This Jumbo Jet CRASHED just after Takeoff, WHY?! Korean Air Cargo flight 8509

this video is brought to you together with blinkist click the link below in the description for your special deal it's the 22nd of december 1999. on runway 2-3 in london stansted airport a boeing 747-200 freighter from korean airlines is getting ready for a standard flight down towards milan malpensa airport onboard the aircraft are three flight crew members and one ground engineer only two minutes later this aircraft will find itself in a 90 degree bank to turn to the left and heading straight down towards the ground at close to 300 knots what has led to this now together let's retrace all of the steps that led up to this disaster as i've told you guys before an aircraft accident very rarely depends on only one action okay it is almost always a link of different events that if any of them would have been done differently well then the outcome would have been very very different and that is definitely the case in this story about korean airlines flight 8509 as well now in order for us to understand these chain of events that led up to this accident we need to go back to the flights that happened before the accident flight so the boeing 747 200 that was involved in this accident was 19 years old and on the same day the 22nd of december 1999 uh it had been flown from sealed to tashkent in uzbekistan it was loaned by a separate flight crew from seoul to tashkent and in tashkent there was a scheduled crew change um but really a quite quick turnaround where they just offloaded some some freight on loaded some new freight took more fuel and then the crew that was leaving the aircraft handed over the aircraft to the new flight crew now that's important because it's always nice as flight crew to be able to speak to the previous crew because if something has happened well then they will be able to tell you the kind of peculiarities of it but the previous flight going from civil had had no problems with the aircraft whatsoever so they handed over the aircraft and the new crew took over the aircraft and got ready to fly from tashkent up to london stansted um in target they used from with zero eight left and it was completely normal take off climbed up to one thousand feet the captain was departed flying for the for the leg and as the captain initiated his right hand turn something strange happened as the aircraft banged through about 15 degrees his attitude indicator as in his artificial horizon froze up it was still working perfectly in pitch but no matter how much he turned the aircraft the aptitude was still stuck at 15 degrees and he knew this because he could see outside it was daylight so he could see that the aircraft continued to bank he looked over at the first officers indicator and the standby indicator they all indicated that the bank continued to increase but his was stuck at 15 degrees when that happened they got something called a comparator warning signal this is an audio warning signal that goes off in the cockpit when a comparator that is comparing the information from the first officer side and the captain side indicates that there is a difference in bank of more than four degrees between the instrumentation for more than one second together with this audible signal there are also numerous lights indicating that something is wrong okay so the captain did what what he was supposed to do when he realized that his instrumentation wasn't working he handed over the controls to the first officer first officer took over he had perfectly working instrumentation continued to fly and the captain did the non-normal checklist that was associated with the problem now what you have to understand here is that the attitude indicators on both the captain and the first of the society the adi that's attitude director indicator they don't have any built-in gyros in the actual instrumentation the instrument is only working on input it gets from something called an inu an inertial navigational unit so in the 747 200 there are three inertial navigation units these are basically picture master gyro all right a big gyro that shows information in both pitch roll and also athema that's in heading that information is fed into a computer and it calculates things like for example ground speed it calculates position heading attitude role and things like that and that is being then fed into the adi okay so part of the non-normal checklist that the captain was performing here was he moved his source selector from normal which would be inu1 to alternate which is inu3 all right the captain has anu 1 first off there's anu 2 and the standby is inu inu3 and when he switched the source over to alternate the fault disappeared right the flags that was indicating there was something wrong retracted and they could reset the lights and there was no comparative warning anymore so this would indicate that there is a problem with the number one inu when this was sorted the captain took back controls he continued to fly and on his way to standstill they tried it a couple of times they switched over back to the normal source and every time they did that as the aircraft started turning they got the comparative warning back again and the same problem appeared so this was a kind of clear evidence that what they had was not a problem with the instrumentation as such it was a problem with the inertial navigation unit the aircraft flies to standstill lands normally in stansted and as they're taxiing in the flight engineer remember this is a 747 200 so it has a captain first officer and a flight engineer the flight engineer starts taking up the log book and enters the default code into the logbook now there is something called a fault reporting manual that they're using in korean airlines at the time and the ford reporting manual gives a code depending on what kind of fault you have right that code basically tells any engineer that takes over the logbook what you know what the exact fault is and the engineer can then use something called a fault isolation manual to see exactly what maintenance procedure needs to be done so let's talk a little bit about the maintenance available for korean airlines when they arrive to london stansted now when a company flies to an outstation as an away from their home base they need access to maintenance for simple tasks like walk around for example or changing oils and things like that that they can choose from either of three options either they have full own maintenance facilities available in all of their outstations that is basically their own engineers their own spare parts their own tooling everything like this obviously that is not practical and it's very expensive because a company might fly to a lot of different outstations the other thing they can do is they can contract in all of the maintenance they need from an external firm that might be a competitor airline or a maintenance organization that has access to all of these things that is not available in all places and also it's fairly expensive to write up contracts like that and the third option which is the most common is that they have their own maintenance representative a ground-based engineer that is either based in the outstation or follows the flights in and out of the stations and does the the kind of paperwork part right like signing off uh any snags that might be in the tech log or or those simple maintenance kind of work and then they contract in from any external maintenance from whatever manpower they need on the day all right that's very flexible and it's less expensive and it's the most common way of doing things and this is the way that korean airlines had done it in stansted so when this aircraft is now arriving on to stand with this particular fault the previous flight engineer has written down the code right he gets met up with the ground-based um representative from korean airlines and he tells him that listen we've had this problem the adi on the captain's side is unreliable and i've written the fault code in the tech log we dealt with it like this we switch from the normal source to the alternate source that seemed to sort the problem okay now remember how i said that there is what's called a fault isolation manual in which there is a specific maintenance procedure that needs to be followed right so it looks like on this day the ground representative engineer didn't have access to that film the vault isolation manual now he could have just called down to seal to ask him to send the manual or he could just confirm what the maintenance procedure was for this particular code but for some reason that didn't seem to happen instead he just heard there's a problem with the adi and he thought right in most cases problems with adi is just some kind of faulty connection with the wires into the actual instrumentation so i'm gonna do my best to fix that and outside of the aircraft at this point there has arrived another engineer that has been contracted in to do what i was talking about before you know doing the walk around replenishing oil and so on the korean airlines maintenance engineer asks this external engineer for tooling to remove the adi now there's no kind of reason for the external engineer to be questioning this in any way he hasn't been looking thoroughly onto the logbook he doesn't know what the reason for this is so he just basically does what he's tall he gets the tooling uh the adi is being removed and they find that it looks like one of the connectors is actually not very well fitted okay the korean airlines represented the things ah there we go that's the fault and another engineer is being called in that is actually allowed to be working on avionics on the instrumentation because you need a specific license for that in the uk now that engineer that comes in once again does not have any reason to believe that anything else needs to be done so he just fixes the connector connects the adi again puts it back into position does a self-test on the adi which works perfectly because remember a self-test on the adi is only designed to check that the actual kind of instrument is working perfectly it doesn't check that the information that's being fed from the inu is correct this self-test works out great the ground-based engineer thinks that okay we have sorted the problem he signs off the logbook so default looks like it has been fixed but it has not been fixed all right the same fault is still there but now it is hidden behind a logbook that looks like it has been sorted and here there's another mistake being made as well by icao standage every time that we write anything in the logbook we need to leave a copy of that logbook behind before we go right that is to make sure that if something happens to the aircraft there's a copy of the logbook so that the kind of maintenance actions that we've done and the much fuel we've uplifted and oil and so on there's records of that left behind on the ground in this case the ground-based engineer is actually going to fly with this flight down to milan de notte and he takes the whole logbook with him and does not leave a copy behind so we don't actually know exactly what he wrote in the logbook now this brings us to the pilots all right so remember how i told you that in the previous turnaround in tashkent the incoming crew had the chance to talk with the outgoing crew right in this case in stansted there was a much longer turnaround so the outgoing crew never got to talk with him going through so they never got to tell them that they've had this issue with the adi and how they had sold it instead the incoming crew is only faced with the logbook right and the logbook looks like whatever problem they had before it was instrumentation has now been sorted now pilot flying on the outgoing leg is going to be the captain the captain is a very senior captain in korean airlines he's 57 years old he's got about 8500 hours on the 747 and before he started with korean airlines he was a colonel in the korean air force on the other hand the first officer is a 33 year old who has just started flying the 747 right he was checked out about two and a half months earlier and he has only about 195 hours on type the flight engineer is 38 years old he is also quite senior he's got 4 500 hours on the 747 so it is a you know it's a mixed crew and why is this important well it is important because korean airlines at this time has already had some problem with what's called the cockpit authority gradient the cockpit authority gradient basically is a measurement of how much of a difference there is in perceived power in the flight deck so with a high gradient the captain is considered close to god and the first officer in flight engineer doesn't feel like they have anything to say against the captain so whatever the captain says goes no one questions it unless it's very serious as the cockpit gradient comes down you start to get a different type of dynamic in the cockpit right the first officer and the flight engineer will start to feel that not only can they tell off the captain they should if they see that something is wrong right and this is the optimum that you're going for when it comes to copy gradient you need to have a gradient as in everyone needs to know who's the responsible person and who actually takes the ultimate decision but everyone should feel encouraged to speak up when something is wrong if you have a flat copy gradient well then the cockpit work becomes very confusing you don't want that right but in this case the corporate gradient is still very high and they know that this is a problem because they've had accidents that happened before that has been traced towards this problem uh two years earlier there was another 747 crash uh that was korean airlines flight 801 where the captain made a series of very serious mistakes during a non-production approach and the first officer flight engineer did not tell him off right so korean airlines have already started working on crm programs but it is a slow process so in this flight deck you probably now have a dynamic where a very junior first officer is flying with a very senior captain who's ex-military and already there you have a potential for issues if something were to happen so the flight crew is getting ready to depart and they're working against schedule as always you know when you're in a cockpit you want to try to be on time and they want to be that as well so at time 1727 the first of the called up stansted delivery to ask for their atc clearance it doesn't get any answer right so he switches over to stansted ground instead and stanza ground tells them that they don't have a flight plan active for korean airline flight 8509 they need to contact their company and update their flight plan right they do so they contact the company and about 10 minutes later they call again and then they get their the clearance and the clearance is you're cleared to milan malpensa via dover six roamy departure score two two three zero right the dover departure is basically a climb out straight ahead and then a left turn down towards a vor beacon called dover so the crew now continues to get the aircraft ready for departure and at time 1806 they called stands the ground again and said that they're now ready for push and start stance the ground tells them that actually you have traffic behind you pushing now there's going to be a five minute delay before you can go so as you can see now there's starting to be some issues you know they've they didn't have a flight plan ready the they didn't get pushed back when they wanted so it's likely that there's a little bit of frustration being built up in the flight deck here on top of that when they actually get their push black clearance which is five minutes later they start pushing and in the middle of the pushback the pushback truck breaks down okay so now they're standing halfway between where they're supposed to go and where they started and that's a problem because the 747 is a big aircraft and you cannot just stop the push and kind of easily taxi away from there instead you're going to need a follow me car if you need to taxi out of that position so here's something really interesting happens because in the middle of this as the pushback truck breaks down the captain starts communicating not only with the pushback crew but also with atc all right remember before the first officer was the one making the atc called now the captain is making all of the calls and now i'm doing a little bit of speculation here but it is a possibility that the captain as he sees that things are starting to become complicated here instead of trying to tell the first officer who hasn't seen this before and who's not native english speaker instead of trying to tell him you're okay you need to tell them this so you need to ask for this the captain just takes over and does it all himself right and it's an indication that he doesn't really trust what the first officer is doing said and done 20 minutes later it takes a lot of time they get access to a follow me car the follow me car helps them out of the apron and they start taxing towards takeoff on runway 2-3 in london stansted now during the taxi out this frustration that the captain had is being shown right we have the cockpit voice recording and he is berating the first officer during the taxi out he starts by telling him off because he's not correcting how he's taxing basically the captain wants the first offer to speak up because he wasn't on the center line now you should tell me when i'm not on the centerline and he also complains about how he's doing his radio work things like this that is likely going to make this first officer who's very junior just feel smaller and smaller okay the captain also notices that he doesn't have a correct reading on his dme that's distance measuring equipment and it's basically needed because during the door six-room departure at one and a half miles from the departure runway they need to make a left-hand turn and if the dme reading is not correct he won't know when he's going to be turning okay and he's probably worried at this point because this is london if you don't do the departure correctly then you might get noise violations and noise fines all right so he talks about this and the flight engineer comes in and says here no it looks like it's fine now and they're also talking a little bit about the fact that normally the dme has incorrect readings on the ground but it sorts itself up once you're airborne so there's a little bit of discussions of this going on but curiously there's no discussion going on about the previous fault right there's no mentioning on the cvr about a threat briefing regarding that the previous crew that had problems with the adi nothing like that is being mentioned at time 1836 korean airlines flight 8509 received its take-off clearance runway 2-3 and london standstid surface wind was given as 190 degrees at 1 8 knot but it was also reported that there were some really strong winds only 2 000 feet above ground about 55 knots or so and this could indicate that the aircraft was about to climb into some quite moderate to severe turbulence the 747 started rolling down the runway and it rotated normally took off and for the first few seconds of the flight everything was normal the first officer called positive rate to which the captain responded gear up they started accelerating but at about 600 feet the first indication of something being wrong came the aircraft entered into an area of turbulence which meant that they started to rock a little bit left to right in roll that set off the first comparator warning remember that's the audible signal that indicates that there is a difference between the captain and first officer's adi of more than four degrees for more than one second yeah so that warning went off but there was no indication that anyone of the flight crew noticed it or talked about it in any way it stopped by itself probably because the aircraft came back in the wings level again but there would still be a warning light that the crew would have to reset anyway the aircraft continued to climb and this comparative awning actually came back a few more times before the aircraft initiated its left-hand turn towards dover never mind the captain didn't seem to worry too much about it he was more worried about the fact that he was still having problems reading his dme and he actually asked the first officer to confirm which distance they needed to turn and to which heading they were going to turn the first officer responded to it he checked his plate he called back to the captain the app at one and a half miles you need to initiate a turn left onto this heading at one and a half miles then the captain now tries to initiate the left-hand turn and the way that we do that is you put aileron into the left but even though his pitch was working perfectly as he was turning now there was no indication of a roll on his adi okay so he continued to put more and more alien into what left but nothing happened but as he was doing this the comparator warning comes on again this time it stays on right this is clearly indicating that something is wrong with the instrumentation the flight engineer who's hearing this warning now makes a couple of statements which are really important now these statements are translated from korean but the the first statement he's saying is basically the role is not accepting indicating that he is likely looking at the captain's adi and doesn't understand why the aircraft is not responding to the turn input but the second call who comes about five seconds later makes more sense this time he calls out bank bank which is the correct standard operating procedure call to make if someone realizes that the aircraft is banking more than 30 degrees okay so this would indicate that at this point the flight engineer is probably scanning the cockpit and looking at the standby horizon and also the adi for the first officer realizing that the bank is increasing more and more wanting to kind of draw the attention of the captain to this now the flight engineer makes two more call outs during the subsequent few seconds that's left of this flight the third one has been hard to translate but it's also indicating bank and it's it's it can be translated and understood as a way for the flight engineer to try to draw the attention of the captain towards the standby horizon and the last call that he's making also include the word bank but it's made in a very resigned voice as in he's now understanding what's about to happen so what's the first officer doing at this point well the first officer during the initial part of the flight is doing exactly what he should be doing as pilot monitoring he's doing his correct call out he is responding to the captain when the captain is asking about information about the departure plate and things like that but just as the turn is being initiated he is being contacted by stansted tower who tells him to change the frequency to stance the departure so as the crew is now initiating the turn the first officer would be looking back changing the frequency on his radio box and getting ready to make the call however that call never happens right the last ever transmission that was made to korean air flight 8509 was when stansted handed him over to departure the subsequent call never happens so after this the first officer must be focusing on something else right now his role as a pilot monitoring is to monitor the flight parameters if he sees that something is wrong as in an overbank condition or a dangerous condition in any kind his job is to call that out to the captain to make the captain aware and potentially even to take over the control if nothing happens but none of this seems to have happened there's no indication of the cockpit voice recorder of the first officer saying anything even though his adi is working perfectly he would be seeing straight in front of him how the aircraft is increasing his bank angle to 30 degrees 40 50 60 70 degrees and another thing that's important to understand here is as the aircraft is increasing its bank angle it's becoming harder and harder to keep the nose up okay so as the aircraft go through 50 60 degrees of bank the nose drops below the horizon and the aircraft reaches a maximum altitude around 2200 feet before it initiates a very quick descent the aircraft finally ends up with a bank angle of 90 degrees towards the left with a negative pitch angle of about 40 degrees it slams into the ground with tremendous force it's been calculated that they probably were at the speed between 250 to 300 knots at that point and they create an enormous explosion so hard that big witnesses from far away can feel the shock wave they could see a mushroom-type cloud rising up towards the horizon remember this is at nighttime and it creates a huge crater only a few miles to the south east of runway 2 3 in stansted [Music] the accident investigation team comes with about 33 different findings in their final report and as always you will find the copy of the final report and the link to it in the description of the video below they come with several different recommendations but i want to highlight two of them the first recommendation is aimed at korean airlines and their training organization and it states korean air must continue to update their training and flight quality assurance programs to accommodate crew resource management evolution and industry developments to address issues specific to their operational environment and ensure adaptation of imported training material to accommodate the korean culture okay this one is really important because it highlights the fact that it's likely a cultural kind of component to why this crash happened right the fact that the first officer obviously did not speak up during this event and crucially not during the last few seconds of the flight and also the fact that the flight engineer even though he did communicate did not communicate effectively enough to get the captain to understand the danger of what was about to happen the second point i want to raise is regarding the maintenance organization and it says korean air continue to review its policy and procedures for maintenance support at international destinations with a view to deploying sufficients of its own full-time engineers at the outstation or delegating the entire task to another operator or third-party maintenance organization locally based at the destination if neither of those approaches is practical then support arrangement must be detailed and of such clarity as to preclude confusion and also korean air review its policy and procedures to ensure that a copy of the relevant pages of the technical log and any other transit certification documents left on the ground at the point of departure all right so what they're highlighting here basically is that if they would have had a full engineering organization or if they would have given the whole engineering responsibility to the outstation maintenance company well then it's likely that someone would have had access to the fault isolation manual they would have recognized that the fault was actually in the inu and not in the instrument of such and this would have never happened also they couldn't find any copy of the technical log so they were unsure about what the ground engineer actually had written in the logbook before he got onto the aircraft and was part of the the four crew that died in this accident so i've chosen to do this video guys because it is very close to my heart i speak often about crm and i speak about how important it is that we as flight crew members support each other and that we maintain a cockpit gradient that is healthy and that the first officers always feel that they can speak up no matter what it is even if they think that they might be wrong they should feel the kind of atmosphere in the cockpit to be supportive enough for them to feel that they can speak up all right so i can as a commander say that actually it's like this you don't have to worry about it but at least the point is being raised in case i have missed something all right it's very important and anytime that i see you know videos of captains berating their first officers or their cabin crew or their ground crew or anyone around them i know that that can lead to a cockpit environment that can lead to an outcome like this it is crucial that we understand this as flight crew members and that we keep working against a cockpit environment that is supportive constructive positive and helps us when things start to go wrong before we go any further i want to send a huge thank you to the sponsor of this episode which is 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Channel: Mentour Pilot

Views: 396,791

Rating: 4.9254894 out of 5

Keywords: Korean Air Cargo flight 8509, Korean air flight 8509, Boeing 747, Boeing 747 Crash, Stansted Crash, Boeing 737, Instrument failure, ADI failure, Air Crash investigations, Seconds from disaster, Aviation explained, Aviation facts, Fear of flying, fear of flying help, Mentour Pilot, Mentour Pilot Boeing 737, Boeing 737MAX, Boeing 787, Airbsu A320, Airbus A380, Airbus A350, How to become a pilot, Nervous flyer, Nervous flyer help, Aviation accidents explained

Id: vZElWMMMn7c

Length: 36min 2sec (2162 seconds)

Published: Fri Feb 12 2021