Korean Air B747 (Stansted crash) report out

[Colonel Blink]

Apologies if this has been posted before (searched and found nothing!)

I first spotted this on the BBC news pages (http://news.bbc.co.uk/2/hi/uk_news/3093849.stm) (see paste below)

and the full (AAIB) report is here (http://www.dft.gov.uk/stellent/groups/dft_avsafety/documents/pdf/dft_avsafety_pdf_503170.pdf)

Plane crashed after maintenance blunder. The failure to repair a faulty navigational aid led to a jumbo jet crashing shortly after take-off from Stansted airport, according to an official accident report. All four people on board the cargo plane - two pilots, a flight engineer and a ground engineer - were killed in the crash in December 1999. It was later confirmed that the plane was carrying hundreds of pounds of depleted uranium.

But investigators said at the time that it had remained intact and therefore did not pose a health hazard to emergency service workers or people living nearby.

The Air Accidents Investigation Branch report, published on Friday, said a fault had prevented the pilots of the Korean Air Boeing 747 from responding properly when the plane was in danger.

'Inexperienced'

The crew, who had flown in from Tashkent had reported the fault on landing, but maintenance work carried out at Stansted failed to rectify it.
The problem involved the attitude director indicator, which gives pilots an indication of the angle of the aircraft at night and in cloud.

The report said maintenance activity at Stansted was "misdirected" before take-off despite the fault being correctly reported.

Consequently, the captain received incorrect plane attitude information when he turned the plane to the left and this lead to it hitting the ground.


The report said that the "inexperienced" co-pilot, who was 33, did not alert the captain to the unsafe position the aircraft had been put into.

Recommendations

It was "a matter of conjecture" whether he had felt inhibited in bringing the situation to the attention of the captain, who was 57.

The report said a lack of clarity regarding responsibility relating to local engineering support for Korean Air's own engineering personnel, had resulted in "erroneous defect identification and misdirected maintenance action".

It made six safety recommendations to ensure a tightening up of safety procedures.


Don't quite know why there are such poignant references to the crews ages (or is this just BBC policy?)

[Rockhound]

Col Blink,
The "full report" to which you provide a link is actually an interim report (a "Special Bulletin") that was released in 2000.
Although the BBC states the full report was released on Friday (presumably July 18), it does not yet appear on the AAIB website. Presumably it will shortly.
Rockhound

[Land ASAP]

Does anyone have to hand a Dangerous Goods Handbook?

What is the weight limit for depleted Uranium as cargo?

[Unwell_Raptor]

I don't think the DU was cargo, but ballast.

[newswatcher]

Similar concerns were expressed after the EL Al 747 accident in Amsterdam('92). More than 800 local residents and rescue workers were reported after the crash to be complaining of a range of problems, including fatigue, skin complaints, joint and bone pains, kidney ailments and respiratory problems.

However, the commission of inquiry did not conclude that these problems had been caused by the DU lost in the crash!

[BEagle]

It is quite outrageous and irresponsible for the BBC to state that the accident was caused by a 'maintenance blunder' and that the AAIB report 'blamed' anyone or anything. Typical journalistic rubbish. And how typically 'SHOCK, HORROR - NUCLEAR MATERIAL WAS ON BOARD DOOMED JET!' gutter journalism about an aspect which had absolutely no bearing on the accident

The fault existed on the previous flight and was handled correctly by the crew. That crew also performed in-flight fault-finding and gave a comprehensive debrief to the maintenance personnel at STN. The cause of the fault was incorrectly diagnosed by the maintnenance personnel and the ac was dispatched with the fault remaining. The accident crew did not respond to the failure indications; there were several distractions and pre-occupations during a busy period of the departure but, unlike on the previous sector, the Commander did not hand control to his First Officer.

I used the initial report from the accident to set up a similar series of events for VC10 pilots during routine simulator training in simulated IMC. Although the attitude system is simpler, the basics remain the same: Compare both primary attitude indicators with the standby and ensure the pilot with the serviceable attitude indicator immediately takes control.

FLY THE JET, then follow the SID, then bother with the nagging Air Traffickers on the wireless. Incidentally, none of the pilots I gave the fault to crashed the simulator.

[Dantruck]

Where did you learn English?

Before seeing what you want to read in the above linked report, try reading the headline and first paragraph, and then deciding what the words say.

The headline states: "Plane crashed after maintenance blunder"

It does not say: 'Plane crashes because of maintenance blunder' as it seems you want it to say.

The first par reads: "The failure to repair a faulty navigational aid led to a jumbo jet crashing..."

The key words here are 'led to.' The paragraph goes on to make clear who holds this opinion: "...according to an official accident report." You are the only person using the word "blame" here.

Perhaps you're one of those people who simply wants to throw mud at the BBC right now, maybe not. Either way, get a grip man!

There are lessons to be learned from the AAIB report and everyone's views of it, but only if we read the words first.

[BEagle]

Dantruck, my comments were made after listening to the report on TV, not through the link.

Yes, there are lessons to be learned. But the AAIB does not apportion blame, it establishes the facts and subsequently makes safety recommendations.

Notwithstanding the link, to the average person the BBC report blamed the crash on a maintenance error. That was not the primary cause, as the full AAIB report makes abundantly clear.

I learned my English at public school, since you ask. Normally my preferred source of news is BBC News 24; however, on this occasion their normal standards slipped. Incidentally, I hope that the BBC sticks to its guns regarding the allegations concerning Phoney Tony's 'sexed up' WMD bolleaux and that the spin doctors get the push.....as well as the other players in that tacky tableau of deceit.

[BEagle]

Mike - thanks for that. The report makes it clear that the inbound Korean crew had done a very good job in analysing the fault and clearly debriefing it; unfortunately the maintenance team had basically focused on the instrument output rather than the faulty input.

That said, the pre-existing failure should not have caused a fatal accident; notwithstanding the ADI 'failure', prompt, correct action would have saved the aeroplane, its crew and cargo.

In my view the root cause could possibly have been too rigid an adherance to the 'If everyone's happy, shall we run the checklist?' culture at a stage of flight when correct, instinctive and well-practised actions were essential.

[Final 3 Greens]

Two facts.

Number 1, it made one hell of a mess of part of our locale and scared the living daylights out of my daughter who happened to be a few hundred metres away at the time.

Number 2, the airline involved has lost more than just this widebody hull in the past few years.

I regret the loss of four crew, but it could have been a lot worse of the aircraft had hit one of the local hamlets, of which there are quite a number.

The AAIB don't apportion blame and nor do I, but neither do I want another incident like this happening aroud here (3.2NM from my house.)

I hope that someone is on the case with preventitive actions.

[Dantruck]

Well, firstly, I’m glad you’ve made it clear you were referring to something other than the link that began this thread. I have not seen the TV report to which you refer so I cannot comment further. If your description of it is accurate I would agree, at least in part, that it was wrong. Your references to gutter journalism, etc, are still misplaced and arguably unfair, however.

If you are going to go off message, by which I mean refer to something other than the source referenced by he who started this thread, perhaps you will make that plain in future.

You said:

“Notwithstanding the link, to the average person the BBC report blamed the crash on a maintenance error. That was not the primary cause, as the full AAIB report makes abundantly clear.”

…And Mike Jenvey added:

“…the “faulty” ADI was run through a full test sequence by the ground engineer (including removing the instrument from the instrument panel)? He also spotted a wiring pin that needed to be reseated – this was done. The Korean Air engineer (also present), then said something to the effect that he was satisfied & required no further assistance.

“How on earth can that be a maintenance blunder??

Can’t you see that to the average person this tragedy is/was maintenance related? Mike Jenvey, you yourself quote a section that refers to the goings-on of two 'engineers' to make your point. The man on the Clapham Omnibus has not the wit nor will to dissect your primary, secondary or any other cause. That’s why they need journalists who, best as they can, must turn multiple pages of deeply complex techno analysis into simple English. On that boiled down basis it was quite correct to point to a ‘maintenance’ error.

Otherwise, according to your analysis, an equally accurate headline would have been ‘pilot’ error. You see my point..?

We’re descending into semantics here somewhat, so please don’t take offence to my remarks. More I hope you understand we all need journalists, even if they do get it wrong sometimes. It helps no one to bang on about “outrageous and irresponsible” reporting in the way you have. Even taking the TV report you belatedly refer to: ‘outrageous’ ?…possibly. ‘Irresponsible ?…no. No one will be damaged by the inaccuracy you claim. Those in the know, know, afteral.

Apologies to anyone bored by this aside to the thread.

Dan Coughlan

[BEagle]

Yes they will. The employees of the maintenance organisation stand wrongly accused by the gutter press of causing the accident. Whereas in reality they merely failed to correct a fault which had occurred and had been correctly dealt with by the flight crew on an earlier sector. The crew on the second sector acted in a different manner to the ADI failure indications and the aircraft crashed shortly afterwards.

Or is that too simplistic for you as well?

What exactly is your point.....ah, I understand now. You claim to be a journalist.

[Kalium Chloride]

This post removed in order not to violate my own rules on retaining self-control and not responding to idiotic and uninformed comments on threads such as this one.

<Chants: inner peace, inner peace...>

[Hilico]

So, do you want the headline to read 'MAINTENANCE OMISSIONS FOLLOWED BY PILOT ERRORS LEAD TO FATAL CRASH!"?

Have you ever seen (I won't say 'read') a copy of the Stun?

If you can't get one sentence per paragraph, you won't get the story in!

Engineers completely failed to fix the fault on the Death Jumbo!

But when the crew took off, they thought it had been fixed!

So the pilots trusted their instruments, as they're supposed to - and the instruments took them to their DOOM!

And that's neither simple enough to be intelligible to the troglodytes, and nor is it a sufficiently accurate summary for insiders. So, gentlemen, we're in a cleft stick.

[Dantruck]

Succinctly put, Hillico.

BEagle - As I said, I did hope you would not take my words amiss, yet you seem determined otherwise. That's your crime. It's also your punishment.

Smoketoomuch - You are right...a national audience does need just one focus. Truth is they're too dumb, disinterested, or too short of time to concentrate on more. Sad, but true. Prime reason is they don't give a damn, at least, not so long as they make it to Alicante and back once a year on their hols.

Why not try and educate them? Well again, if they'd listen, or were interested, journalists would, Unfortunately countless tests have shown a national audience care just long enough to turn the page, or flip channels, and this happens double quick just as soon as anything techie is mentioned. To a lesser extent this is even true in aviation journals. People just don't have the time to stop and smell the avtur anymore, believe me! Again, sad, but true.

Kalium Chloride - I do hope you will reconsider whatever it was that prompted you to consider posting. All contributions and criticism are worthwhile - assuming they're constructive and not just more 'gutter journalism' remarks, of course.

Mike J - Journalists cannot be expected to understand every subject they are required to cover - no more than you or I can be expected to know some or even all of the London Underground, ship scheduling, or any other aspect of a single industry. And this presumes we are only the transport correspondent. They bother because they have a job to do, pure and simple. Not perfect everyone agrees, but the alternative is a newspaper cover price no one is prepared to pay.

In short, society gets the media it deserves - or at least is prepared to pay for.

Oh, and BEagle. Yes I do claim to be a journalist. I have 19 years experience, so I hope all here will consider me qualified to speak on the subject.

By the way, you don't substantiate your first statement in your last post. I am interested to know how this will happen given you, me, the AAIB, the CAA, Korean Air, probably most ppruners, and almost certainly everyone else in aviation either understand or have it in their means to understand what happened, as you describe. Or do you believe the engineers concerned will be fired by their bosses over a single 'outrageous' BBC TV report?

You can't have it both ways, you know.

Still, just so long as you're keeping an open mind.

Constructively

Dan


Edited for a couple of typos

[Final 3 Greens]

Dantruck, Hilico

In the interests of clarity, let's see if this can be explained this at a level suitable for the average non expert reader.

"On an airliner, you have two (at least) of anything important.

That includes ADIs (Attitude Direction Indicators), important instrument used to control the aircraft. False indications from an ADI are potentially very dangerous.'

This risk is well understood and to reduce it, each pilot has an ADI on the panel in front of them and there is a third standby unit too.

If the pilots ADIs have different readings, they should cross check both against the standby and then fly safely using the two instruments that agree."

Now, if I (a non expert, non journo) can explain this concept in 86 words, then is it not reasonable to expect a professional journalist to be able to undertake some brief research and produce a piece of integrity, which is interesting, well written and concise and rather more lucid than

Plane crashed after maintenance blunder

which is as equally accurate as saying

Plane crashed after take off into bad weather

or

Plane crashed with uranium on board

Plane crashed after taking off with inflammable substance on board (excuse this last one, but fuel is an inflammable substance ;-))

Whilst a journalist may be safe from libel action with these wordings, a reasonable person would 'read between the lines.'

So what I really object to about the reporting in this instance is that the simplistic conclusion implies a very nice neat conclusion, which is wrong.

[BEagle]

F3G - quite so.

But that journalist will tell you otherwise, no doubt.

The maintenance crew, seemingly blamed by the media, don't have to be 'fired' to be 'damaged by the inaccuracy' of the report. Which is something many journalists seem incapable of comprehending; people have feelings and can be very hurt by inccurate press reports.

And as for "As I said, I did hope you would not take my words amiss, yet you seem determined otherwise. That's your crime. It's also your punishment." - what utter twaddle.

Going back to the thread, the cause of the accident was the reaction of the crew to the failure of the capt's attitude display.

[The Nr Fairy]

Beags :

I'm writing from a position well down the experience ladder, but surely the incorrect reaction of the crew to a single incorrect ADI display wasn't the sole cause of the accident - the defining one perhaps, but not the only one.

If the maintenance crew had decoded the fault code they would have been in a better position. They didn't have a copy, nor apparently did the KAL engineer.

If the crew hadn't been distracted before departure by an unfiled flightplan and all the other bits, they might have been more prepared.

If they HAD compared ADIs and the captain handed over to the FO then they would probably have not ended up impaling the aircraft.

I stand ready to be corrected.

[Dantruck]

Excellent post F3G

You're getting there, but you're not there yet.

To take the BBC Online story as an example, that journalist had just 314 words to work with, headline included. You’ve done well to explain one element of the story in 86 words, but there are still eight or nine other elements to include and you’ve already used more than a quarter of the space available.

See how tricky this is becoming?

Broadly the same is true in TV reporting. You don’t have the luxury of so much time. And you’ll put your audience to sleep with that much detail, I'm afraid. Remember, it's the man on the street we're writing for here.

Hope you don’t feel knocked back by what I’ve said, your piece would sit very well in a magazine feature or a radio documentary where the space exists to go into detail. It is just that news reporting is a different animal.

This is how and why complex news stories get boiled down into all too few words, and how complete clarity must often be sacrificed. Those close to the story, such as pilots in this case, should not be irked by such brevity and the simplification it brings. They are not the target audience, afteral.

[Final 3 Greens]

Dantruck

Of course my words were too long, but then I am neither a journalist nor a professional pilot and I took no more 2 minutes to write the 86 words.

However, I do review text books in my area of expertise for a respected journal with a 300 word limit and do a considerably better job, IMHO, than the journalist did here, whatever you might say, as I am covering typically the content of 15 chapters as well as making buy/not buy recommendation.


You should re-read your last post; What you are saying is that it is okay to write a story that is misleading.

[AtlPax]

As a pax, I hope this isn't too dumb a question. :oh:

Isn't there a backup ADI within your same field of vision as the Primary ADI? Wouldn't good peripheral vision pick out a discrepancy between the two?

[BEagle]

The Nr Fairy - in fact the previous crew had acted totally correctly to the ADI comparator warning. Wheras the accident crew were distracted by other events to an extent that perhaps they weren't able to focus on the primary task. If they'd had the chance to talk to the previous crew, perhaps the captain would have flown with his ADI selected to the standby source and would have entrusted the take-off to his co-pilot? How easy it is to be wise after the event though.

Of course, even if the INS fault had been correctly diagnosed and repaired, there is nothing to say that a totally unassociated ADI failure couldn't have occurred on the next take-off. Which is why CRM is so important in recovering the situation. Never mind the radio, stop worrying about the DME, if an attitude comparator warning occurs in IMC, both pilots must immediately become involved in swift and correct 'Compare and handover' actions before non-recoverable extremes of attitude are reached. And that must be second nature.

[Final 3 Greens]

Atlpax

I'm sure that one of the pros will give you a better answer than this, but here's a starter based on some hours under training in a proper simulator.

The backup ADI is a lot smaller than the primary instrument and is not directly in front of the pilots, so it isn't in their primary scan, which is the area that they trained to focus on. Peripheral vision would not pick up the backup ADI IMHO.

There is normally some type of warning that let's them know if there is a difference between the 2 primary instruments, following which there is a cross check between the two and the back up unit and a decision made as to which is correct.

The pilot with the correctly reading will then take control and fly the aircraft.

As in most things in the airline sector, this procedure is learned and refreshed by practice and safety comes from the swift and sure application by the pilots.

If you take a minute to re-read BEagles posts, you will see his thinking and he speaks with expert authority, which I do not.

[Slim20]

We DO need journalists. Quite true.

But as DanT says it is in the interests of those who sell us the news to make sure the said public is kept largely ignorant of pertinent facts and underlying issues on the basis that "it would be too complicated for them to understand" (or some other patrician bulls**t) in order to preclude the application of costly "journalism" rather than cheap sensationalism.

They bother because they have a job to do, pure and simple. Not perfect everyone agrees, but the alternative is a newspaper cover price no one is prepared to pay. In short, society gets the media it deserves - or at least is prepared to pay for.

Basically you are saying it's all right for a journalist to write a story which he knows is wrong or inaccurate on the basis that no-one will pay him enough to write the factual truth.

But if any of us took that attitude and it caused a plane crash, I can guess who the first people on the scene will be, shaking their heads in grave rebuke at the terrible negligence. But again, hypocrisy always has been the mass media's strongpoint.

[Dantruck]

Slim20

You misunderstand, and your words may mislead.

Ignorance is in no one’s interest, obviously. Rather I am saying the necessity for brevity does not allow a fully detailed and therefore more explanatory story to be told. And please don’t misquote me. I never said, nor intimated, that anything is too complicated for the reader to understand. I said the reader doesn’t care or have time enough to wade through sufficient explanation to distinguish between, for example, a maintenance fault that leads to a crash, and a maintenance blunder compounded by crew error that leads to the same thing, and to do it to a level that would satisfy some here.

In short, the problem lies with the reader and circumstance, not the news provider. It should be obvious that any media would like nothing more than to fully explain everything to everyone. If there were a market for that I’d have a job for life, wouldn’t I?

And no, I’m not saying it's all right for a journalist to write a story he knows to be wrong or inaccurate, as well you know. You are misinterpreting my message. And your line associating costly journalism with cheap sensationalism is a nice little play on words, but that’s all. Those two issues are so unrelated as to be poles apart. Ever considered a career as a headline writer?

Guys, wake up. Just what do you expect?

The news reporting media is an imperfect device, yes, and for all the reasons I have tried to share with you. But you cannot demand that it and the public take as much interest in a complex issue as your training, experience and insight allows you to, just because you think they should. Remember, those that want the full detail can also read the AAIB report if there’s any doubt.

OK, for those still grappling with my argument, tTry looking at this another way…the big picture. This was a national news story of relatively minor interest to the 44million or so people who live in Britain. Indeed, arguably the biggest issues for them were who might have been hurt on the ground, and the fears raised earlier over the DU aboard.

Would you have been happier if the publication of the AAIB’s report had been ignored, or had been taken over by some larger news event that day? But then you or certainly someone else here would be complaining the media never publishes anything about the accident investigation that exonerated the crew. Of course, whatever is reported should be accurate, but, at national news level, it does not have to be so accurate as to the level you demand. The reader just wants to know enough that he may comfortably forget about it all and turn the page. Hence all the references to maintenance.

I’ve tried to explain as well as complain, but if you can’t get your head around what the media is, how it works, what the public wants (and is prepared to pay for) and the slant one’s own knowledge puts on everything we read, I’m afraid you’re doomed to be unhappy with most of what you see, read and listen to. I can’t help you further in that case.

[Slim20]

I’ve tried to explain as well as complain, but if you can’t get your head around what the media is, how it works, what the public wants (and is prepared to pay for) and the slant one’s own knowledge puts on everything we read, I’m afraid you’re doomed to be unhappy with most of what you see, read and listen to. I can’t help you further in that case.

Likewise with you and aviation, buddy.

[WHBM]

Should it not be part of the AAIB's remit that in addition to publishing the full report, for the benefit of those in the Aviation world, like PPRuNers, they should simultaneously do 500 word summaries (for Daily Telegraph journalists) and 100 word summaries (for Sun journalists), etc which ensure that as much of the relevant issue as possible can be got across, and in the appropriate style, in media that only makes this limited amount of space available.

Because otherwise non-aviation journalists will have to do the same for a short deadline, and inevitably may miss the key items. If you want the message done accurately, do it yourself.

[Gertrude the Wombat]

Guys, wake up. Just what do you expect?The continuing demise of the middle man, since you ask.

Just as the internet is taking over from the employment agent, the rental agent, the estate agent, the travel agent, and so on, it has scope for taking over from journalists who just regurgitate misinterpreted digests of real news stories.

It's not everybody who's doing it yet by a long way, but don't underestimate the desire of an increasingly significant number of people to ignore the journalistic interpretations of things like this and go to the source.

I read the report.

In the old days that would not have been posible (well, not without sending a postal order for 12/6 to Her Majesty's Stationery Office and waiting a month), so I'd have been stuck with journalists' manglings of things they don't understand. These days that, and the journalists, are no longer necessary.

[Colonel Blink]

Sometimes you wish you never posted - sorry, I was only advising everyone about the article and report. I had no intention of creating yet another journo slanging and member v member battle.

[eng123]

Ignoring all this media argument,I have skipped through it and not read it,I would like to pick up on the 'maintenance blunder' part of this.

To my mind,one of the most important parts of the report is the AAIB highlighting the existance of the 'partial maintenance support' [or whatever they called it in the report]. This agreement had a direct effect on the defect diagnosis at the time.The point they make about the division of responsibilities is crucial.I was working on the night it crashed and heard the thump as it hit the ground and exploded.

I personally know the two UK based engineers involved and remember speaking to them minutes after we heard the news.Hopefully I'm never in that situation.I would like to point out that they are both extremely experienced and competent engineers.

If Korean Air had given the contract to FLS on a full support basis,I have no doubt that the defect would have been correctly diagnosed and perhaps the accident would never have happened.

The trouble arises when you are tasked to support a foreign airline with a different culture and language when they are calling all the shots.I have experienced this myself.You seem to be immediatly kept out of the loop as soon as any defect occurs and you are relegated to a general dogs-body,doing as the airline engineer [and common language speaker] requests,often,as in this case,without knowing the full details.The report said that the inbound crew wrote in the log 'Capt ADI unreliable in roll',but the inbound flight engineer stated that he de-briefed the airline engineer [presumably in Korean] that selecting to alternate rectified the fault.This crucial part of the de-brief would be lost on the Fls engineer who,in all probability,was not even at the de-brief because it is the sole responsibility of the airline engineer.

Having had the de-brief,the airline engineer then asked the local engineer to remove the ADI,at which point the pushed back pin is found.As he is not an avionic engineer,he asks his colleague to attend to rectify the fault.The avionic guy turns up and carries out the task requested of him correctly,he re-seats the pin and functions the instrument,which works correctly.He asks the Korean guy if he is finished with him and when told yes he leaves.The Korean guy then signs the log.The rest is history.

Now,the different scenario is that FLS has the full support contract.What would have happened is as follows [if I was the meeting A&C engineer,and I'm sure would be the same with the engineer involved].

Upon de-brief [in english],hearing the defect was avionic based,an avionic engineer would have immediatly been called,had the proper de-brief from the F/E and,in all probability, have diagnosed correctly and the aircraft despatched with a seviceable ADI or correctly deferred IAW the MEL.

OK,it could be argued that there was a maintenance error but I just wanted to point out that it goes deeper than that.However,it must be said that the actual cause of the accident has to be crew error in failing to respond to multiple comparator warnings.The f/o should have reacted but I'm sure that having had the Captain already b@ll@ck him several times for trivial matters,it made him reluctant to speak up.

[SLF3]

Can someone write a summary, in less than 314 words, including the headline, which accurately reports the accident and the results of the AAIB investigation, in terms a layman can understand?

If it can be done, the pilot community is vindicated and journalists aren't terribly good at their job. If it proves more difficult than expected, journalism is vindicated and the pilots should stick to flying.

[Final 3 Greens]

SLF3

I should like to counter propose that it would be far more entertaining if the journos were tasked to fly a couple of circuits in a 747 by themselves so that they could demonstrate how they can make complex things simple ;)

[Ghostflyer]

Isn't it amazing that when ever I read something in the paper, that I know something about, it tends to be misleading at best; b*llocks at worst.

What does that say about all the other info that I read that I am not so clued up on?!? No wonder I keep losing a fortune on the stock market!

Journos sell papers and sadly some of them never let fact get in the way of a good story. However, many do have high standards of probity. The ruthless and competent wordsmith can put across just about any message they want to the punters reading, without exposing themselves to litigation.

Yep Dan is right when he says 'Guys, wake up what do you expect!' Its ok to expect unbiased reporting of the facts but how boring would that be. The story has to get 'sexed up' or 'spun' to some degree to make the average punter keep reading.

Anyway back to the thread, the true disaster is the loss of life. Thank goodness no one was hurt on the ground. There should be no attribution of blame. Like most of these incidents a chain of events lead to a crash that could probably have been prevented if one of the players involved had acted differently. I am sure there are engineers and pilots out there that believe they might have acted differently in the circumstances and this might potentially have resulted in a different outcome. We are all fallible, even journos!

Ghost

[Smoketoomuch]

>Can someone write a summary, in less than 314 words

SLF - If you start with the correct headline then everything follows from there. Instead of 'Maintenance blunder led to.....' they could try 'Tragic sequence of events led to....'. In fact probably 90% of all aviation incidents could and should start with that headline.

[DCS99]

Interesting post Eng123.

I worked at Kimpo for Korean Air some years ago - they have a BA based Res and Check-in system. What an amazing experience.

On my first day there, I still remember being terrified to see the IT director at the time going absolutely ballistic shouting his head off in front of the office at a junior manager for some fook-up or whatever. I actually thought he was going to hit or kill the junior manager. The verbal haranguing went on for 10 minutes solid. But the junior guy (30-35ish years old) just stood there in front of him. Never said a word. Not a single word. He was paralysed.

Yeah, I know very well that's on the ground and not in the air. But having already had a minor boll*cking from his skipper, I would guess the F/O knew exactly what was happening, but just sat there terrified to speak up whilst the man in the LHS drove that 747 into the ground.

Different culture. You have to see it to believe it.

[GlueBall]

From a pilot's perspective the message is: Include the SAI in your primary instrument scan during IMC!

I thought that everyone had learned about that from the COPA B73-2 crash in Panama in 1992. :(

[Dantruck]

Thanks ever so much for that last, ever so constructive contribution. :rolleyes:

I note from your profile you describe yourself as: "a bit of a tosser," :) your interests as: "my wallet" :eek: and your occupation as: "complaining." ;)

You really should try to live up to your own expectations!

Please feel free to complain if I have misquoted you. :bored:

[B737NG]

True, You can write down your expirience and nobody would
believe it. I had a buddy who told something out of Taiwan and
we thought he is telling bullocks but it was only the surface what
he was talking about. That asian culture is tramendous and the
acceptance to learn from others and there past is nearly non -
existent. It took 5.000 years of human history to get there. It
will take a while until this is acknoledged there and will acceptet
as a fact that humans make errors and they need to be rectified.
Investigations in Asia are not there for prevention, they are there
for punishment. Rememer the Air-law? all regulation are based on
punishment, first they talk about fines and sentences then about
the rules. It is a diffrent world there, it started to change as well
but slowly. Since three years there is a diffrence to see and an
improvement. Today the F/O would shout, to take the controlls
from the LHS to the RHS without be authorized from the Captain?
Difficult in that part of the world. As confuzius system works there:
A older or a higher rank person is allways right!!!. How dare can
the F/O takes the controlls of that person he has to respect and
it is nearly untouchable. One day I heard: The Captain is the King,
how can You start a revolution?.
All those "facts" are not in the report, no journalist would have a
clue what is going on the society in Asia. So how to write an
article then with all the facts? Technical and humans? Difficult I would say. I have still a lot of question how that could happen?,
it is unbelievable but true, it happend but I hope never again!!!.

[Anthony Carn]

GlueBall quote - Include the SAI in your primary instrument scan during IMC!
I disagree. Never been taught to do that, never taught anyone to do that and don't see a need for it in two-crew operation. I wonder if it's even a practical idea.



Situation -- two pilots, eg Korean 747. If one of the pilots, whether handling or monitoring, sees a possible/actual problem, he should state this to the other pilot and action should be taken, subject to correct priorities being applied, to resolve the anomaly/problem.

If some wierd cultural pecking order prevents this, then such people are unfit to hold flying licences. Please don't tell me that a good dose of CRM training will cure the problem. A good dose of permanent grounding is needed.

Apply the above and your Korean 747 would still be in one piece.

End of story, regardless of maintenance shortfalls.

[Final 3 Greens]

Anthony

There was also a flight engineer who expressed concern about the ADI differences.

It's pretty scary that most of the people who live around here have no real idea of the situation that caused this 'accident' and take on trust the operation of airline flights.

Fortune only meant that the 747 didn't take out one of the many hamlets of villages around the airport and that isn't good enough.

[Flight Detent]

Hi all,
My understanding, in addition to all the situational awareness problems that were happening during the initial/final moments of this flight, is that the Flight Engineer was the ONLY one that actually knew what going on.

The report I read, stated that the FE called out, repeatedly, "Attitude - Attitude - Attitude ......." all the way to the ground contact, exactly what he is supposed to do, apparently the FO was quite busy with flight path (above the ground) following, ie, departure SID, and comms with the controlling authority, to respond!!

And......er...in my aviation career so far, Avtur IS flammible, if it was inflammable, I would have a real job starting the engines!!!

Cheers

[Final 3 Greens]

Flight Detent

Thanks for pointing out my typo! I meant flammable :O

[Flash2001]

Gents

Flammable and inflammable mean the same thing. Just another curiosity of our wonderful language.

After an excellent landing you can use the airplane again.

[Golf Charlie Charlie]

<<<
Flammable and inflammable mean the same thing.
>>>

I have noticed that this linguistic confusion is now often countered with the use of the word 'non-flammable'.

[Memetic]

To take the BBC Online story as an example, that journalist had just 314 words

Dantruck

Did the journalist really have just 314 words?

You make realistic points about how much "joe public" would actually be interested or motivated to read on this subject. So I agree that to engage the reader the journalist needed to boil the story down, get the news up front et cetera however the article under discussion was online!

Obvoulsy (As you know!) print editorial space is dictated by advertising space and cover price so there is more pressure on word count. But online the marginal cost of additional copy is basically the time take to reseach and write it.

I think this is a case of a journalist having this story on a long list of stuff to be covered and doing a fairly bog standard "air disaster report write up" - scan the report then write a reminder of remind people when and where it happened, highlight simply digested major causes, move on to next story.

Just the sort of copy that gets up the nose of professionals in any industry that know of or can see more complex issues below the surface of a rushed and over simplified news report, but as you say it's what the punters like!

[Dantruck]

You ask:

“Did the journalist really have just 314 words?”

The answer is: possibly

You are correct that text written for an online publication is not in itself hindered by space constraints (as much of the verbiage hereabouts testifies), yet often in these multitasking days ‘copy’ is re-used in print and broadcast media too – especially when the employer is as big as the BBC. Hence a need to ‘keep it tight’ still applies.

In any case good journalism will always be defined in part by an ability to convey the maximum amount of information in the minimum number of words. (How am I doing?)

Also, as you probably realise, I used the example of the BBC’s online news story linked at the start of this thread partly because it was accessible, but also to illustrate a wider point about brevity…not that I’m sure it was understood by all. A better example might have been taken from a newspaper, I grant you.

Hope this adds to the great pot of understanding, and that the vast vat of deliberate, diversionary and debasing misunderstanding be drained by an equal amount.

Daniel (still in the lions’ den) Coughlan

[jafa]

Yeah. Well, anyrate, just going on the evidence so far, we don't have to look too hard at this one to see where the blame should end up. On the desk of UK ATC for one, for requiring crews to do things other than fly the airplane when operating close to the ground at night. And for another, on the desk of whichever committee of neophytes ordered the installation and use of those time and attention consuming idiotic and dangerous zillion decimal VHF tuning heads.

Don't think so? Obvious. Captain flying, head full of the departure. Horizon locks up. Airplane wanders off in roll, as it will. FE calls the bank display error; captain doesn't register; FO, meantime, head down in the VHF set, concentrating on changing the numbers.

Boom.

[Anti Skid On]

JAFA - that's why all heavy commercial flights are two, sometimes three, crew - one to fly the aircraft, one to handle the radios, set flaps, retract gear, and in three man ops to monitor the engines. True, ATC will require a frequency change, but even in the 172 I fly this can be set to be the push of a button to the next frequency. The erroneous ADI output seems to be the issue here.

[moggie]

Mike: Jeppesen/AERAD plates will include departure frequencies on many SIDs (certainly those associated with major airports) and if not printed on the plate, ATC will give the freq as part of the clearance. London Control freqs ARE on the Stansted plates.

In my opinion, the issue with the FO is not so much that he had a lot to do but that he did not appear prioritise those tasks successfully. The frequency change to London will often clash with a turn on a SID, thrust reduction or flap retraction procedures or maybe even a level off. This is unfortunate but is a simple fact of life and as such has to be dealt with.

Priorities are always: Aviation, Navigation, Communication, Adminstration. The flying of the aeroplane in accordance with the standard flight profiles (attitudes, speeds, acceleration etc) coupled with following the SID take care of numbers 1 and 2 priority - AND ATC MUST WAIT THEIR TURN! In fact, there is a strong arguement to suggest that priorities 1 and 2 are infact inseperable when operating commercial aeroplanes under IFR - but comms and paperwork are always lower priorities.

You will hear cries of "but you must talk to London ASAP or you are not being controlled" but this is tosh (and I have this first hand from controllers there). The reasons are obvious if you think about it - what do you do if you lose comms? You follow the cleared departure and level off at the assigned altitude/Flight Level. This is what the controller is expecting you to do and he will be expecting you to be following that departure until he (or she of course) hears you check in and then tells you otherwise.

So, if you have to delay ATC check-in 10, 20, 30 seconds while you get the Captain to put his flight path right, then you do just that. ATC will still be there - but you opportunity to correct a flightpath error may not.

I get the impression that the FO was head down and distracted by the comms and was unduly pre-occupied with matters other than monitoring the performance of the aeroplane and the Captain, which is to FO's primary duty. If he had been paying more attaention to what the Captain was doing and had joined the FE in making "Attitude" calls or even taking control (I know from experience that this takes some nerve!) then the accident may well have been avoided. It does appear from the report, however, that the Captain was behaving in an autocratic and "superior" manner towards the FO, making (quote) "derogatory" comments towards him.

The following passage from the accident report is telling, I think:

In May 1999, a survey of KAL flight crews was conducted by the University of Texas Department of Psychology, through the consulting project. Over 550 pilots and flight engineers participated, in what was called the Flight Management Attitudes Questionnaire (FMAQ), responding to questions regarding 'Command Structure'. They were asked to detail their level of agreement to the following statements:

1. Juniors should not question the captain unless there is a threat to safety.

2. First Officers should never assume command of the aircraft.

3. Captains should take control/fly in emergencies.

Responses regarding these statements were then combined to form a composite score, from which was measured the differences in attitudes toward command. These were then compared to the results from sixteen other national airlines in which identical surveys had been conducted. The results showed, among other things, that KAL flight crews as a whole preferred the 'captain-centered' methodology of flight deck operation, with a relatively greater reliance on the captain.


Ultimately, it was not a "maintenance error" but an "aircrew error". The aeroplane was serviceable apart from a single instrument and there were two other instruments (more if you count the performance instruments such as HSI etc) telling the crew what was REALLY going on. The Captain appears to have belittled his FO to the extent that the chap was unwilling to question the Captain's performance and it is (speculation here) likely that the Captain would have been unreceptive to that questioning, anyway.

It bears a striking resemblance to the performance of Captain Keys in the BA Trident crash at Staines in the 70's - 25 years of lessons unlearned, it would appear.

[moggie]

Mike - your question refered to UK SIDs, though, and anyway, at STN the freq is published.

Bottom line, though, is that it still boils down to the fact poor MCC/CRM/prioritisation that caused this wholly avoidable crash.

The sad thing was that when I heard about the accident on the news my first though was not "RIP chaps" or some such but "KAL - what a surprise!"