How the Dots Connected at Helios

Investigations into the August 2005 crash of a Helios 737-300 have been completed and finding revealed (ATW). Once again we find that is was not single large fatal error but a collection of small things that led to a tragedy, the dots have once again been connected.

Boeing: "ineffectiveness of measures taken by the manufacturer in response to previous pressurization incidents in the particular type of aircraft."

Helios, now Ajet Airways: found to have "deficiencies in...quality management and safety culture."

Helios Maintenance: "Maintenance workers were at fault for failing to return the pressurization mode selector to the "auto" position after performing nonscheduled maintenance.

Helios Pilots: "not recognizing the cabin pressurization switch's incorrect setting before takeoff

Helios Pilots: ""nonidentification" of warnings once the plane was airborne"

Dot to dot to dot...the crew passes out from hypoxia due to the lack of pressurization on the aircraft and after 90 minutes on auto pilot, fuel exhausted, the engines flamed out. The aircraft descended rapidly and crashed into hilly terrain just 33 km from Athens Airport killing all 121 people on board.
So there they are, the dots connected and the accident happens. According to the report new policy and procedures in place but it sounds like a corporate culture needs to change too. It bears repeating: the little things matter.