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 (Wikipedia, 2012Bibliography item Wikipedia2012 not found.).
Cause of crash
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 (Wikipedia, 2012Bibliography item Wikipedia2012 not found.).
The main reason for the fatal accident of KAL flight 8509 was caused by Korean Air’s autocratic cockpit culture and Korean national culture. According to Khoury (2009) one year before the accident of KAL flight 8509, The Internal Safety Audit report 20th September 1998 written by an external New Zealand check and training pilot group found the problems of Korean Air. Ignorance of 1998 report brought a fatal disaster of KAL flight 8509 (On 22 December, 1999). The report mentions that Korean Air has an endemic level of complacency, arrogance and incompetence pervading all section of Korean Air flight operations. “There is a volatile cocktail of complacency, arrogance, apathy and a lack of self-discipline. These attitudes must be removed from the flight deck at all costs” (Khoury, 2009, October 1, p. 26). Furthermore, Khoury (2009) states that between 1970 and 1999 Korean Air had total 16 aircraft incidents and accidents, with almost 700 casualties. More importantly Korean Air’s main problem was its organizational culture. Most of employees at Korean Air are Korean people. Therefore, their organizational culture is formed by their typical Korean national culture.
There were total four people on flight 8509, the flight crew consisted of 57-year-old Captain (ex military colonel single fighter jet, Park Duk-kyu, 33-year-old First Officer Yoon Ki-sik, 38-year-old Flight Engineer Park Hoon-kyu, and 45-year-old maintenance mechanic Kim Il-suk (Wikipedia, 2012). Helmreich (1998, p. 2) states that too strong national culture (autocratic leadership) causes higher probability of accident. Captain Park learnt his flight skills and leadership skills in South Korea Air Force, he was a colonel flying single-seat jet fighter. In 1990’s and before 1990’s most of the pilots working at Korean Air were ex-military pilots. Thus, Korean Air had a strong military hierarchy culture within its organization. It is not just Airline companies but most of Korean organization has a strong military hierarchy culture.
According to Rowley, et al. (2002, p. 79) Korea is a male-dominated society. All man in Korea has to do military service for at least two years. Their exposure to military life influences over their whole careers. Therefore, it is common for Korean male workers to follow hierarchy system. “The experience of life in military camps contributes heavily to ideas on how organizations should be designed and operated. It influences behaviour even in later life, predisposing men to emphasize hierarchical command, a result- oriented 'can-do spirit', and aggressive competition” (Rowley, et al, 2002, p. 73). This Korean’s military life based national culture badly affected on Korean Air’s cockpit culture. When Korean Air trains cadet pilots, they always taught them their hierarchy culture. Not to say opposite idea to their Captain what ever happen. They thought it is dishonor for them and for their Captain. Moreover, low ranked Korean pilots were afraid that if they stand against their Captain they might ruin their entire pilot career in Korean Air. Therefore, this autocratic organizational culture especially cockpit culture made the First Officer to keeping quiet without saying any comments to the Captain. If the First Officer made a right decision, he would have saved himself and other crews’ lives.
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|Video embedded from YouTube on 10 August 2012 (see Cineflix, undated1)|
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- Korean Air Cargo Flight 8509
- This Wikipedia page provides more details about this occurrence.
- Crew Resource Management training
- This page provides more information on Crew Resource Management training.