KOREAN AIR CARGO 8509 ACCIDENT : BAD ATTITUDE

HUMAN FACTOR STUDY CASES

• Date : 22 DEC 1999• Place : Near Great Hallingbury (United

Kingdom)• Time : 18:38 UTC• Operator : Korean Air• Aircraft Type : Boeing 747-2B5F(SCD)• Departure Airport : London-Stansted

Airport, United Kingdom

FIGURE 1: KAL CARGO 8509

• Destination Airport : Milano - Malpensa Airport, Italy

• Crew : Occupants : 4 / Fatalities : 4

• Passenger : Occupants : 0 / Fatalities : 0

• Aircraft 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

CAUSAL FACTORS1. MECHANICAL ERRORS.

2. HUMAN ERRORS

MECHANICAL ERRORS LIVEWARE – HARDWARE (L-H) One of its Inertial Navigation Unit

(INUs) had partly failed, providing incorrect roll data to the captain’s 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 ERRORS The 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…

SWISS CHEESE MODEL

LACK OF TEAMWORK

LACK OF KNOWLEDGELACK OF AWARENESS

HUMAN ERRORS LACK OF AWARENESS Comparator Warning Pilot 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 ERRORS But 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 : CAPTAIN’S ADI AND THE INST WARN LIGHT

HUMAN ERRORS LACK OF TEAMWORK FIRST OFFICER ACTION The 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 ERRORS Also, because of autocratic

organizational cockpit culture in Korea.

He felt inhibited to bringing the situation into the commander concerned.

HUMAN ERRORS LACK OF KNOWLEDGE/ REFERENCE The 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 ERRORS He 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 Air’s 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?

COMPANY Flight 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 INDUSTRY Safety 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/Accident

Flight 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

REFERENCES CINEFLIX (undated). Mayday - Bad Attitude (Korean Air Cargo Flight

8509). Retrieved from YouTube, 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 END

THANK YOU