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Islamov D. senior lecturer "Air navigation Systems" Department "Aerospace technology" Faculty Tashkent State Technical University named after Islam Karimov Tashkent, Uzbekistan IS BLAMING PILOTS ALWAYS RIGHT?
In this article, I would like to discuss the accident of Korean Air Cargo Flight 8509, On 22 December 1999just after take-off from London Stansted Airport.
Keywords: experience, skills, manual, emergency, flight safety.
Исламов Д. старший преподаватель кафедра «Аэронавигационные системы» факультет «Авиакосмические технологии» Ташкентский государственный технический университет имени
Ислама Каримова Узбекистан, г. Ташкент
В этой статье я хотел бы обсудить катастрофу рейса "Korean Air Cargo"-8509 22 декабря 1999 года сразу после взлета из Лондонского аэропорта Станстед.
Ключевые слова: опыт, навыки, инструкция, аварийная ситуация, безопасность полетов.
On 22 December, 1999 just after take-off from London Stansted Airport, Korean Air Cargo Flight 8509, headed to Milano-Malpensa Airport, crashed due to pilot error. The aircraft was a Boeing 747-2B5F, registered HL7451 and crashed into Hatfield Forest in the neighborhood of the Great Hallingbury village. The crew of four on board were killed. It was getting dark when the aircraft departed from Stansted. The captain found that his ADI was not banking and the comparator alarm worked when he wanted the aircraft to turn left. While the flight engineer shouted out "bank", the first officer was quite whose instrument should have shown the true angle of turn. The captain did not respond and kept turning more and more left. At 18:38, 55 seconds after take-off at 1838, Flight 8509 hit into the ground in a 40° pitch down, 90° left bank and at a speed between 250 and 300 knots.
The following causal factors were determined:
1. During the climb after departing from Stansted, the pilots did not properly respond to the comparator warnings even though there were alerts from the flight engineer.
2. The captain kept a left turn control input, turning the aircraft to around 90° of left bank and there was no control input to adjust the pitch attitude throughout the turn.
3. The first officer did not identify the serious attitude that developed or he
did not warn the captain during the climbing turn.
4. The maintenance work at Stansted was misdirected, even though the fault having been properly reported by the Fault Reporting Manual instructions. As a result, the aircraft was on hand for service with the identical fault experienced on the earlier sector; the No 1 INU roll signal driving the captain's ADI was incorrect.
5. The arrangement for local engineering support of the Operator's engineering employees was vague on the division of responsibility, resulting in incorrect defect recognition, and mis-directed maintenance achievement.
After the aircraft's departure from Tashkent on the earlier flight segment, one of its inertial navigation units (INUs) had partly failed, providing incorrect roll data to the captain's attitude director indicator (ADI or artificial horizon). The first officer's ADI and a backup ADI were correct, a comparator alarm called attention to the inconsistency, and in daylight the incorrect warning was straightforwardly recognized. The ADI's input selector was switched to the another INU and the correct indications returned.
At Stansted, the engineers attempted to repair the ADI without having the correct Fault Isolation Manual and did not consider to replace the INU. One of them found and repaired a broken connecting plug on the ADI. When the ADI responded properly to its "Test" button, they thought the error had been corrected, even though this button only tested the ADI and not the INU. The ADI's input selector was left in the ordinary position.
It was dark when the plane took off from London Stansted Airport, with the captain flying. When the captain tried to bank the plane to turn left, his ADI showed it not banking, but the comparator alarm sounded repeatedly. The first officer, whose own ADI would have shown the true angle of bank, failed to participate in (or was uncomfortable with) full crew resource management techniques, saying nothing to challenge his captain's actions nor made any attempt to take over the flight with his own controls. The older and more experienced flight engineer did call out "bank" four times in 19 seconds, but the captain ignored his warnings, continued to ignore the chiming alarm, made no verbal response, and actually continued to increase the left bank angle. At 18:38, 55 seconds after take-off, Flight 8509's left wing dragged along the ground, then the aircraft plunged into the ground at a speed of between 250 and 300 knots, in a 40° pitch down and 90° left bank attitude. The aircraft exploded on impact.
After the investigation, the United Kingdom's Air Accidents Investigation Branch issued recommendations to Korean Air to revise its training program and company culture, to promote a more free atmosphere between the captain and the first officer. The first recommendation of the AAIB's final accident report was that:
Korean Air 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.
I also consider one important factor-"Human factor". It all happened only for 55 seconds, it is a very short time to recognize any fault properly. After take-off, the
captain was busy with aircraft controlling and navigation as PF(pilot flying). The first officer as PM(pilot monitoring) role probably was busy with complying PF commands such as "gear up", "flaps up", mode selection on FMS, etc. and also he was responsible for RT commutation, SID monitoring, etc. Time to recognize the fault in this situation started 19 seconds before impact. It is very difficult to figure out what's going on during such a high crew workload phase. Of course, it happened spontaneously and crew didn't expect it. There was very little chance to escape this situation. That's why we should consider that the main reason for the accident was INU failure.
References:
1. CINEFLIX (undated). Mayday - Bad Attitude (Korean Air Cargo Flight 8509). Retrieved from YouTube on 10 August 2012.
2. 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 9 September 2012.
3. Helmreich, R. L. (1998). "Error management as organisational strategy", In Proceedings of the IATA Human Factors Seminar (pp. 1-7). Bangkok, Thailand, April 20-22, 1998.
4. Rowley, et al. : Rowley, C., Sohn, T.-W., & Bae, J. (2002). Managing Korean business : organization, culture, human resources and change / editors, Chris Rowley, Tae-Won Sohn, Johngseok Bae: London ; Portland, OR : F. Cass, 2002.
5. Wikipedia. (2012). Korean Air Cargo Flight 8509. Retrieved from [http://en.wikipedia.org/wiki/Korean_Air_Cargo_Flight_8509] on 11 September 2012.
