F n l "-l \ r - r e nd D a ' l r o m ' \ " ' u l h F L " p l an d r d ' h " ' p n r " rI l i g h " n g i p b o n " " c i R r a p " . O n " o .h p s " r - r F d o F a r n p - r l h P o h " r \ $ F r p nol identifiable on commenls the ATC lapewas.thal interesling One of lansen's '. . . there'was llcwin:l in or out of the cockpitwjlh quile a loud air noise. .. il he [the caplain]had an orygen mask on thesenorse ' nol be as loud lon ihe tape]' wouLd sounds ot Durins lhe publicheafingof the tsoard lnquifv all ot the CVR wefe debated tapeaninot only the last l minuteand 1'1seconds r u d p l p d , vr \ P 5 ' u r h A f r i L d n L Vl lr,': " C"',tM".g".ir r"rpon"F ' u A i t \ d \ s P i l os q s s o , . " r i orn l " d n " r l h FC V R l r d n s r r i o a 1 u r e l vp ' c ' o n a l r r e ' r d r " . - n gi n , o ' . " i " n o a 1 n Fi - \ " . , i H d to n . n u d n o rL e n , d " p u L , l ' r . oI onlv plavedto lhe members The fulliecordingwas th€relorc was Boardand the transcript of lhe lasl 1 minule and 1il seconds the feadoui in DUblic the conversation'in ifanscfipt what DCA notedas unintellisible in upon bv Jansen his of the Air Traffic Control lape \aas amplified The recordinSson the Arr €videncebefor€ ihe Boatd of Inquirv. were generallv iraffic ContLoltape from 00:0ir34to 00r02:1'r to hive been intended for Maurilius but to be acceDtednot on uninienlionallransmissions the VHF channelintendedfol cockpitcommunication.

27_

s of conversation' Jansen interprelalion the unintelligible Iwhich DCA couldnot concurwilhl included: 00r01r34 295 Plaisance Springbok Two Nine Five, w€ ve openedih€ door to seeif we 0an : . . Prcssuretwelve Lhousand. . . . genoeg . . . and€rstekan ons vlLrg iF verongeluk. by as lTranslated Jansen '. . . is enough.. . otherwise could we havean a.cidenl. . .'.1
Dr Lecnd..t.ld,sen. o loferstc erpe.i, wos .r0ni.ocied 1o tr0ns.rribc ih.r..co.diDgs oI li.l cocApll vonxr fecorder 0no corvri.s-.orion e D tween tlre Hclde.bers fJjsi,r crew drd Ai. T.dlfic Contro/ or Pldj s a n . e A r r y r o d .A l t i r n r s Ils inlcrp.ctolion of c o n v e . s o l ( ) nc o n l l i c l e d wrri tie opi"iims ol

01r36r00 00:02:10 00:02::14

295 295 2S5

Y0(rx,b Klodocdbus wds ri. dn lrniini drnt(tl-". on dLrry 0r Plo; sonce arrporl wh.rn coni.rct rvas Josi r.1,ltl tld Hcld€.befs. He !r.rs l i . l d n p . f s o n t o s p e r k l o l i r cc r c r ' . I l . m j s j n l e i p f e t e dC o p t 0 i n U y s s comnlunnidlnD th.i the Hel.lerbers wos 65 nri/es Irun 'rs .exl cfieck poinlosh.jng 6i nllesi.om Mau.i lius. Tltr Helderberg wos ir loct ot ilot s10ge firll 1,lrl lril.s froJn 1Ie ft {Th{r Sta4

_28

In th€ statement of Ai. Traffic Controller Yacoob Khodacabus preseniedto the Board,additional commentarynot noted by Jansen was ins€rted, suchasl 23i52:51 00102127 295 295 I tell you pui down the oxygen ther€. l o e . . . q u i c k l y. . . w e a r e . . . ? t h o u s a n d . . . o n g e l u ka c c i d e n.t.]. [

As regardsthe CVR tape,Advocate SouthwoodsubmirtedJansen's tree'translationof the first 28 minutes of the CVR tape to the Board only. Som€of that commentary however did come to lighr in the public crossexamination AdvocateSoLrthwood fansenand by of may therefore published. be This included suchCVRcommenls asl
'11.22 '14102 14:05 74:14

.,.ons,.,andeas,, l...we...otherwise Who is going to cook? Th€y are coming to felch him at around midnight. This is a good thing if you tell him that.

Further input as regardsconversationrecordedon the Air Traffic Conlrol tape was made during the formal inquest by Roy Downes, DCA's lnvestigator: Operationall
00101:34 00:01:57 2S5 295

We. . . position. . . We shouldbe okay. switch up quickly. . . Joe,

The Helderbergcrashedinto the Indian Ocean at a position deter minedto be about19o10'S 5go3B'E roughlyai a point within and a triangle formed by theislands of Mauritius, Rodriquesand Carga dos/SiBrandon just after midnight,at about00:07.

17

The Historyof FlightSA2s5
On 27 November1987Flight SA295was scheduled deparifrom to T ; i o e i s C h i " n g K a . S h p k A i r f n r t " t t J : 0 0l o r P l a i . a n c ;A i r p o r t . Maudtius,on a scheduled international flight.Adverseweatherand l l - pl . r t p r r i v d o ' a c o n n p u t i n g ' r rd " lta y p d " p a , r u r"e d t h p" i r " . "h n crafttook off an hour and 23minuLes late.On boardwere149 000 ka n ' ' U e l . 4 1 2 " l q n f o " g g " g e n dc a r g o . 4 0 " r . o n g o . 'a n d " c r " r ^ 2 a 1 p of five flight crew membersand 14 cabin crew members. The calculated flight time was 10hours:14 minutes. Take off was normalin all respects for thefirst few hoursof theflight routinecommuniand cationswere madewith Hong Kong radar and flight information c€niresat Hong Kong, Bangkok,Kuala Lumpur, Colonbo, Cocos l. anrls nd M"uritrus. r At 15:5 5:18 roulinereportwas madeto Springbok a fohannesburg RadioStationIcodename ZUR],the international radio commLrnicationscentre adjacent SAA'Sbaseai Ian SmutsAirport. The flight lo cre\,v confirm€d ZUR their take off from Taipeiat 14:23, to ihaLthe Heiderberg r,r'asflying at flight lev€l 310 and that arrival time at Maurilius r'las estimaiedat 00:35. ZUR's radio oDerator informed F r i ; n l A 2 q h h a l h es , l e r l i r , p , l i n g . 1 . . r nl S t L C A L l .. j ! \ h i ,h t 5 "l lhe radiostationcouldcall an individualaircraft, was unserviceable and requested flighl crew call at 18:00. a

THE MISSING ZURTAPE
ZUR cam€underheavyfire duringthe publicheafing the Board ot of lnquiry into the Helderbefg accideni. was qLrestioned its It on failurc to contactthe Heiderbergh'henth€ llighl crer'\'had made not th€ ZUR requ€sted at 18:00, the lossof ihe ZUR tapeh'hich call on rvould have recorded communicationbetween ZUR and the Helderberg alsoon log entries. and Evidencewas given bir Eliennedu Toil, Communications Offi.er purpose at ZUR, $'ho explained that ZUR'S was'. . . to assistour aircraft, including any otherjnternational aircraflon the domestic positionreporlsand and int€rnational routes,r\ith taking do\,\,n also1oassist iftherearean-vtechnical snags thai wecouldpossibl-v pass onlo engin€ering, anythineto assjstthesepeople.The and SELCAL syslem, t€stified Toit,hadbeen ol opefation two Du out tor

accidentA log bookas $e as rrceksat ihe lime of the Iieidr:rberg

;",'j;il;;; ;;;l;;" "i"irzui "o"*'"r""yli:,1':,\:pJ"I':: ',"r,:::., '".,'f-:-'fl "'r'': ;; ,'' ;: '";'ir' , ''-"'''" , , ' ' n so , \ " I .Ll,,h:lr,i: d,'o.h" '
; J , ; ' + ; " " : ; : i:l : p , . - ; . , ; ;
tu*t" 6a,l'gone HelLlerLerr sF!",:h-ou' ,q':" "'
conlronted Du Toit \'vilh '

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a

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ion that lhere \!as a

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c.oss.:xanlnairon rhe €nsuins ir"" *","-.""".i"J r'r""aisapPeafed

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i'l;., in ol ^ i,." il ^i it r'".r r-g" llumber eniries it e\cludinsrhe
r e t e f e n c el o L h i s r i o n v e r s a i i o n , !DuT'|'r 'r' rl r r p , l r ' r ' ,r| ' p r h ' 'n'it

sir' forser' n,, i";" o"" *-'ra l"!e rob{ian aNlullvsi'od

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(-'hoifllrdriWhrl is vour ans\teri

_20

At about 22:23Captain Uys calledMaLritius Air Traffic Control and advisedthat position the ofhis aircraftwouldbe070o EastandFlisht L p v e l3 5 0 \ 4 i l h i ns i x m i n u t e sH e q a v ea l u r r h e ri n d i L d t i o o l i h e . n flight's progress by informing Air lraffic Control that the Heiderberg would rcach position 0650East at 23::t2. confiroed that He positionprogress 23113t27,minute and 27 seconds at a bevondthe e s l i m " l e di m p .A s i t c a nb ea c c e p l etd a t t h ea i r c r a f w . s o n t r a c k . l h l givenas065o theposiiion Eastwould havebeen atlatitude15040,12,, South 6nd position 0600East at latitude 18057'54" South.

Fligit poth of ihe Helderberg,tie route whicfi S AA..rirctofrfly frcm"toipei, Republicol Ciina, to JonSmuts Airport. TheHetd€rbergirod compleiedthe Iorgestsiretci ol tie jou.ney wfien it plungcd inlo the Indion Oceonno.ih eostof Mouririus (Adapted from ihe Citizenl

rrF

W.d

, !!-. : ;,

The Stena Workhorse, o lorge moto. vesseldesignedto support offshore o lield work, wos ihe mothership which suppo ed the ROV operoiion dnring the searci ond recove.yphose.Its largeo penfit wo*deck wos ideal for the temponry stowogeof debris brought to ,he deck by lour cronesAl

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'Jill

T r , - P n . \ b - n r l p p t a J " d , o n .I / . ( F ' l d V l o ^ r i r - p . L r p D \l , t n " t . t I . t^ L\alt,n d 4 , 0 r- d . r ' , J - e o b r . u t d a u n . o t L - d u , . . t n er c , n ,e 6 p " y , . 6 " 6 r , . 1 , .p , , 1 r j

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IDCA]

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Routineradio transmissionsbetweenthe Helderbergand Mauritius ended at 23:-14. The nexi radio communicationwith plaisancewas " 1 , 2 ' l : 4 8 : \ \1- p nC a p t a i rU y s , a l l e dM d u r i t i u s i r T r a l i r rC o n . r o l , 5l A v \ h p r e i r l t d r l i r c o n l r o l l e\rd L o o bh n o d a b a , u s d \ o n d L l ! . T h e d w official Lranscriptionof the plaisance Air Traffic Controt Lipe as n r . s e n l p d y l h e D s p " 1 , m . r 'o l T r a n s p o , r o t h F B o a r d l l n o u i r \ b o M R U d e n o r i n gy ' a u r i t i La r d 2 9 5 d p n o t i n g h e H . i d p ; b n , ; [!\irh \ s t cockpitlreadsas follows: TIME

SPEAKERRECORDEDINFORMATION
Eh, Mauritius, Springbok Two Nine Five. Springbok Two Nine Five,eh,good morning, eh, go ahead. Eh,goodmorning,we have.eh,a snoke,ehp,eh,problemand we're doingemergency descenl level one to five, eh. one four zero. Confirm you wish to descendto flight teveloneI0ur zero. Ya, we havealreadycommenced, eh, due to a smokeproblemin the aeroplane, Eh, Roger, you are clearto descend immediately to flight level one four
zefo,

23148:51 295 23:49:00 MRU 23:491O7 295

23:49:18 MRU 23:49:00 295 23:49:25 MRU 23:49:30 295 23:49140 MRU 23.49148 23:49.51 23i49i54 23:49:56 295 MRU 255 MRU

23:50:00 295 23:5O:O2 MRU 23t'OiM 295

Roger,we will appreciateif you can aleri,eh,fire, ehp,ehp,eh, eh. . . Do you wish to, eh,do you requesta full emergencv? O k a yJ o ek a n 1 ' y .. . v i r o n s . . . , Springbok Two Nine Five, Plaisance. Sorry,go ahead. Do you, eh,requesta full emerqencv pleasea full emergencv? Allirmative.that'sCharlieCharlie. Roger,I declarea full emergency, Roger. Thank you.

-22

.| 23:50r40 MRU 23:50i44 295 23:50:46 MRU 23i50:51 295 2 3 : 5 0 : 5 5 MRU Eh, go ahead.

J

Tuu Nine five, Plai:am4 Springbok dcc i"q-,t""t fou" u.t""t Position
and your DME dlsianca

23i51r00 295 23r51:02 MRU 2 3 : 5 1 : 0 92 9 5 23i51:12 MRU 2 3 : 5 1 : 1 52 9 5 23i51:18 MRU 23:52:19 MRU 23:52:30 MRU 23152t32 295 23i52:33 MRU 23:52:3ti 2 S 5 23t52t4l MRU 2 3 : 5 2 r 5 0295 MRU 231-12:52 00r01:34 2S5 00:01:3ti 295 00:01:45 295 00:01:57 295 00i02::10 295 00r02:14 295 00i02:25 295 00:02:38 295 00:02:4'l MRU 00:02i43 2 S 5 00:02:45 MRU

Sh,'ie hav"nt gottheDMEYeL a"tt'"1 ih, nog"" "nd -vout please. Eh,sayagain?
Your actualPosjtioni we Now we'velosi a lot of electrics' got anything on the aircralt haven't Eh, Roger,I declarea lull immediatelY. Affirmative Roger. Two Nine Eh, Springbok EchoTangoAlla ha\e an please? Two Nine Springbok Ya, Plaisance Do vou havean EchoTango Alfa Ph please? sance eh,zerozero.eh tsben t €e Ya.
Roqer, zero zero three zero' tltilt He-v loe, shr.rtdown the oxYgen

Soiry saYagainPlease transmrssron'l lUnintelliEiblc transmrssron l lUnintelligible transmlsslon l lUnintelhgible l t ea n s m i s s i o n r lUninlelligjbl trdnsmrssLon l lUninlelligibl€ transmissionl iUnint€lligible """'9' [Carrierwave onty.]. - o Niaf

*, l::ii,*. i';1"::,\i:1''\i: I
s.]Y-dgarn againplease, . Were now si\l\ tive mlles' Confirm sixtYfive miles'

;"":'sp;i;cbok rrr

23

OO:02i47 295 00rLl2:5{l MRU

Ya, affirmativeCharlieCharlie. Eh, Roger, Splingbokeh Two Nine Five,eh re you'rerecleared fiight level live zero.Recleared llight levelfive Roger, live zero. And, SplingbokTrvo Nine Five copy aclualu,eather Plaisance copy actual r,vealher Plaisance. wind oneone The zelo degrees zerofive knots.The visibility aboveonezerokilometres. Ancl w-" havea precipitation sightto th€ in north.Clouds, five oclasone six z€ro zero,on€octafive thousand feet. 'I emp€rature lv,'enty is two. two t\,vo. And the QNH onezeroone eightheclopascals, zero0neeightover, one R0ger, one zerooneeight, Affirmative,€h and bolh runwavs available you wish. if And Tra'o Nine Five,I request pilot's lntenlr0n. Eh rve'dlike to track in eh,on eh one three. Confirmrunway on-"four. CharlieCharlie. Affirmative and you'recleared, eh dir'€ct FoxtrotFoxlrot.You report to approaching zero. five Ka-r. T$,o Nine Five,Plaisance. Springbok T!vo Nine Fiv€,Plaisance. Springbok Trvo Nin""Five,Plaisance.

00:02:58 2 9 5 {J{Ji03:Uu ]\,IRU

0{l:03:28 2 9 5 U0:0:l:ll1 MRU 00i03:43 N,IRL] 00:03:4ti 2 9 5 00:0ll:51 MRU 0{l:03:5,1 295 {10:0llr5fi N,1RL]

00r0,1r02 00r08r00 00:08r11 00r08:35

255 MRU MRU \IRU

Additionalhistoryof the llight tas r.etrie,.'ed the miraculously from .e(jovefed CockpitVoiceRecofder Onlv lhelast 1 minuteand lCVRl. 14seconds thc 30minuter-"cording of cycleof theCVRn'hichfe{rords cockpil (ionversation lr,as reasonablvclear.. Sullicient data '"vas recover""d duringthc analysis the CVR tapeto determin€ ol that ihe

-24

priorto the souldingofthe smokewarningbeli cockpitcolversation 'Joe', to referred in thetranscripiion' topicsonly. had 6eenon generai was the senlor flight-engineet Guiseppe Michele Bellagarda The by aspresented againtheolficialversion cript is once followingtrans the Boardof InquirY: DCA to

TIMEIN AND MINi]TES SECONDS FROM START OFTAPE ORIGIN
2813'I 28:35 28:36 28:37 28..40 28142 28145 28:46 28148 28149 28i52 28157 29:O1 291O2 29:05 29:08 29:09 29:11 29i12

CONVERSATION/REMARKS

Fire alarm a]mostimmediately.l bell IStopped lntercom chime What'sgoingon now? Ioe Huh? ! Cargo? Joe It cameon afierwards. loe IStrongclick sound.] And where is ihat? ? (Clicksound.l ? Iust to the right. Ioe Say again[?]. ! Main deckcargo. Ioe Then the otheronecameon as well. loe I've got two, the ShallI lget/push] [bottle/button] Ioe overthere? la, Leesvir ons die checklist daar hoor' Captain click sound.] IDouble Die buik [?] se lig is af [?]. ? Huh. [Two click sounds.) main deckcargolight Checkiist ? Captain Ja. can be heard Isoundsof movement with clicks and clunks.l

2i

2g:33 29r36 29:38 29:40 29t41 29tA 29146 29:5'I 29t52

Captain

[CURSE]dis die feit dat altweeaangekomhet - dit sleurmens.

Intercom chime [Whi]ecapiainis speakins.J ? Aag shit. ||I [800Hz Test Tonesigna] commences,l Captain Wat de donnergaannou aan? toneof voice.J {Saidin a surprised loud sound.l {Sudden (Largeand rapid changesin amplitude of test tonestarts.J (Endof test signal,very irregular nearend.l IEnd of recording.]

According ihe 30-minute to cyclecockpitvoicerecording which had no timecoding, muchof thefirst 28 minuteperiod was uninte)ligible. TwenLy-eight minutesand 30 seconds after commencement lhe of recording cycle,the smokewarning bell sounded. probSomebody, ably lhe piloi,inquiredwhereit was from and received replv that the i ' r . a m er o m i h p m a i r d c rl . , a r 8 o T h en i l o rt h e n s k e d o r t h r , h p 'k l . a f list to be read.Some30 seconds later somebodv the flipht deck on urlcrpd n o;th.Thisword was lolluv\"d \ th; LVR 800"H2 esl " b T Tone and endedin a warble at 29 minutes52 seconds after commencement the recording. is assumed of It that the recorded cockpit conversation had commenced very shortlv after communication with Plaisance 23:14:00 endedshortlv after the communica ai and l i o n w i l h M aLf i l i u sA i r T r al l i ' . C o rt r L ,d , 2 3 : 4 8 : 5 1 . l

THE'ALTERNATIVE' TAPETRANSCRIPTS
As had beenthe casewilh olher internaiional disasters, air lhe content andcorrectness oftransoripts ofthe Heldcfbcrg's CVRrape as well as the MauritiusAir'l'rallic Controltape wefe disputed. Olficial and non-otficial versionslvere debatedbeforc LheBoard of Inquiry.Readtogelher thoughpefhapsnot at all iimesvalid lhe transcripts in cfucialgapsin ihe historyof thedisasler fill flighi.

-

2Fj

formerlv with Dr Jansen, DCA contracted [Brigadier] l-eendert Lo privateconsultanl' and now a Laboratorl' S.ience lhe Forensic lapes He madeuse transcribeboih th€ CVR and Air Tfaffic Control 'machine' to of a self designe.l Ihis own modesi descriptionl] lt uses a computer-tvpememory to transcribe ihe CVR recording. ."ioin tn" lnfo.t"ation und is coupled to a tape recorderin such a go€s the the wav ihal lhe moment Stopbuttonis pressed, machine iranol mode of the past 4 seconds tape to faciLitat€ LepeaL into hiter exte.sive oompuier analysis synthesis m€thods an'i the filleringmethods computer lansenlinallv compl€ied transcrlpt ' as goodas one coLrl!l as th; .n.l;lescribed CVR transcripLion r n d ,I p r F o F d s o " n ' ' p l ' u l L h p o o s s i L 'e " r a "ur"'' "nd dtt" ' brn "o"", nern shi'h l'P o"'r'dl'o . p c o n . li n s h r \ n - u n d . r l i " . " ^ r o . " d ,rr "no " ..-..l ' " r o n r a , e s , h . ' o" . o s . o lw l ' r r h l ' " h a d r n d o u u r ' d b o u l l f o ' AirTfaffic Controltapehe madeuse ofthe Plaisance ihe transcripl \ o i o a L o m D u t p r. F r , ud h u m s . \ o ' o i n r o \ \ n h p l i r u r l l b P o f p n F B ' d r do l I n q L ' r \ t"n*n.:n,c,.'F\dmndr'on m i n i o n e o r l - "h e w a - , J - \ , n L F o nd " r e a n s d l " d . r | \ F d i l t P r F n l "-l \ r - r e nd D a ' l r o m ' \ " ' u l h F L " p l an d r d ' h " ' p n r " rI l i g h " n g i p b o n " " c i R r a p " . O n " o .h p s " r - r F d o F a r n p - r l h P o h " r \ $ F r p nol identifiable on commenls the ATC lapewas.thal interesling One of lansen's '. . . there'was llcwin:l in or out of the cockpitwjlh quile a loud air noise. .. il he [the caplain]had an orygen mask on thesenorse ' nol be as loud lon ihe tape]' wouLd sounds ot Durins lhe publicheafingof the tsoard lnquifv all ot the CVR wefe debated tapeaninot only the last l minuteand 1'1seconds r u d p l p d , vr \ P 5 ' u r h A f r i L d n L Vl lr,': " C"',tM".g".ir r"rpon"F ' u A i t \ d \ s P i l os q s s o , . " r i orn l " d n " r l h FC V R l r d n s r r i o a 1 u r e l vp ' c ' o n a l r r e ' r d r " . - n gi n , o ' . " i " n o a 1 n Fi - \ " . , i H d to n . n u d n o rL e n , d " p u L , l ' r . oI onlv plavedto lhe members The fulliecordingwas th€relorc was Boardand the transcript of lhe lasl 1 minule and 1il seconds the feadoui in DUblic the conversation'in ifanscfipt what DCA notedas unintellisible in upon bv Jansen his of the Air Traffic Control lape \aas amplified The recordinSson the Arr €videncebefor€ ihe Boatd of Inquirv. were generallv iraffic ContLoltape from 00:0ir34to 00r02:1'r to hive been intended for Maurilius but to be acceDtednot on uninienlionallransmissions the VHF channelintendedfol cockpitcommunication.

27_

s of conversation' Jansen interprelalion the unintelligible Iwhich DCA couldnot concurwilhl included: 00r01r34 295 Plaisance Springbok Two Nine Five, w€ ve openedih€ door to seeif we 0an : . . Prcssuretwelve Lhousand. . . . genoeg . . . and€rstekan ons vlLrg iF verongeluk. by as lTranslated Jansen '. . . is enough.. . otherwise could we havean a.cidenl. . .'.1
Dr Lecnd..t.ld,sen. o loferstc erpe.i, wos .r0ni.ocied 1o tr0ns.rribc ih.r..co.diDgs oI li.l cocApll vonxr fecorder 0no corvri.s-.orion e D tween tlre Hclde.bers fJjsi,r crew drd Ai. T.dlfic Contro/ or Pldj s a n . e A r r y r o d .A l t i r n r s Ils inlcrp.ctolion of c o n v e . s o l ( ) nc o n l l i c l e d wrri tie opi"iims ol

01r36r00 00:02:10 00:02::14

295 295 2S5

Y0(rx,b Klodocdbus wds ri. dn lrniini drnt(tl-". on dLrry 0r Plo; sonce arrporl wh.rn coni.rct rvas Josi r.1,ltl tld Hcld€.befs. He !r.rs l i . l d n p . f s o n t o s p e r k l o l i r cc r c r ' . I l . m j s j n l e i p f e t e dC o p t 0 i n U y s s comnlunnidlnD th.i the Hel.lerbers wos 65 nri/es Irun 'rs .exl cfieck poinlosh.jng 6i nllesi.om Mau.i lius. Tltr Helderberg wos ir loct ot ilot s10ge firll 1,lrl lril.s froJn 1Ie ft {Th{r Sta4

_28

In th€ statement of Ai. Traffic Controller Yacoob Khodacabus preseniedto the Board,additional commentarynot noted by Jansen was ins€rted, suchasl 23i52:51 00102127 295 295 I tell you pui down the oxygen ther€. l o e . . . q u i c k l y. . . w e a r e . . . ? t h o u s a n d . . . o n g e l u ka c c i d e n.t.]. [

As regardsthe CVR tape,Advocate SouthwoodsubmirtedJansen's tree'translationof the first 28 minutes of the CVR tape to the Board only. Som€of that commentary however did come to lighr in the public crossexamination AdvocateSoLrthwood fansenand by of may therefore published. be This included suchCVRcommenls asl
'11.22 '14102 14:05 74:14

.,.ons,.,andeas,, l...we...otherwise Who is going to cook? Th€y are coming to felch him at around midnight. This is a good thing if you tell him that.

Further input as regardsconversationrecordedon the Air Traffic Conlrol tape was made during the formal inquest by Roy Downes, DCA's lnvestigator: Operationall
00101:34 00:01:57 2S5 295

We. . . position. . . We shouldbe okay. switch up quickly. . . Joe,

The Helderbergcrashedinto the Indian Ocean at a position deter minedto be about19o10'S 5go3B'E roughlyai a point within and a triangle formed by theislands of Mauritius, Rodriquesand Carga dos/SiBrandon just after midnight,at about00:07.

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