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On April 15, 1999, a McDonnell Douglas MD-11F operated by Korean Air Cargo went into a high-speed nosedive due to pilot confusion between metric and imperial measurements. The aircraft crashed shortly after taking off from Shanghai-Hongqiao International Airport. All three crew members on board and five people on the ground were killed.
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00:00Keep turning left, keep turning.
00:02Keep turning?
00:03The controller really needs the aircraft to be going on the expected path.
00:08But seconds later...
00:10Nose up, nose up, nose up!
00:11The MD-11F crashes near a residential neighborhood.
00:16The impact registered the equivalent of a 1.6 earthquake.
00:21When investigators reconstruct the flight in a simulator...
00:25Start the dive in 3, 2, 1, go!
00:29They come to a shocking realization.
00:32The data showed that the upset was caused by a pilot input.
00:35And that becomes a mystery.
01:03It's a mild and overcast spring day at Hongchao International Airport in Shanghai, China.
01:14Korean Air Flight 6316 is being prepared for departure.
01:18The cargo plane is loaded with 86 tons of non-hazardous materials.
01:25Check list peak and light.
01:28Before start checklist, sir.
01:31The captain is 54-year-old Hong Sung Sil.
01:35Captain Hong is a very experienced pilot with 13,000 flight hours and a very good safety record.
01:42Today, his first officer is 35-year-old Park Boon Sok.
01:48First officer of Park is less experienced than a captain, but also has an excellent safety record.
01:57Doors and windows.
01:59Closed and locked.
02:02Korean Air is South Korea's flag carrier.
02:05Its headquarters is located at Gimpo International Airport in Seoul.
02:11In 1999, Korean Air is one of the top three passenger airlines in Asia.
02:17And its cargo division is top three in the world.
02:22Its route is covered Asia, South America and Europe.
02:41The flight tech is a mechanic on board who is not a part of the flight crew.
02:48His job is just to make sure this aircraft has no mechanic issue and will take off safely.
02:56Engine ignition.
02:58Stand by.
02:59Stand by.
03:00Fuel panel.
03:02Auto.
03:03Air panel.
03:05Auto.
03:06Before start checks complete.
03:08Before the aircraft can begin taxiing to the runway, it must be pushed into position on the taxiway.
03:15Captain, can you release the parking brake?
03:18Okay, brake released.
03:23All aircrafts are arced facing terminal or the cargo apron, which means the aircraft has no ability to reverse by
03:32themselves.
03:32So it's need a tow truck to push them back onto the taxiway.
03:37But as flight 6316 is being pushed back...
03:44Something's not right.
03:46The captain notices something amiss.
03:49Why is that brake temperature light on?
03:52It seems this brake isn't released.
03:54The captain noticed there is a caution that shows there is a high temperature on one of the brakes.
04:01It doesn't mean this brake is failing.
04:04It just means this brake is hotter than the others.
04:07Yeah, when we landed, that brake temp showed up.
04:12In some rare conditions, the hot brake can lead the fire in flight.
04:16But at this point, the hot brake is not a serious issue.
04:19You just keep an eye on it.
04:29I wonder what's going to happen when we take off.
04:38Captain, clear to start engines.
04:40Three, one, two.
04:42Roger, starting number three.
04:46The pilots are flying a McDonnell Douglas MD-11F.
04:52The MD-11 is a large, wide-body aircraft.
04:56This is a very high-performance airplane.
04:59And once you understand the MD-11, it is a very pleasurable airplane to fly.
05:05But it does require the pilots to be on top of their game.
05:12Korean Air 6316, taxi via Kilo 7, Tango 0 for runway 18.
05:22The aircraft begins taxiing to runway 18.
05:29Right side, clear.
05:31Right side, clear.
05:34Left side, clear.
05:44So many airlines at this airport.
05:50It's 77.
05:52It's normal now.
05:55The elevated brake temperature has returned to normal.
06:00Korean Air 6316, clear for takeoff.
06:03Clear for takeoff, 6316.
06:06Confirming we're clear for takeoff.
06:18Check thrust.
06:21Thrust is set.
06:2280 knots.
06:26V1.
06:30Rotate.
06:31Rotate.
06:34Just after 4 p.m., they lift off from Shanghai.
06:40Positive climb.
06:43Gear up.
06:53The flight from Shanghai to Seoul is expected to take two hours.
07:01Shortly after takeoff, the controller provides the pilots with their climb-out instructions.
07:06Korean Air 6316, now turn left direct to November Hotel Whiskey, then climb and maintain 1,500 meters.
07:14The MD-11 is to continue climbing and turn left to intercept NHW.
07:22NHW, or November Hotel Whiskey, is a ground-based navigation beacon that assists pilots in guiding their plane through the
07:30skies.
07:32Okay, direct November Hotel Whiskey, and say again, altitude?
07:37Reconfirming the altitude instruction is smart.
07:40Every aircraft had their assigned route or assigned altitude by the ATC.
07:46So that is very important, to hold this altitude, to avoid the conflicts with others.
07:53But as the pilots confirm their instructions, the controller notices the plane has yet to turn towards the NHW navigation
08:02fix.
08:03Flight 6316, turn left, direct to November Hotel Whiskey, then climb and maintain 1,500 meters.
08:12The controller can see on the radar scope that the aircraft is not turning left, and so is reminding the
08:20crew that they need to turn left by reissuing the clearance.
08:28But as the controller repeats his instructions...
08:32I don't see NHW.
08:34...the navigation fix does not appear on the captain's display screen.
08:41Where is it?
08:43Uh, here.
08:44Keep turning left.
08:47Keep turning.
08:49Keep turning?
08:50Yes, keep turning more.
08:52As the pilots continue their turn, the controller realizes the plane isn't climbing.
08:59Korean Air 6316, climb and maintain 1,500 meters.
09:04Are they asking us to...
09:06Yes, they're telling us to climb.
09:07Yes, they're telling us to climb.
09:12The aircraft hasn't even reached the initial altitude that they were cleared to.
09:16So this is a way to remind the crew, we need to get moving, we need to climb.
09:23Just as Flight 6316 nears its assigned altitude...
09:30...it disappears from radar.
09:41The plane is diving uncontrollably towards the ground, too fast to be picked up by radar.
09:48The controller is unaware of its descent.
09:51Korean Air 6316, do you read?
09:56Wait, wait, wait, pitch!
10:01Korean Air 6316, radio check.
10:09Korean Air Flight 6316 bursts through the clouds above Shanghai.
10:14Nose up, nose up, nose up!
10:23And slams into the ground, seven miles from the airport.
10:29Less than two and a half minutes after takeoff.
10:34At the speed they hit the ground, the impact was so severe that it registered the equivalent of a 1
10:42.6 earthquake.
10:45The aircraft crashes in Xinhuang, on the outskirts of the town's residential area.
10:53The accident claims the lives of both pilots and the flight technician.
11:00Five civilians are killed, 40 more are injured.
11:11The investigation into the crash is handled jointly by the three countries involved.
11:16Representatives from the Korean Civilian Aviation Bureau are on site on behalf of the airline.
11:23With the crash occurring on Chinese soil, the investigation is led by the Civil Aviation Administration of China.
11:33And as the plane is manufactured in the U.S., an American investigator from the National Transportation Safety Board joins
11:41the team.
11:42What did you find?
11:43The debris trail runs nearly two kilometers.
11:46Fan pattern.
11:50Typically on impact, as the airplane hits the ground, all of a sudden pieces will start coming apart.
11:59The biggest pieces will keep going straight.
12:01The other pieces will start fanning out.
12:04They'll spread.
12:06They had to impact at a relatively shallow angle to make that pattern.
12:11But as investigators continue to analyze the crash site, they learn that critical evidence has been destroyed.
12:19Not much left of the flight data recorder.
12:25One of the major tools in a modern aircraft accident investigation is the flight data recorder.
12:32More modern ones can record thousands of parameters.
12:35Angle attack, airspeed, engine parameters.
12:39The lack of a flight data recorder during an investigation is a major blow.
12:53Police say some of the cargo has been stolen from the crash site.
12:57In the chaos, some of the local residents decided to help themselves to some of the cargo.
13:02This creates a situation where investigators might not find critical parts that they need to solve the accident.
13:10Has anyone found the cockpit voice recorder?
13:20If you don't have a flight data recorder, and you don't have a cockpit voice recorder,
13:26you really have to go back to the basics to try to figure out what happened.
13:31Investigators start by examining impact scars left by the engines to determine at what attitude the plane struck the ground.
13:40The ground slope's 30 degrees down from the horizontal.
13:44Slope is the same for the other ground scar, and wings were level.
13:50The aircraft engines are very heavy.
13:53They'll make their own craters.
13:55So you look at the angle the engines are in.
13:59That gives you a very good idea of the pitch angle at impact,
14:03because those parts are basically going to try to just bore a hole into the dirt.
14:09So, the aircraft takes off.
14:12Roughly three minutes later, it crashes in a dive, 30 degrees nose down, with wings level.
14:18So what caused the dive?
14:22The ground information tells you how the airplane went down.
14:26We don't know why it went down.
14:28And that takes a lot more effort.
14:31We need to test for explosives.
14:34Get at least a dozen specimens from the wreckage, and send those samples to the lab for testing.
14:39Chinese authorities wonder if an act of terrorism could have caused the accident.
14:44In any investigation, anything could have happened.
14:47And one of those events could have been sabotage or a bomb.
14:50So it's important in investigations to rule out something like that as soon as possible.
14:59As police look for evidence of explosives, investigators interview the air traffic controller.
15:07Anyone who talked to the crew is a witness to the investigation.
15:12And the controller is the last person to talk to the crew.
15:14So it was very important to get his impressions, what he did, what he's hearing back from the pilots,
15:20and understand what was happening that night.
15:25To start, what stood out to you about the flight?
15:29Takeoff seemed normal.
15:30But afterwards, the pilots struggled to maintain the flight plan.
15:35Turn left, direct to November, Hotel Whiskey.
15:38Then climb and maintain 1,500 meters.
15:42They eventually made their turn, but I had to remind them.
15:44After that?
15:45As they corrected their turn, I noticed they were still too low.
15:49So I told them to climb.
15:57I had to remind them a second time before they started to climb.
16:02I thought they were off safely.
16:05The next thing I knew, the plane disappeared from radar.
16:10The air traffic controller sees the aircraft climbing.
16:15Everything looks normal and fine.
16:17And then all of a sudden, things go very wrong.
16:20Korean Air 6316, do you read?
16:24Korean Air 6316, radio check.
16:31Is that the radar data?
16:33Yes.
16:35Looks like your communication was by the book.
16:38Thank you.
16:40Looking at the radar recordings is very important, especially if you haven't looked at the COPKAT voice recorder or the
16:47FDR.
16:48This gives you an initial framework to work with.
16:52Can the radar data provide any clues?
16:57The plane climbs to 1371 meters, or 4,500 feet.
17:03Roughly 16 seconds later, it impacts the ground.
17:07That's a descent rate of roughly 17,000 feet per minute.
17:19We have a saying in aviation called a minute to die rule, which means that if your rate of descent
17:25in feet per minute is greater than your altitude, that's a dangerous situation.
17:32Flight 6316's rate of descent was more than three times greater than their altitude.
17:39It's virtually impossible to recover the aircraft.
17:44What would cause the plane to descend at such an incredible speed?
17:49Maybe there's a problem with the aircraft.
17:52I'll pull the maintenance records.
17:55During the initial stages of the investigation, the investigators will look at all of the maintenance records of the aircraft.
18:02Any write-ups of issues on handling, delayed maintenance for some reason, anything at all that would give a clue
18:12to what could have happened here.
18:19Here's something.
18:21Investigators examine maintenance records of Korean Air Flight 6316, looking for clues to explain why a modern jetliner plunged from
18:30the sky so soon after takeoff.
18:32On May 25, 1996, the aircraft experienced a tail strike at LAX.
18:40The incident required a repair that took 63 days to complete.
18:46That is an interesting finding, because if the repairs to the aircraft from the tail strike are not done properly,
18:54it can cause that area to detach in flight, and in the process, damage the pitch controls of the airplane.
19:01And we've seen that before.
19:02In 1978, a Japan Airlines Boeing 747 suffered a tail strike while landing at Osaka.
19:11A faulty repair led to explosive decompression seven years later, tearing off the tail and killing 520 people.
19:23If that's what happened here, that could explain everything.
19:28Did poor maintenance cause the plane's tail to break apart mid-flight?
19:43Well, here's the vertical stabilizer.
19:47Investigators find pieces of Korean Air Flight 6316's tail section in the wreckage.
19:54With all the pieces of the tail this close to the main crash site, it didn't separate in flight.
20:00So the repair was done correctly?
20:03They conclude that a tail strike did not cause any part of the MD-11's tail to detach from the
20:09plane.
20:10Maybe the dive was caused by a failure in one of the plane's control surfaces.
20:14Like the horizontal stabilizer?
20:19The horizontal stabilizer is the small wing on the tail that controls the pitch of the aircraft.
20:27Maybe the jack screw jammed.
20:33When commanded, a jack screw in the tail rotates, moving the horizontal stabilizer up or down.
20:41If the jack screw has jammed in a nose-down position, now the airplane would suddenly pitch over and the
20:49flight crew would be fighting to try to get the nose up.
20:53Pitch!
20:54Okay, okay.
20:56But they would have a lot of forces on the control column trying to fight the aircraft from pitching down
21:02towards the Earth.
21:08Was the horizontal stabilizer jammed in a nose-down position, causing the plane to plummet?
21:17Well, the jack screw isn't jammed, so the stabilizer was working as intended.
21:21And what position is it in?
21:2810.25 inches, so it was set to 0.65 degrees.
21:34Nose up.
21:37The pilots were fighting against the dive.
21:43Nose up, nose up, nose up!
21:44Trimming the horizontal stabilizer nose up while pulling back on the controls to try to arrest the descendant.
21:53H3454-1, 30-3!
22:07Chemical analysis report is in from the wreckage.
22:10No evidence of explosives.
22:12I'll start typing this up for the press.
22:15We need to reassure the public it's safe to fly in China.
22:18Sounds good.
22:23The Civil Aviation Administration of China, along with its U.S. and Korean counterparts,
22:29released a bulletin almost two weeks after the incident.
22:32The Chinese investigation wants to make two things clear.
22:35One, it's not a bomb. Two, it's not a fault from the Chinese ATC controller.
22:41With terrorism, air traffic control and poor maintenance discounted,
22:46investigators now focus their attention on the pilots.
22:49Let's start with the captain.
22:51In all accidents, one of the tasks is investigating the background of the pilots
22:58to ensure that there's no issues.
23:01V1. Rotate. Rotate.
23:05Training can make a very big difference, and also things going on in their personal life.
23:11We want to make sure that the person wasn't under any particular stressors
23:15that could cause distractions and inhibit their performance in any way.
23:21Captain Hong was quite seasoned, almost 13,000 flight hours, with nearly 5,000 on the MD-11 alone.
23:28No psychological burdens, and a perfect safety record.
23:33Yeah. First Officer Park. Over 1,800 hours. Majority on the MD-11.
23:38No psychological burdens, and also a perfect safety record.
23:42Two model pilots.
23:49Yes.
23:51Yes.
23:52Is it intact?
23:54They found the cockpit voice recorder.
23:59Yes.
24:01Is it intact?
24:08They left, and they found the CVR.
24:13Memory is safe. Full data recovery.
24:17Excellent work, and thank you.
24:21They're going to get the transcripts ready for us.
24:23At this point in the investigation, we're wondering what caused a mechanically sound airplane piloted
24:31by two well-trained, experienced pilots to suddenly dive into the ground, and that becomes
24:37a mystery.
24:46Okay, let's start with an aerodynamic stall from 1371 meters.
24:55Using a Boeing simulator in California.
24:59We'll see what rate of descent we get.
25:03Investigators combine radar data with evidence from the wreckage of Korean Air Flight 6316
25:10to determine why the plane plummeted to the ground.
25:16In the simulator, the investigators accomplished over a hundred different scenarios, trial and
25:21error. How do we match the data points?
25:28Rated descent was 3,314 feet per minute. Not even close to 17,000. It couldn't have been a stall.
25:38And so, they take all this information, and then the simulator try to determine what's the best fit for
25:46the data. And you start limiting things.
25:49Let's try out-of-control elevators. The accident plane impacted nose down.
25:53At an estimated 20 to 40 degrees.
26:09The pitch is way too sharp. Let's try to pull up anyway for accuracy.
26:14Through all the simulator runs they did.
26:17Pull up.
26:20Eighty-six degrees, okay? It was not out-of-control elevators either.
26:25They found that you could not match the rate of descent and the profile you needed to match the data
26:33with an aerodynamic stall or mechanical failure.
26:41Try intentionally pushing the plane into a dive.
26:54Push it nose down. The vertical speed increase. Then trim the horizontal stabilizer up. Then try to pull out of
27:01it.
27:08Start the dive in. Three, two, one, go.
27:19Stabilizer moving.
27:23Only one simulation precisely replicates the data from flight 6316.
27:29Dive time, 18 seconds, 25 degrees, nose down. Maxed out rate of descent.
27:36That's the closest we've been yet.
27:38Investigators conclude that the plane must have been put into a nose dive intentionally.
27:43The data showed that the upset was caused by a pilot input.
27:47And so now the focus becomes on why would the pilot do this?
27:53Knowing that the crash of flight 6316 could have resulted only from deliberate pilot input,
27:58investigators listened to the CVR to determine why the pilots commanded the airplane into a steep dive.
28:05Okay. Let's have a listen.
28:09Captain, can you release the parking brake?
28:13Okay. Brake released.
28:17Uh-oh. Something's not right.
28:21Why is that brake temperature light on?
28:24Is the high brake temperature somehow connected to the nose dive?
28:30Yeah, when we landed, that brake temp showed up.
28:33But soon after...
28:35It's dropping down now.
28:38So the brake was a non-factor.
28:42Agreed. Let's keep going.
28:46Flight 6316, copy ATC clearance.
28:50Go ahead. Korean Air 6316.
28:53Korean Air 6316, after departure, turn left direct to November Hotel Whiskey.
28:58Initially climb and maintain nine or hundred meters.
29:01Read back, please.
29:02Okay, sir. Initially maintain 900 meters. Then after takeoff, turn left direct to November Hotel Whiskey. Is that correct?
29:09That's affirmative.
29:11Did he say 900 meters?
29:13Yeah, 900 feet.
29:18Did you catch that? After the controller read the altitude clearance.
29:23Investigators hear that there's some confusion about altitude measurements.
29:28Why are they using metric at all? Imperial is the airspace standard.
29:33Not in China.
29:36Most of this world, including South Korea, measure altitude in feet.
29:41The Chinese aviation industry is based on the old Soviet Union aviation industry.
29:49The USISR used the metric system.
29:52So today, China still used the metric system.
29:58Okay. But I imagine the captain will sort that out in the takeoff briefing.
30:03Let's find out.
30:05Korean Air 6316, clear for takeoff.
30:09Clear for takeoff, 6316. Confirming we're clear for takeoff.
30:16Wait. Did the captain skip his takeoff briefing?
30:20I'm not seeing one in here.
30:23A takeoff briefing is a way to create what we call a shared mental model,
30:29where both pilots are on the same page. Otherwise, you're simply not prepared for the flight.
30:34The briefing would also have noted that Shanghai uses metric altitudes.
30:40So did skipping the briefing somehow play a role in the nosedive?
30:52Investigators revisit the CVR, searching for evidence that the omission of a critical briefing
30:58contributed to the crash of flight 6316.
31:01Let's start with the initial climb.
31:06Turn left, direct to November, Hotel Whiskey, then climb and maintain 1,500 meters.
31:12The team hears the controller giving the pilots their climb-out instructions.
31:17I don't see NHW.
31:21Where is it?
31:23But the captain can't find the navigation beacon on his display.
31:28Sounds like an issue with the captain's narrow display.
31:32Uh, here. Keep turning left.
31:36The recording suggests the first officer's navigation display was functioning properly.
31:41Keep turning.
31:43Keep turning?
31:44Yes, keep turning more.
31:47Damn.
31:48Why isn't an NHW showing?
31:51The CVR portrays a captain who appears confused.
31:57I bet he zoomed in too far on the nav display.
32:00That's why he can't see the beacon.
32:02Had the pilot reached up and changed the range on his display, he would have had that available to him.
32:08That would explain why it took them so long to turn left.
32:12Had they done the takeoff briefing, they could have caught the issue.
32:17Had they discussed completely in the pre-flight briefing, here's where we're going, and cross-checked their displays, that would
32:24have been caught.
32:26And it wasn't.
32:28It still doesn't explain the dive though.
32:33Korean Air 6316, climb and maintain 1,500 meters.
32:38Are they asking us to-
32:40Yes, they're telling us to climb.
32:45Seems like they're so preoccupied getting the plane to turn left.
32:49They forgot to climb.
32:51Especially since the controller told them, twice.
32:58Then investigators hear a warning, telling the pilots that they're approaching their target altitude.
33:03Altitude.
33:06Pitch, sir.
33:08The first officer points out that they're climbing too quickly.
33:13Why is he climbing so quickly?
33:18His mistakes are adding up.
33:22He's trying to overcompensate to get to his altitude.
33:27He's pitching up too fast.
33:29He's doing things too quickly.
33:32Was the nosedive just another mistake?
33:42How far are they telling us to climb?
33:46He still doesn't know his altitude clearance.
33:49It doesn't look like the first officer knows either.
34:04They're talking in terms of feet, even though the controller's instructions were in meters.
34:09They're talking in terms of feet.
34:10Investigators now realize the controller and the pilots are using different altitude measurements.
34:17No, no, no, no.
34:45What kind of training do they have?
34:47They require their pilots to watch a single training video to learn metric conversion.
34:52According to the pilot records, the captain had only flown into Shanghai once prior.
34:59The first officer had never flown there before.
35:03Which means the first officer would have watched the training video for the first time only that morning.
35:12Investigators conclude that the pilots of flight 6316 confused metric and Imperial.
35:19Fifteen.
35:21Because they were inadequately prepared for the flight.
35:24For the pilots to operate in a metric environment, this is something that you need to get into a simulator
35:30and you need to practice it.
35:32Watching a video is just not going to be enough, period.
35:36So was the metric confusion the reason why they pushed the plane into a nosedive?
35:46How far did they tell us to climb?
35:49As the flight reaches its assigned altitude of 4,500 feet or 1,500 meters...
35:541,500 feet, sir.
35:58The first officer leads the captain to believe they should be much lower at 1,500 feet.
36:03The captain, thinking that they have blown through their clearance, would be extremely alarmed because now there is a very
36:12strong potential for a traffic conflict.
36:16Fifteen.
36:18I'm too high.
36:21Descend, descend, descend.
36:24The quickest response is to push forward on the controls.
36:36The captain pushes the plane into a steep dive to descend to a much lower altitude.
36:47You can hear the captain trim the plane down.
36:49He put them in the dive.
36:53He pitches the aircraft nose down and simultaneously is trimming the horizontal stabilizer, which relieves the control column pressure.
37:04But the combination of these things put the aircraft into a dive for which it's almost impossible to recover.
37:12During the descent, the first officer suddenly recognizes the seriousness of their situation.
37:18Wait, wait, pitch.
37:19Oh, oh, oh, oh, okay, okay.
37:23But by the time the pilots realize the danger...
37:27No, stop, no, stop, no, stop.
37:33It's too late.
37:39Investigators conclude that the crash was caused by the captain's confusion over his altitude measurement.
37:45Even if the captain thought he was too high, why not descend more gradually?
37:56Wait, wait, wait, wait, wait.
38:03First he climbed too quickly, then he descended way too quickly.
38:07Investigators try to determine why the captain of Korean Air Flight 6316 reacted so drastically to his belief that the
38:14aircraft was too high.
38:16Maybe he was trying to cover up his mistakes.
38:22On one hand, the captain knows it is dangerous when they're overshooting the altitude.
38:28How far did he tell us to climb?
38:31On the other hand, the captain doesn't want the controller to know that he made a mistake.
38:37So he tried to get down quickly to save face.
38:41What I don't understand is, why didn't the first officer try to stop him?
38:47Especially since he was guiding him earlier.
38:53There's a lot going on, and the first officer is not only trying to read back the clearances,
39:01but also trying to ensure that the captain is turning in the direction that needs to be turned.
39:06Keep turning.
39:08Keep turning?
39:09Yes, keep turning more.
39:15I've got the CVR all set for the moment before the dive.
39:20Did the first officer ever recognize the error?
39:28How far did he tell us to climb?
39:311,500 feet, sir.
39:34Oh.
39:35Oh.
39:41Wait, wait, wait, wait.
39:44Investigators hear the first officer hesitate after providing the captain with the wrong altitude.
39:50Maybe at that point the first officer recognized his mistake was feet and meters, we don't know.
39:55Just a moment.
40:03Wait, pitch.
40:04Oh, oh, oh, okay, okay.
40:10So the dive starts, and he says, wait, wait, wait.
40:19Then after five full seconds of free fall, he says, wait, pitch.
40:28Clearly, there should have been some input, some effort for the first officer to try to slow things down.
40:43In my opinion, the first officer was speaking, but he wasn't speaking up.
40:49Wait, wait, wait, wait, wait.
40:51Just, just a moment.
40:52He gave little hints that things were going wrong to the captain, but it was apparent that the pilots were
40:58not on the same page.
41:07At the end of the day, the captain caused the dive.
41:13He overreacted.
41:16The rate of descent was so high that now it became very difficult to recover once you got down to
41:24the lower altitudes.
41:26And probably they didn't realize the trouble they were in until they could see breaks in the clouds and see
41:31the ground.
41:32No, stop, no, stop, no, stop.
41:34Pull up.
41:36Pull up.
41:43In their final report, investigators conclude that confusion over the metric system led the first officer to relay the wrong
41:51altitude.
41:53How far did they tell us to climb?
41:551,500 feet, sir.
41:59That mistake caused the captain to overcompensate.
42:03Wait, wait, wait, wait.
42:05Just a moment.
42:07And push the aircraft into a fatal dive.
42:12We can look at this as a training accident as much as anything else.
42:18The way the pilots were trained at that time resulted in a series of decisions and actions that put the
42:27airplane in an unrecoverable situation.
42:30In Chinese aviation industry, we have a motto.
42:33Every line in the checklist is written in blood.
42:37Because behind every line in the checklist is a disaster.
42:41But it's an opportunity to improve.
42:45One of the recommendations was that Korean Air reinforce its cockpit resource management training.
42:52It's part of the fabric that holds a safe flight together.
42:55And that includes things like a free takeoff briefing.
42:58So these are some of the items that, in my mind, were most important.
43:05Today, Korean Air is recognized as one of the safest airlines in the world.
43:13The amount of standardization through all the airlines, the amount of training now, is much higher level than it was
43:20before.
43:21The digital airplanes, there's a button you can turn, and all your displays show meters instead of feet.
43:29But it does bring up the need for vigilance.
43:33Because this crew made so many errors, losing control of a big airplane is very unusual, and hopefully we won't
43:42see it again.
43:42Thank you.
43:44Thank you.
43:46Thank you.
43:46Thank you.
43:47Thank you.