- vor 16 Stunden
On 15 April 1999, Korean Air Cargo Flight 6316 crashes into an industrial zone shortly after takeoff from Shanghai, China, killing all 3 crew members on board and 5 people on the ground. The pilots lost altitude situational awareness and made abrupt flight control inputs.
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00:03Korean Air 6316, now turn left, direct to November Hotel Whiskey.
00:07Where is it?
00:08The pilots of Korean Air 6316 struggle to navigate in the skies above Shanghai, China.
00:14Keep turning left, keep turning.
00:16Keep turning?
00:18The controller really needs the aircraft to be going on the expected path.
00:23But seconds later...
00:24Nose up, nose up, nose up!
00:25...the MD-11F crashes near a residential neighborhood.
00:30The impact registered the equivalent of a 1.6 earthquake.
00:35When investigators reconstruct the flight in a simulator...
00:38Start to dive in 3, 2, 1, go.
00:42...they come to a shocking realization.
00:45The data showed that the upset was caused by a pilot input, and that becomes a mystery.
01:15It's a mild and overcast spring day at Hongchao International Airport in Shanghai, China.
01:25Korean Air flight 6316 is being prepared for departure.
01:30The cargo plane is loaded with 86 tons of non-hazardous materials.
01:36Checklist peak and light.
01:39Before start checklist, sir.
01:41The captain is 54-year-old Hong Sung-sil.
01:45Captain Hong is a very experienced pilot with 13,000 flight hours and a very good safety record.
01:53Today, his first officer is 35-year-old Park Boon Sok.
01:58First officer Park is less experienced than a captain, but also has an excellent safety record.
02:07Doors and windows.
02:09Closed and locked.
02:11Korean Air is South Korea's flag carrier.
02:15Its headquarters is located at Gimpo International Airport in Seoul.
02:20In 1999, Korean Air is one of the top three passenger airlines in Asia.
02:26And its cargo division is top three in the world.
02:30Its route is covered Asia, South America and Europe.
02:39The flight tech is on board.
02:40Hey guys, any issues or concerns?
02:43All good so far.
02:45Also on board is 48-year-old flight technician Park Byung Ki.
02:50The flight tech is a mechanic on board who is not a part of the flight crew.
02:55His job is just to make sure this aircraft has no mechanic issue and will take off safely.
03:03Engine ignition.
03:05Standby.
03:07Standby.
03:08Fuel panel.
03:09Auto.
03:10Air panel.
03:11Auto.
03:13Before start checks complete.
03:15Before the aircraft can begin taxiing to the runway, it must be pushed into position on the taxiway.
03:21Captain.
03:22Can you release the parking brake?
03:25Okay.
03:26Brake released.
03:30All aircraft are arc the facing terminal or the cargo apron.
03:34Which means the aircraft has no ability to reverse by themselves.
03:38So it needs a tow truck to push them back onto the taxiway.
03:43But as flight 6316 is being pushed back.
03:50Something's not right.
03:51The captain notices something amiss.
03:54Why is that brake temperature light on?
03:57It seems this brake isn't released.
04:00The captain noticed there is a caution that shows there is a high temperature on one of the brakes.
04:06It doesn't mean this brake is failing.
04:08It just means this brake is hotter than the others.
04:11Yeah.
04:12When we landed, that brake temp showed up.
04:16In some rare conditions, the hot brake can lead the fire in flight.
04:20But at this point, the hot brake is not a serious issue.
04:23You just keep an eye on it.
04:26It's dropping down now.
04:33I wonder what's going to happen when we take off.
04:41Captain, clear to start engines. 3, 1, 2.
04:45Roger, starting number 3.
04:49The pilots are flying a McDonnell Douglas MD-11F.
04:54The MD-11 is a large, wide-body aircraft.
04:59This is a very high-performance airplane.
05:01And once you understand the MD-11, it is a very pleasurable airplane to fly.
05:07But it does require the pilots to be on top of their game.
05:13Korean Air 6316, request taxi.
05:17Korean Air 6316, taxi via Kilo 7, Tango 0 for runway 18.
05:24The aircraft begins taxiing to runway 18.
05:30Right side, clear.
05:32Right side, clear.
05:34Left side, clear.
05:45So many airlines at this airport.
05:51It's 77.
05:53It's normal now.
05:55The elevated brake temperature has returned to normal.
05:59Korean Air 6316, clear for takeoff.
06:03Clear for takeoff, 6316.
06:05Confirming we're clear for takeoff.
06:17Check thrust.
06:19Thrust is set.
06:2280 knots.
06:24V1.
06:28Rotate.
06:30Rotate.
06:32Just after 4 p.m., they lift off from Shanghai.
06:38Positive climb.
06:40Here.
06:41We're up.
06:51The flight from Shanghai to Seoul is expected to take two hours.
06:58Shortly after takeoff, the controller provides the pilots with their climb-out instructions.
07:04Korean Air 6316, now turn left, direct to November Hotel Whiskey.
07:07Then climb and maintain 1,500 meters.
07:11The MD-11 is to continue climbing and turn left to intercept NHW.
07:18NHW, or November Hotel Whiskey, is a ground-based navigation beacon that assists pilots in guiding their plane through the
07:26skies.
07:28Okay, direct November Hotel Whiskey.
07:30And say again, altitude?
07:33Reconfirming the altitude instruction is smart.
07:37Every aircraft has their assigned route or assigned altitude by the ATC.
07:42So that is very important to hold this altitude to avoid the conflicts with others.
07:48But as the pilots confirm their instructions, the controller notices the plane has yet to turn towards the NHW navigation
07:57fix.
07:58Flight 6316, turn left, direct to November Hotel Whiskey.
08:03Then climb and maintain 1,500 meters.
08:07The controller can see on the radar scope that the aircraft is not turning left.
08:12And so is reminding the crew that they need to turn left by reissuing the clearance.
08:22But as the controller repeats his instructions...
08:25I don't see NHW.
08:27The navigation fix does not appear on the captain's display screen.
08:34Where is it?
08:36Here.
08:37Keep turning left.
08:39Keep turning.
08:41Keep turning?
08:43Yes, keep turning more.
08:45As the pilots continue their turn, the controller realizes the plane isn't climbing.
08:52Korean Air 6316, climb and maintain 1,500 meters.
08:57Are they asking us to...
08:58Yes, they're telling us to climb.
09:03The aircraft hasn't even reached the initial altitude that they were cleared to.
09:08So this is a way to remind the crew, we need to get moving, we need to climb.
09:15Just as flight 6316 nears its assigned altitude...
09:21It disappears from radar.
09:31The plane is diving uncontrollably towards the ground, too fast to be picked up by radar.
09:37The controller is unaware of its descent.
09:41Korean Air 6316, do you read?
09:46Wait, wait, wait, pitch!
09:51Korean Air 6316, radio check.
09:59Korean Air 6316 bursts through the clouds above Shanghai.
10:03Nose up, nose up, nose up!
10:05Pull up!
10:08Pull up!
10:12And slams into the ground, seven miles from the airport.
10:18Less than two and a half minutes after takeoff.
10:22At the speed they hit the ground, the impact was so severe that it registered the equivalent of a 1
10:30.6 earthquake.
10:33The aircraft crashes in Xinxuang, on the outskirts of the town's residential area.
10:41The accident claims the lives of both pilots and the flight technician.
10:48Five civilians are killed, 40 more are injured.
10:58The investigation into the crash is handled jointly by the three countries involved.
11:03Representatives from the Korean Civilian Aviation Bureau are on site on behalf of the airline.
11:10With the crash occurring on Chinese soil, the investigation is led by the Civil Aviation Administration of China.
11:20And as the plane is manufactured in the US, an American investigator from the National Transportation Safety Board joins the
11:27team.
11:27What did you find?
11:29The debris trail runs nearly two kilometers.
11:32Fan pattern.
11:36Typically on impact, as the airplane hits the ground, all of a sudden pieces will start coming apart.
11:44The biggest pieces will keep going straight.
11:46The other pieces will start fanning out.
11:49They'll spread.
11:51They had to impact at a relatively shallow angle to make that pattern.
11:56But as investigators continue to analyze the crash site, they learn that critical evidence has been destroyed.
12:04Not much left of the flight data recorder.
12:10One of the major tools in a modern aircraft accident investigation is the flight data recorder.
12:15More modern ones can record thousands of parameters.
12:19Angle of attack, airspeed, engine parameters.
12:23The lack of a flight data recorder during an investigation is a major blow.
12:29Thank you, sir.
12:31Thank you, sir.
12:31Thank you, sir.
12:32Please tell me.
12:36Police say some of the cargo has been stolen from the crash site.
12:40In the chaos, some of the local residents decided to help themselves to some of the cargo.
12:45This creates a situation where investigators might not find critical parts that they need to solve the accident.
12:52Has anyone found the cockpit voice recorder?
12:58Hopefully that wasn't stolen, too.
13:02If you don't have a flight data recorder and you don't have a cockpit voice recorder, you really have to
13:08go back to the basics to try to figure out what happened.
13:12Investigators start by examining impact scars left by the engines to determine at what attitude the plane struck the ground.
13:21The ground slope's 30 degrees down from the horizontal.
13:25Slope is the same for the other ground scar, and wings were level.
13:31The aircraft engines are very heavy. They'll make their own craters.
13:35So you look at the angle the engines are in, that gives you a very good idea of the pitch
13:42angle at impact.
13:44Because those parts are basically going to try to just bore a hole into the dirt.
13:48So, aircraft takes off.
13:52Roughly three minutes later, it crashes in a dive 30 degrees nose down with wings level.
13:57So what caused the dive?
14:01The ground information tells you how the airplane went down.
14:05We don't know why it went down.
14:07And that takes a lot more effort.
14:10We need to test for explosives.
14:12Get at least a dozen specimens from the wreckage and send those samples to the lab for testing.
14:18Chinese authorities wonder if an act of terrorism could have caused the accident.
14:22In any investigation, anything could have happened.
14:25And one of those events could have been sabotage or a bomb.
14:29So it's important in investigations to rule out something like that as soon as possible.
14:36As police look for evidence of explosives, investigators interview the air traffic controller.
14:44Anyone who talked to the crew is a witness to the investigation.
14:49And the controller is the last person to talk to the crew.
14:51So it's very important to get his impressions, what he did, what he's hearing back from the pilots.
14:57And understand what was happening that night.
15:02To start, what stood out to you about the flight?
15:05Takeoff seemed normal.
15:07But afterwards, the pilots struggled to maintain the flight plan.
15:11Turn left, direct to November, Hotel Whiskey.
15:14Then climb and maintain 1,500 meters.
15:18They eventually made their turn, but I had to remind them.
15:20After that?
15:21As they corrected their turn, I noticed they were still too low.
15:24So I told them to climb.
15:28Korean Air 6316, climb and maintain 1,500 meters.
15:33I had to remind them a second time before they started to climb.
15:38I thought they were off safely.
15:40The next thing I knew, the plane disappeared from radar.
15:45The air traffic controller sees the aircraft climbing.
15:50Everything looks normal and fine.
15:52And then all of a sudden, things go very wrong.
15:55Korean Air 6316, do you read?
15:58Korean Air 6316, radio check.
16:05Korean Air 6316, radio check.
16:06Is that the radar data?
16:07Yes.
16:09Looks like your communication is by the book.
16:14Looking at the radar recordings is very important,
16:17especially if you haven't looked at the cockpit voice recorder or the FDR.
16:22This gives you an initial framework to work with.
16:25Can the radar data provide any clues?
16:30The plane climbs to 1371 meters or 4,500 feet.
16:35Roughly 16 seconds later, it impacts the ground.
16:39That's a descent rate of roughly 17,000 feet per minute.
16:51We have a saying in aviation called a minute to die rule, which means that if your rate of descent
16:57in feet per minute is greater than your altitude, that's a dangerous situation.
17:04Flight 6316's rate of descent was more than three times greater than their altitude.
17:10Pull up.
17:11It's virtually impossible to recover the aircraft.
17:15What would cause the plane to descend at such an incredible speed?
17:20Maybe there's a problem with the aircraft.
17:22I'll pull the maintenance records.
17:25During the initial stages of the investigation, the investigators will look at all of the maintenance records of the aircraft.
17:32Any write-ups of issues on handling, delayed maintenance for some reason, anything at all that would give a clue
17:42to what could have happened here.
17:49Here's something.
17:51Investigators examine maintenance records of Korean Air Flight 6316, looking for clues to explain why a modern jetliner plunged from
17:59the sky so soon after takeoff.
18:01On May 25, 1996, the aircraft experienced a tail strike at LAX.
18:09The incident required a repair that took 63 days to complete.
18:15That is an interesting finding because if the repairs to the aircraft from the tail strike are not done properly,
18:22it can cause that area to detach in flight and in the process damage the pitch controls of the airplane.
18:29And we've seen that before.
18:31In 1978, a Japan Airlines Boeing 747 suffered a tail strike while landing at Osaka.
18:38A faulty repair led to explosive decompression seven years later, tearing off the tail and killing 520 people.
18:50If that's what happened here, that could explain everything.
18:55Did poor maintenance cause the plane's tail to break apart mid-flight?
19:10Well, here's the vertical stabilizer.
19:13Investigators find pieces of Korean Air Flight 6316's tail section in the wreckage.
19:20With all the pieces of the tail this close to the main crash site, it didn't separate in flight.
19:26So the repair was done correctly?
19:28They conclude that a tail strike did not cause any part of the MD-11's tail to detach from the
19:34plane.
19:34Maybe the dive was caused by a failure in one of the plane's control surfaces.
19:39Like the horizontal stabilizer.
19:44The horizontal stabilizer is the small wing on the tail that controls the pitch of the aircraft.
19:52Maybe the jack screw jammed.
19:57When commanded, a jack screw in the tail rotates, moving the horizontal stabilizer up or down.
20:05If the jack screw has jammed in a nose down position, now the airplane would suddenly pitch over and the
20:12flight crew would be fighting to try to get the nose up.
20:16Pitch!
20:17Okay, okay.
20:19But they would have a lot of forces on the control column trying to fight the aircraft from pitching down
20:25towards the Earth.
20:30Was the horizontal stabilizer jammed in a nose down position causing the plane to plummet?
20:39Well, the jack screw isn't jammed, so the stabilizer was working as intended.
20:43And what position is it in?
20:5010.25 inches, so it was set to .65 degrees.
20:56Nose up.
20:59The pilots were fighting against the dive.
21:04Nose up, nose up, nose up!
21:05Trimming the horizontal stabilizer, nose up, while pulling back on the controls to try to arrest the descendant.
21:27Chemical analysis report is in from the wreckage.
21:30No evidence of explosives.
21:32I'll start typing this up for the press.
21:35We need to reassure the public it's safe to fly in China.
21:38Sounds good.
21:42The Civil Aviation Administration of China, along with its US and Korean counterparts, release a bulletin almost two weeks after
21:50the incident.
21:51The Chinese investigation want to make two things clear.
21:54One, it's not a bomb.
21:56Two, it's not a fault from the Chinese ATC controller.
21:59With terrorism, air traffic control, and poor maintenance discounted, investigators now focus their attention on the pilots.
22:08Let's start with the captain.
22:10In all accidents, one of the tasks is investigating the background of the pilots to ensure that there's no issues.
22:19V1.
22:21Rotate.
22:23Training can make a very big difference, and also things going on in their personal life.
22:28We want to make sure that the person wasn't under any particular stressors that could cause distractions and inhibit their
22:36performance in any way.
22:38Captain Hong was quite seasoned.
22:41Almost 13,000 flight hours, with nearly 5,000 on the MD-11 alone.
22:46No psychological burdens and a perfect safety record.
22:49Yeah.
22:50First Officer Park, over 1,800 hours, majority on the MD-11.
22:54No psychological burdens and also a perfect safety record.
22:59Two model pilots.
23:00Yeah.
23:06Yes.
23:08Is it intact?
23:11They found the cockpit voice recorder.
23:15After the accident, there was very heavy rain in the Shanghai area.
23:20So they pumped out some water from some of the ponds that were left, and they found the CVR.
23:28Memory is safe.
23:29Full data recovery.
23:32Excellent work, and thank you.
23:36They're going to get the transcripts ready for us.
23:38At this point in the investigation, we're wondering what caused a mechanically sound airplane, piloted by two well-trained, experienced
23:48pilots, to suddenly dive into the ground.
23:50And that becomes a mystery.
24:00Okay, let's start with an aerodynamic stall from 1371 meters.
24:09Using a Boeing simulator in California...
24:12We'll see what rate of descent we get.
24:16Investigators combine radar data with evidence from the wreckage of Korean Air Flight 6316 to determine why the plane plummeted
24:25to the ground.
24:28In the simulator, the investigators accomplished over a hundred different scenarios, trial and error.
24:34How do we match the data points?
24:37Hold up.
24:40Rate of descent was 3,314 feet per minute.
24:44Not even close to 17,000.
24:47It couldn't have been a stall.
24:50And so they take all this information, and then the simulator try to determine what's the best fit for the
24:57data.
24:58And you start limiting things.
25:01Let's try out of control elevators.
25:02The accident plane impacted nose down at an estimated 20 to 40 degrees.
25:19The pitch is way too sharp.
25:21Let's try to pull up anyway for accuracy.
25:24Through all the simulator runs they did.
25:27Pull up.
25:3086 degrees.
25:32Okay, it was not out of control elevators either.
25:34They found that you could not match the rate of descent and the profile you needed to match the data
25:41with an aerodynamic stall or a mechanical failure.
25:50Try intentionally pushing the plane into a dive.
26:02Push your nose down, the vertical speed increase, then trim the horizontal stabilizer up, then try to pull out of
26:09it.
26:16Start the dive in 3,2,1, go.
26:30Only one simulation precisely replicates the data from flight 6316.
26:36Dive time, 18 seconds, 25 degrees nose down.
26:41Maxed out rate of descent.
26:42That's the closest we've been yet.
26:45Investigators conclude that the plane must have been put into a nose dive intentionally.
26:49The data showed that the upset was caused by a pilot input.
26:53And so now the focus becomes on why would the pilot do this.
26:59Knowing that the crash of flight 6316 could have resulted only from deliberate pilot input, investigators listened to the CVR
27:06to determine why the pilots commanded the airplane into a steep dive.
27:11Okay, let's have a listen.
27:15Captain, can you release the parking brake?
27:18Okay, brake released.
27:22Uh-oh, something's not right.
27:25Why is that brake temperature light on?
27:29Is the high brake temperature somehow connected to the nose dive?
27:35Yeah, when we landed, that brake temp showed up.
27:38But soon after, it's dropping down now.
27:43So the brake was a non-factor.
27:46Agreed. Let's keep going.
27:50Flight 6316, copy ATC clearance.
27:54Go ahead, Korean Air 6316.
27:57Korean Air 6316, after departure, turn left direct to November Hotel Whiskey.
28:02Initially climb and maintain 900 meters.
28:04Read back, please.
28:05Okay, sir. Initially maintain 900 meters. Then after takeoff, turn left direct to November Hotel Whiskey. Is that correct?
28:12That's affirmative.
28:14Did he say 900 meters?
28:16Yeah, 900 feet.
28:20Did you catch that?
28:22After the controller read the altitude clearance.
28:25Investigators hear that there's some confusion about altitude measurements.
28:30Yeah, why are they using metric at all?
28:33Imperial's airspace standard.
28:34Not in China.
28:38Most of this world, including South Korea, measure altitude in feet.
28:44The Chinese aviation industry is based on the old Soviet Union aviation industry.
28:50The USSR used the metric system.
28:54So today, China still use the metric system.
28:59Okay, but I imagine the captain will sort that out in the takeoff briefing.
29:04Let's find out.
29:06Korean Air 6316.
29:08Clear for takeoff.
29:09Clear for takeoff, 6316.
29:12Confirming we're clear for takeoff.
29:15Wait.
29:17Did the captain skip his takeoff briefing?
29:20I'm not seeing one in here.
29:23A takeoff briefing is a way to create what we call a shared mental model,
29:28where both pilots are on the same page.
29:31Otherwise, you're simply not prepared for the flight.
29:34The briefing would also have noted that Shanghai uses metric altitudes.
29:40So did skipping the briefing somehow play a role in the nosedive?
29:51Investigators revisit the CVR, searching for evidence that the omission of a critical briefing contributed to the crash of Flight
29:586316.
30:00Let's start with the initial climb.
30:04Turn left, direct to November, Hotel Whiskey, then climb and maintain 1,500 meters.
30:10The team hears the controller giving the pilots their climb-out instructions.
30:14I don't see NHW.
30:19Where is it?
30:20But the captain can't find the navigation beacon on his display.
30:25Sounds like an issue with the captain's nav display.
30:29Uh, here.
30:32Keep turning left.
30:33The recording suggests the first officer's navigation display was functioning properly.
30:38Keep turning.
30:40Keep turning?
30:41Yes, keep turning more.
30:43Damn.
30:44Why isn't NHW showing?
30:47The CVR portrays a captain who appears confused.
30:53I bet he zoomed in too far on the nav display.
30:56That's why you can't see the beacon.
30:58Had the pilot reached up and changed the range on his display, he would have had that available to him.
31:04That would explain why it took them so long to turn left.
31:07Had they done the takeoff briefing, they could have caught the issue.
31:12Had they discussed completely in the pre-flight briefing, here's where we're going, and cross-checked their displays, that would
31:19have been caught.
31:21And it wasn't.
31:23It still doesn't explain the dive though.
31:27Korean Air 6316, climb and maintain 1,500 meters.
31:33Are they asking us to?
31:34Yes, they're telling us to climb.
31:39It seems like they're so preoccupied getting the plane to turn left.
31:43They forgot to climb.
31:45Especially since the controller told them.
31:47Twice.
31:52Then investigators hear a warning, telling the pilots that they're approaching their target altitude.
32:00Pitch, sir.
32:01The first officer points out that they're climbing too quickly.
32:06Why is he climbing so quickly?
32:11His mistakes are adding up.
32:15He's trying to overcompensate to get to his altitude.
32:19He's pitching up too fast.
32:21He's doing things too quickly.
32:24Was the nosedive just another mistake?
32:34How far are they telling us to climb?
32:38He still doesn't know his altitude clearance.
32:40He doesn't look like the first officer knows either.
32:47F-fif-fif-fif-fifteen hundred feet, sir.
32:50F-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif-fif
32:52-fif-fif...
32:54They're talking in terms of feet, even though the controller's instructions were in meters.
33:01Investigators now realize the controller and the pilots are using different altitude measurements.
33:07Weren't they trained to use metric?
33:10Should be. Well, let's check.
33:13Certainly. The more training you have, that would have helped greatly in terms of sorting out the meters versus feet.
33:22I see. Thank you for your time.
33:25They look deeper into the training procedures for Korean Air pilots.
33:29Korean Air says the Seoul to Shanghai route is the only one where their pilots need to use metric.
33:34What kind of training do they have?
33:36They require their pilots to watch a single training video to learn metric conversion.
33:41According to the pilot records, the captain had only flown into Shanghai once prior.
33:48The first officer had never flown there before.
33:51Which means the first officer would have watched the training video for the first time only that morning.
34:01Investigators conclude that the pilots of flight 6316 confused metric and Imperial...
34:07Fifteen.
34:09...because they were inadequately prepared for the flight.
34:12For the pilots to operate in a metric environment, this is something that you need to get into a simulator
34:18and you need to practice it.
34:20Watching a video is just not going to be enough, period.
34:23So was the metric confusion the reason why they pushed the plane into a nosedive?
34:32How far did they tell us to climb?
34:35As the flight reaches its assigned altitude of 4,500 feet or 1,500 meters...
34:411,500 feet, sir.
34:44The first officer leads the captain to believe they should be much lower at 1,500 feet.
34:49The captain thinking that they have blown through their clearance would be extremely alarmed...
34:56...because now there is a very strong potential for a traffic conflict.
35:01Fifteen.
35:04I'm too high.
35:06Descend. Descend. Descend.
35:09The quickest response is to push forward on the controls.
35:18Wait. Wait, wait, wait, wait, wait, wait.
35:20Just a moment.
35:21The captain pushes the plane into a steep dive to descend to a much lower altitude.
35:31You can hear the captain trim the plane down.
35:34He put them in the dive.
35:37He pitches the aircraft nose down and simultaneously is trimming the horizontal stabilizer...
35:45...which relieves the control column pressure.
35:47But the combination of these things put the aircraft into a dive...
35:52...for which it's almost impossible to recover.
35:55During the descent, the first officer suddenly recognizes the seriousness of their situation.
36:01Wait, wait, pitch.
36:03Okay, okay.
36:06But by the time the pilots realize the danger...
36:09Nose up, nose up, nose up, nose up!
36:16...it's too late.
36:21Investigators conclude that the crash was caused by the captain's confusion over his altitude measurement.
36:27Even if the captain thought he was too high, why not descend more gradually?
36:38Wait, wait, wait, wait, wait, wait.
36:44First he climbed too quickly, then he descended way too quickly.
36:48Investigators try to determine why the captain of Korean Air Flight 6316 reacted so drastically to his belief that the
36:55aircraft was too high.
36:56Maybe he was trying to cover up his mistakes?
37:02On one hand, the captain knows it is dangerous when they're overshooting the altitude.
37:08How far did they tell us to climb?
37:11How far did they tell us to climb?
37:11On the other hand, the captain doesn't want the controller to know that he made a mistake.
37:16So he tried to get down quickly to save face.
37:21What I don't understand is, why didn't the first officer try to stop him?
37:27Especially since he was guiding him earlier.
37:33There's a lot going on, and the first officer is not only trying to read back the clearances,
37:39but also trying to ensure that the captain is turning in the direction that needs to be turned.
37:45Keep turning.
37:46Keep turning?
37:48Yes, keep turning more.
37:54I've got the CVR all set for the moment before the dive.
37:58Did the first officer ever recognize the error?
38:06How far did they tell us to climb?
38:09F-fif-fif-fifteen hundred feet, sir.
38:12Uh...
38:12Oh.
38:18Wait, wait, wait, wait.
38:21Investigators hear the first officer hesitate after providing the captain with the wrong altitude.
38:27Maybe at that point, the first officer recognized his mistake was feet and meters. We don't know.
38:32Just a moment.
38:39Wait, pitch.
38:40Uh, uh, uh, okay, okay.
38:46So the dive starts, and he says, wait, wait, wait.
38:54Then after five full seconds of free fall, he says, wait, pitch.
39:03Clearly, there should have been some input, some effort for the first officer to try to slow things down.
39:18In my opinion, the first officer was speaking, but he wasn't speaking up.
39:23Wait, wait, wait, wait, just a moment.
39:27He gave little hints that things were going wrong to the captain, but it was apparent that the pilots were
39:32not on the same page.
39:41At the end of the day, the captain caused the dive.
39:46He overreacted.
39:50The rate of descent was so high that now it became very difficult to recover once you got down to
39:57the lower altitudes.
39:59And probably they didn't realize the trouble they were in until they could see breaks in the clouds and see
40:03the ground.
40:04The rate, the rate, the rate.
40:05No, stop, no, stop, no, stop.
40:07Pull up.
40:08Pull up.
40:13Pull up.
40:15In their final report, investigators conclude that confusion over the metric system led the first officer to relay the wrong
40:23altitude.
40:24How far did they tell us to climb?
40:271,500 feet, sir.
40:30That mistake caused the captain to overcompensate.
40:35Wait, wait, wait, wait.
40:36Just a moment.
40:38And push the aircraft into a fatal dive.
40:42We can look at this as a training accident as much as anything else.
40:48The way the pilots were trained at that time resulted in a series of decisions and actions that put the
40:57airplane in an unrecoverable situation.
41:00In Chinese aviation industry, we have a motto.
41:04Every line in the checklist is written in blood.
41:07Because behind every line in the checklist is a disaster, but it's an opportunity to improve.
41:14One of the recommendations was that Korean Air reinforce its cockpit resource management training.
41:21It's part of the fabric that holds a safe flight together, and that includes things like a pre-takeoff briefing.
41:27So these are some of the items that, in my mind, were most important.
41:34Today, Korean Air is recognized as one of the safest airlines in the world.
41:41The amount of standardization through all the airlines, the amount of training now, is much higher level than it was
41:48before.
41:49The digital airplanes, there's a button you can turn, and all your displays show meters instead of feet.
41:57But it does bring up the need for vigilance.
42:01This crew made so many errors.
42:04Losing control of a big airplane is very unusual.
42:08And hopefully we won't see it again.