Korean Air B747 (Stansted crash) report out
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As a pax, I hope this isn't too dumb a question. 
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?
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?
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.
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.
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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.
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.
Grim Sleeper
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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.
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.
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.
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.
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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.
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.
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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.
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.
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.
Last edited by WHBM; 28th Jul 2003 at 04:54.
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Guys, wake up. Just what do you expect?
Guys, wake up. Just what do you expect?
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.
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Sorry Danny - didn't mean it, honest!
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.
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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.
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.
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.
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.
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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
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!
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>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.
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.
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The F/O said nothing and did nothing.
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.
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.
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The SAI is your friend in IMC
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.
I thought that everyone had learned about that from the COPA B73-2 crash in Panama in 1992.
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Slim20
Thanks ever so much for that last, ever so constructive contribution. 
I note from your profile you describe yourself as: "a bit of a tosser,"
your interests as: "my wallet" 
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.
I note from your profile you describe yourself as: "a bit of a tosser,"
your interests as: "my wallet" 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.
Last edited by Dantruck; 29th Jul 2003 at 07:01.
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OCS 99
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!!!.
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!!!.
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GlueBall quote -
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.
Include the SAI in your primary instrument scan during IMC!
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.
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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.
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.