- 19 hours ago
Air Crash Investigation - Season 26 - Episode 10: Mixed Measures (Korean Air Cargo Flight 6316)
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TVTranscript
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 a flight in a simulator...
00:25Start to dive in 3, 2, 1, go.
00:30They come to a shocking realization.
00:32The data showed that the upset was caused by a pilot input.
00:35And that becomes a mystery.
00:40MD, MD, MD.
00:45Up!
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.
01:19The cargo plane is loaded with 86 tons of non-hazardous materials.
01:25Checklist peak and light before start checklist, sir.
01:31The captain is 54-year-old Hong Sung Seel.
01:35Captain Holm is a very experienced pilot with 13,000 flight hours and a very good safety record.
01:43Today, his first officer is 35-year-old Pak Boon Sok.
01:47The first officer 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.
02:31Hey guys, any issues or concerns?
02:34All good so far.
02:36Also on board is 48-year-old flight technician Pak Byung Ki.
02:42The 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.
02:58Standby.
02:59Standby.
03:01Fuel panel.
03:02Auto.
03:03Air panel.
03:05Auto.
03:05Before start check is 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 aircraft are arc the facing terminal or the cargo apron, which means the aircraft has no ability to reverse
03:31by themselves.
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.
03:55The 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 heartbreak can lead the fire in flight.
04:16But at this point, the heartbreak 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.
04:57This 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 6-3-1-6, request taxi.
05:15Korean Air 6-3-1-6, taxi via Kilo-7, Tango-0 for runway 1-8.
05:23The aircraft begins taxiing to runway 1-8.
05:29Right side, clear.
05:31Right side, clear.
05:33Left side, clear.
05:44So many airlines at this airport.
05:50It's 77.
05:53It's normal now.
05:55The elevated brake temperature has returned to normal.
06:00Korean Air 6-3-1-6, clear for takeoff.
06:03Clear for takeoff, 6-3-1-6.
06:06Confirming we're clear for takeoff.
06:18Check thrust.
06:21Thrust is set.
06:2380 knots.
06:26V-1.
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 6-3-1-6, now turn left, direct to November Hotel Whiskey, then climb and maintain 1,500
07:13meters.
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 to November Hotel Whiskey, and say again, altitude?
07:38Reconfirming the altitude instruction is smart.
07:41Every 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.
08:13The 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...
08:31I 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.
08:53As 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.
09:12The 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.
09:41...the 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, 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!
10:24And 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...
10:38...that it registered the equivalent of a 1.6 earthquake.
10:45The aircraft crashes in Sinshuang, 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.
11:17Representatives from the Korean Civilian Aviation Bureau are on site on behalf of the airline.
11:24With 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.
11:47Fan 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.
12:26One 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 sum 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?
13:16Hopefully that wasn't stolen, too.
13:21If you don't have a flight data recorder, and you don't have a cockpit voice recorder, you really have to
13:27go 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 is 30 degrees down from the horizontal slope is the same for the other ground scar, and
13:47the 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, because those parts are basically going to
14:06try to just bore a hole into the dirt.
14:09So, aircraft takes off.
14:12Roughly three minutes later, it crashes in a dive 30 degrees nose down with wings level.
14:18So what goes to 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.
14:32We 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.
14:51So 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, and the controller is the last person to
15:14talk to the crew.
15:14So it was very important to get his impressions, what he did, what he's hearing back from the pilots, and
15:21understand 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.
15:45After that?
15:45As they corrected their turn, I noticed they were still too low, so I told them to climb.
15:52Korean Air 6316, climb and maintain 1,500 meters.
15:57I had to remind them a second time before they started to climb.
16:03I 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, everything looks normal and fine, and then all of a sudden, things
16:19go very wrong.
16:20Korean Air 6316, do you read?
16:24Korean Air 6316, radio check.
16:31Is that the radar data?
16:33Yes.
16:39Looking at the radar recordings is very important, especially if you haven't looked at the Copka voice recorder or the
16:47FDR.
16:49This gives you an initial framework to work with.
16:52Can the radar data provide any clues?
16:58The 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 the 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.
17:40It'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.
18:47That 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?
19:44Well, 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.
21:22And what position is it in?
21:2810.25 inches, so it was set to 0.65 degrees.
21:34Nose up.
21:38The pilots were fighting against a dive.
21:43Nose up, nose up, nose up!
21:45Trimming the horizontal stabilizer nose up while pulling back on the controls to try to arrest the descendant.
21:53Great.
22:07Chemical analysis report is in from the wreckage.
22:10No evidence of explosives.
22:13I'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, release a bulletin almost two weeks
22:31after the incident.
22:32The Chinese investigation want to make two things clear.
22:36One, it's not a bomb.
22:37Two, it's not a fault from the Chinese ATC controller.
22:40With terrorism, air traffic control, and poor maintenance discounted, investigators 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 to ensure that there's no issues.
23:01V1.
23:03Rotate.
23:04Rotate.
23:05Training can make a very big difference.
23:08And also things going on in their personal life.
23:10We want to make sure that the person wasn't under any particular stressors that could cause distractions and inhibit their
23:19performance in any way.
23:21Captain Hong was quite seasoned.
23:23Almost 13,000 flight hours, with nearly 5,000 on the MD-11 alone.
23:29No psychological burdens and a perfect safety record.
23:32Yeah, 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.
23:44Yeah.
23:50Yes.
23:52Is it intact?
23:55They found the cockpit voice recorder.
24:00After the accident, there was very heavy rain in the Shanghai area.
24:05So they pumped out some water from some of the ponds that were left, and they found the CVR.
24:13Memory is safe.
24:14Full data recovery.
24:17Excellent work.
24:18And 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 by two well-trained, experienced
24:33pilots to suddenly dive into the ground.
24:36And that becomes a 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
25:09to determine why the plane plummeted to the ground.
25:15In the simulator, the investigators accomplished over a hundred different scenarios, trial and error.
25:22How do we match the data points?
25:25Pull up.
25:28Rate of descent was 3,314 feet per minute.
25:33Not even close to 17,000.
25:35It couldn't have been a stall.
25:38And so, they take all this information, and then the simulator tried to determine what's the best fit for the
25:46data, and you start limiting things.
25:50Let's try out-of-control elevators.
25:52The accident plane impacted nose down at an estimated 20 to 40 degrees.
26:09The pitch is way too sharp.
26:10Let's try to pull up anyway for accuracy.
26:14Through all the simulator runs they did...
26:17Pull up.
26:2086 degrees.
26:22Okay, 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
26:32with an aerodynamic stall or a mechanical failure.
26:41Try intentionally pushing the plane into a dive.
26:54Push your nose down.
26:56That vertical speed increase.
26:58Then trim the horizontal stabilizer up.
27:00Then try to pull out of it.
27:08Start the dive in 3,2,1, go!
27:19Table line for your mommy.
27:23Only one simulation precisely replicates the data from Flight 6316.
27:29Dive time, 18 seconds.
27:3225 degrees, nose down.
27:34Max 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 pile 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, investigators listened to the CVR
28:01to 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?
28:25Is 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.
28:43Let'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 900 meters.
29:01Read back, please.
29:02Okay, sir. Initially maintain 900 meters.
29:05Then after takeoff, turn left direct to November Hotel Whiskey.
29:08Is that correct?
29:09That's affirmative.
29:11Did he say 900 meters?
29:13Yeah, 900 feet.
29:18Did you cast that?
29:19After the controller read the altitude clearance.
29:23Investigators hear that there's some confusion about altitude measurements.
29:28Yeah, why are they using metric at all?
29:31Imperial is the airspace standard.
29:33Not in China.
29:37Most of this world, including South Korea, measure altitude in feet.
29:42The Chinese aviation industry is based on the old Soviet Union aviation industry.
29:48The USISR used the metric system.
29:53So today, China still use the metric system.
29:58Okay.
29:59But I imagine the captain will sort that out in the takeoff briefing.
30:03Let's find out.
30:05Korean Air 6316.
30:07Clear for takeoff.
30:09Clear for takeoff, 6316.
30:11Confirming we're clear for takeoff.
30:15Wait.
30:17Did 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.
30:31Otherwise, you're simply not prepared for the flight.
30:35The 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 contributed to the crash of flight
31:006316.
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 nano display.
31:32Uh, here.
31:35Keep 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 NHW showing?
31:50The 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,
32:20here's where we're going, and cross-checked their displays, that would have 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.
32:54Twice.
32:58Then investigators hear a warning, telling the pilots that they're approaching their target altitude.
33:04Altitude.
33:06Up pitch, sir.
33:08The first officer points out that they're climbing too quickly.
33:14Why is he climbing so quickly?
33:18His mistakes are adding up.
33:23He'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.
33:54To get up.
33:565-5,500 feet, sir.
33:595-5.
34:04They're talking in terms of feet, even though the controller's instructions were in meters.
34:10Investigators now realize the controller and the pilots are using different altitude measurements.
34:17and weren't they trained to use metric should be well let's check certainly the more training you
34:25have that would help greatly in terms of sorting out the meters versus feet I see thank you for
34:34your time they look deeper into the training procedures for Korean air pilots Korean air
34:40says the Seoul to Shanghai route is the only one where their pilots need to use metric what kind
34:46of training they have they require their pilots to watch a single training video to learn metric
34:51conversion according to the pilot records the captain had only flown into Shanghai once prior
34:59the first officer had never flown there before which means the first officer would have watched
35:05the training video for the first time only that morning investigators conclude that the pilots of
35:15flight 6316 confused metric and Imperial because they were inadequately prepared for the flight for
35:25the pilots to operate in a metric environment this is something that you need to get into a simulator
35:31and you need to practice it watching a video it's just not going to be enough period so was the
35:37metric
35:37confusion the reason why they'd push the plane into a nose dive how far did they tell us to climb
35:48as the
35:49flight reaches its assigned altitude of 4500 feet or 1500 meters 1500 feet sir the first officer leads the
36:00captain to believe they should be much lower at 1500 feet the captain thinking that they have blown
36:07through their clearance would be extremely alarmed because now there is a very strong potential for a
36:14traffic conflict
36:18I'm too high
36:21descend descend descend descend descend the quickest response is to push forward on the controls
36:33wait wait wait wait wait wait this is just a moment the captain pushes the plane into a steep dive
36:40to
36:40descend to a much lower altitude
36:47you can hear the captain trim the plane down he 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 wait pitch
37:23but by the time the pilots realize the danger
37:27nose up nose up nose up nose up
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
37:48why not descend more gradually
37:56wait wait wait wait wait
38:03first he climbed too quickly
38:05then he descended way too quickly
38:07investigators try to determine why the captain of Korean Air Flight 6316 reacted so drastically
38:13to his belief that the aircraft 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 overshooting the altitude
38:28how far did they tell us to climb?
38:31on the other hand the captain doesn't want the controller to know that he made a mistake
38:36so he tried to get down quickly to save face
38:41what I don't understand is
38:43why didn't the first officer try to stop him?
38:48especially since he was guiding him earlier
38:54there's a lot going on
38:55and the first officer is not only trying to read back the clearances
39:00but also trying to ensure that the captain is turning in the direction that needs to be turned
39:06keep turning
39:08keep turning?
39:09keep 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?
39:31f-f-fifteen hundred feet sir
39:35uh...
39:37oh...
39:41wait, wait, wait, wait
39:43investigators hear the first officer hesitate after providing the captain with the wrong altitude
39:51maybe at that point
39:52maybe at that point the first officer recognized his mistake was feet and meters
39:55we don't know
39:55this is just a moment
40:03wait, pitch
40:04oh, oh, oh, oh, okay, okay
40:11so the dive starts and he says, wait, wait, wait
40:19wait, wait, wait
40:20then after five full-second
40:21and freefall
40:22he says
40:24wait
40:25pitch
40:28clearly there should have been some
40:32input
40:32some effort for the first officer to try to slow things down
40:43in my opinion the first officer wasn't
40:45speaking but he wasn't speaking up wait wait wait wait just a moment he gave
40:53little hints that things were going wrong to the captain but it was apparent
40:57that the pilots were not 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 and probably they didn't realize the trouble they were in until they
41:29could see breaks in the clouds and see the ground
41:43in their final report investigators conclude that confusion over the metric system led the first
41:50officer to relay the wrong altitude how far did they tell us to climb 1500 feet sir that mistake
42:00caused the captain to overcompensate wait wait wait wait just a moment and push the aircraft into a
42:09fatal dive
42:12we can look at this as a training accident as much as anything else the way the pilots were trained
42:20at
42:20that time resulted in a series of decisions and actions that put the airplane in an unrecoverable
42:28situation in Chinese aviation industry we have a motto every line in the checklist is written in blood
42:37because behind every line in the checklist is a disaster but it's an opportunity to improve
42:45one of the recommendations was that Korean air reinforce its cockpit resource management training
42:51it's part of the fabric that holds a safe flight together then that includes things like a pre-take-off
42:57briefing so 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
43:20was before the digital airplanes there's a button you can turn and all your display show meters instead of
43:27feet but it does bring up the need for vigilance this crew made so many errors losing control of the
43:37big
43:38airplane is very unusual and hopefully won't see it again
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