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Korean Air B747 (Stansted crash) report out

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Korean Air B747 (Stansted crash) report out

Old 25th Jul 2003, 09:33
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Korean Air B747 (Stansted crash) report out

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

I first spotted this on the BBC news pages (see paste below)

and the full (AAIB) report is here

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.


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.


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?)
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Old 25th Jul 2003, 10:45
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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.
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Old 25th Jul 2003, 17:34
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Does anyone have to hand a Dangerous Goods Handbook?

What is the weight limit for depleted Uranium as cargo?
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Old 25th Jul 2003, 17:40
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I don't think the DU was cargo, but ballast.
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Old 25th Jul 2003, 17:54
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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!
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Old 26th Jul 2003, 16:01
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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.
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Old 26th Jul 2003, 18:10
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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.

Last edited by Dantruck; 26th Jul 2003 at 18:22.
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Old 26th Jul 2003, 20:00
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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.
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Old 26th Jul 2003, 21:35
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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.
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Old 27th Jul 2003, 01:12
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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.
Old 27th Jul 2003, 03:39
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Dear BEagle (and Mike Jenvey)

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
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Old 27th Jul 2003, 03:50
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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.
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Old 27th Jul 2003, 04:44
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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...>

Last edited by Kalium Chloride; 27th Jul 2003 at 04:55.
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Old 27th Jul 2003, 05:19
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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.
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Old 27th Jul 2003, 07:22
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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.



Edited for a couple of typos

Last edited by Dantruck; 29th Jul 2003 at 07:17.
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Old 27th Jul 2003, 12:20
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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

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.
Old 27th Jul 2003, 15:09
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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.
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Old 27th Jul 2003, 16:31
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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.
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Old 27th Jul 2003, 16:43
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Final 3 Greens

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.
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Old 27th Jul 2003, 17:17
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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.

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