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Korean Air Cargo Crash

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Causal Factors

KOREAN AIR CARGO 8509 ACCIDENT : BAD ATTITUDEHUMAN FACTOR STUDY CASES

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Date : 22 DEC 1999Place : Near Great Hallingbury (United Kingdom)Time : 18:38 UTCOperator : Korean AirAircraft Type : Boeing 747-2B5F(SCD)Departure Airport : London-Stansted Airport, United Kingdom

FIGURE 1: KAL CARGO 8509

Destination Airport : Milano - Malpensa Airport, ItalyCrew : Occupants : 4 / Fatalities : 4Passenger : Occupants : 0 / Fatalities : 0Aircraft Damage(s) : Written off (damaged beyond repair)Description of the Incident/Accident.

How it Happened

Previous flight from Tashkent to Stansted arrived at 15.05 UTC.The flight engineer made an entry in the Technical Log prior to leaving the aircraft. During turnover repair works on the ADI were carried out.The new crew for the next flight boarded the flight.The flight delayed for an hour because ATC had not receive the flight plan.The Flight 8509 was cleared to depart at 18.25 UTC.The ADI comparator buzzer sound three times when the flight climbing through 900ft.

Climbing through 1400ft, ATC instructed the crew to contact London Control.The aircraft banked left progressively and entered a descent until struck the ground.

FIGURE 2 : During the impact

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Causal FactorsMECHANICAL ERRORS.HUMAN ERRORS

MECHANICAL ERRORSLIVEWARE HARDWARE (L-H)One of its Inertial Navigation Unit (INUs) had partly failed, providing incorrect roll data to the captains attitude director indicator (ADI).Captain ADI was showing the right climbing attitude but not the roll attitude of aircraft.Despite the problem had been reported, but the maintenance is misdirected by the ground engineer.The ground engineer was supposedly replace the no. 1 INUs if he was not misdirected.

MECHANICAL ERRORSThe no. 1 INUs was not working in providing the correct roll attitude. The pilot ADI was using the no. 1 INU as the roll attitude.When the aircraft was turn to left, the captain ADI shows no movement in roll attitude.But, the commander was failed to realize that his ADI roll attitude was not functioning.He also failed to compare his ADI with the standby ADI provided at the panel and decide which one is correct and which is not.

FIGURE 3 : FLIGHT DIRECTOR INDICATOR

Swiss Cheese Model

HUMAN ERRORSLACK OF AWARENESSComparator WarningPilot was not properly respond to the warning.The comparator warning was triggered for three times,The first triggered was at 17 seconds after takeoff, The second triggered was at 8 seconds (1200 ft agl) after the first triggered.

HUMAN ERRORSBut there was no audio response from the crew about the warning.The third triggered was after 5 seconds later, when the left turn was initiated.After that, the horn sounding was cancelled by the commander.The flight engineer had made three comment.

FIGURE 7 : CAPTAINS ADI AND THE INST WARN LIGHT

HUMAN ERRORSLACK OF TEAMWORKFIRST OFFICER ACTIONThe first officer either did not monitor the aircraft attitude during the climbing turn or, did not alert the commander to the extreme unsafe attitude that developed.There was a marked difference in age and experience between the commander and the first officer.Also, the first officer was inexperienced. (with 195 hours on type)The first officer had been criticized prior to takeoff. (By the pilot)

HUMAN ERRORSAlso, because of autocratic organizational cockpit culture in Korea. He felt inhibited to bringing the situation into the commander concerned.

HUMAN ERRORSLACK OF KNOWLEDGE/ REFERENCEThe maintenance activity at Stansted was misdirected, despite the fault having been correctly reported using the Fault Reporting Manual (FRM). The Inertial Navigation Unit (INU) no.1 for pilot was supposedly be replaced, but instead the Attitude Director Indicator (ADI) was being fixed off.Korean Air does not provide a copy of fault isolation manual (FIM).

HUMAN ERRORSHe uncertain about the correct course of action but does not seek for advice from any specialists at Stansted or contact maintenance control at Seoul.Later, endorse help from local engineer.When removing the ADI from panel, the socket no 2 was pushed back.The ground engineer feeling that the problem was with the connecting pin (asking the local eng. to replace the pin).

THE WAY THE INCIDENT/ ACCIDENT COULD HAVE BEEN PREVENTED The accident could have been prevented if Korea Airs accept The Internal Audit Report (20th September 1998) written by an external New Zealand. Change their autocratic cockpit culture that has an endemic level of complacency, arrogance and incompetence.Repair the ADI with having the correct Fault Isolation Manual and consider to replace INU. Do an observation of the maintenance before the plane took off.

FIGURE 8: DISTANCE FROM AIRPORT TO THE CRASH SITE

ERROR CHAIN

If any one of the links in this chain had been broken by building in measures which may have been prevented a problem at one or more of these stages.The accident could have been prevented if we break the crew link of the chain.The Korean culture. Autocratic cockpit culture.

How the accident has affected the company and the aviation industry?

COMPANYFlight operations selection upgrading system, stricter requirement.Flight crew training and checking more training being introduced.Organisation and management improve standardisation, rationalised documentation.Flight Quality Assurance various audit.Maintenance and engineering manpower, new system, maintenance training.

AVIATION INDUSTRYSafety Recommendation No 2003-62 KAL update their training and programmes.Safety Recommendation No 2003-63 KAL review their policy and procedures.Safety Recommendation No 2003-64 Technical log must have copied at ground.Safety Recommendation No 2003-65 Carrying dangerous good must be informed to the Authority.Safety Recommendation No 2003-66 Review the current methods of tracking air cargo.Safety Recommendation No 2003-67 necessary data and risk management advice.

What Can Be Learned From This Incident/AccidentFlight crew must not using autocratic organizational culture in their system.Flight crew must realize their responsibility when onboard and they must take and appropriate action when some problem occurred.All aircraft must have appropriate Fault Isolation manual to be referred to do the maintenance.

Organizational CultureSafety Culture ICAO HF - a set of beliefs, norms, attitudes, roles, and social and technical practices concerned with minimizing exposure of employees, managers, customers and members of the general public to conditions considered dangerous or hazardous.

Figure 9 : On 22 December 1999, Korean Air Cargo Flight No: 8509 Aircraft: B747-2B5F (HL 7451) on a cargo flight to Milan-Malpensa, Italy, crashed shortly after takeoff from London Stansted Airport, Essex, England killing all 4 on board

FIGURE 8 : PART OF BODY OF KAL CARGO 8509 THAT CRASHED

FIGURE 9 :AT THE SITE OF THE KAL CARGO 8509 CRASHED

FIGURE 10 : VIEW AT NIGHT FROM THE CRASH SITE.

FIGURE 11: DURING INVESTIGATION AT THE CRASH SITE

FIGURE 12: VIEW FROM ABOVE OF THE CRASH SITE

REFERENCESCINEFLIX (undated).Mayday - Bad Attitude (Korean Air Cargo Flight 8509).Retrieved fromYouTube, Retrieved from http://www.youtube.com/watch?v=aG3_nJYtrO8 on 3 March 2014.Khoury, M. (2009, October 1).Korean Airlines Safety Audit Findings. Retrieved from http://www.flight.org/blog/2009/10/01/korean-airlines-internal-audit-report-an-airline-waiting-to-happen/ on 4 March 2014.Wikipedia. (2012).Korean Air Cargo Flight 8509. Retrieved from http://en.wikipedia.org/wiki/Korean_Air_Cargo_Flight_8509 on 11 March 2014."Report on the accident to Boeing 747-2B5F, HL-7451 near London Stansted Airport on 22 December 1999".Air Accident Investigation Branch(AAIB), Retrieved from http://www.aaib.gov.uk/cms_resources.cfm?file=/3-2003%20HL-7451.pdf on 4 March 2014.

Q&ASESSION

THE ENDTHANK YOU

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