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Air Crash Investigation - Season 26 - Episode 10: Mixed Measures Korean Air Cargo Flight 6316
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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.
01:34Captain Hong Kong 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.
01:47First officer Park is less experienced than a captain, but also has an excellent safety record.
01:57Doors and windows closed 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.
02:57Stand 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.
03:33So 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 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.
05:15Korean 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.
05:59Korean Air 6316, clear for takeoff.
06:03Clear for takeoff, 6316.
06:06Confirming we're clear for takeoff.
06:18Check thrust.
06:21Thrust is set.
06:2380 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?
07:38Reconfirming the altitude instruction is smart.
07:41Every aircraft has 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.
08:52As 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.
09:12The 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, 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.
11:46Fan 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.
12:26One 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 of 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 with 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?
13:16Hopefully that wasn't stolen, too.
13:20If 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.
14:1430 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.
14:31We need to test for explosives.
14:33Get 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 13,71 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.
17:33Flight 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.
18:01Any 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.
19:03In 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 is in jams, so the stabilizer was working as intended.
21:22And what position is it in?
21:2810.25 inches, so it was set to .65 degrees.
21:34Nose up.
21:37The pilots were fighting against the dive.
21:43Nose up, nose up, nose up, nose up.
21:45Trimming the horizontal stabilizer, nose up, while pulling back on the controls to try to arrest the descendant.
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.
22:22The Civil Aviation Administration of China, along with its U.S. and Korean counterparts, release a bulletin almost two weeks
22:31after the incident.
22:41With terrorism, air traffic control and poor maintenance discounted, investigators now focus their attention on the pilots.
22:49Let's start with the captain.
22:52In all accidents, one of the tasks is investigating the background of the pilots to ensure that there's no issues.
23:01V1.
23:02Rotate.
23:04Rotate.
23:06Rotate.
23:12Rotate.
23:15Rotate.
23:18Rotate.
23:27Rotate.
23:30Rotate.
23:32safety record. Yeah, First Officer Park, over 1,800 hours, majority on the MD-11. No psychological
23:39burdens and also a perfect safety record. Two model pilots. Yeah. Yes. Is it intact?
23:55They found the cockpit voice recorder.
23:59After the accident, there was very heavy rain in the Shanghai area. So they pumped out some water
24:06from some of the ponds that were left and they found the CVR. Memory is safe. Full data recovery.
24:17Excellent work and thank you. They'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
24:31piloted by two well-trained, experienced pilots to suddenly dive into the ground. And that
24:37becomes 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 100 different scenarios, trial and error.
25:22How 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 the
25:46data.
25:47And you just start limiting things.
25:50Let's try out-of-control elevators. The accident plane impacted nose down at 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.
26:2086 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
26:32with an aerodynamic stall or a mechanical failure.
26:3695 degrees.
26:41Try intentionally pushing the plane into a dive.
26:54Push the nose down, the vertical speed increase.
26:58Then trim the horizontal stabilizer up.
27:00then try to pull out of it
27:08start to dive in three
27:11to one go
27:23only one simulation precisely replicates the data
27:27from flight 6316
27:29dive time 18 seconds 25 degrees nose down max out rate of descent
27:36that's the closest we've been yet
27:37investigators conclude that the plane must have been put into a nose dive
27:42intentionally
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
27:57deliberate pilot input investigators listen to the CVR to determine why the
28:02pilots commanded the airplane into a steep dive
28:05okay
28:06let's have a listen
28:10captain can you release the parking brake
28:13okay break 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
28:43let's keep going
28:46flight 6316
28:48copy ATC clearance
28:50go ahead
28:51Korean Air 6316
28:52Korean Air 6316
28:54after departure
28:55turn left
28:56direct to November
28:57Hotel Whiskey
28:58initially climb and maintain 900 meters
29:00read back please
29:02okay sir
29:03initially maintain 900 meters
29:05then after takeoff
29:06turn left
29:06direct to November
29:07Hotel Whiskey
29:08is that correct?
29:09that's affirmative
29:11did he say 900 meters?
29:13yeah 900 feet
29:18did you catch that?
29:19after the controller read the altitude clearance
29:22investigators hear that there's some confusion about altitude measurements
29:28yeah why are they using metric at all?
29:30Imperial is the airspace standard
29:33not in China
29:36most of this world including South Korea
29:39measure altitude in feet
29:41the Chinese aviation industry is based on the old Soviet Union aviation industry
29:48the USSR 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
30:08clear for takeoff
30:10clear 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
30:28where both pilots are on the same page
30:31otherwise 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 contributed to the crash of flight
31:006316
31:01let's start with the initial climb
31:06let's start with the initial climb
31:06turn left
31:07direct to November
31:08hotel whiskey
31:09then climb and maintain 1500 meters
31:13the 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
31:33here
31:35keep turning left
31:36the recording suggests the first officer's navigation display was functioning properly
31:42keep turning
31:42keep 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
32:06he 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
32:22and cross-checked their displays
32:24that would have been caught
32:26and it wasn't
32:28it still doesn't explain the dive though
32:33what's going on?
32:33Korean Air 6316
32:35climb and maintain 1,500 meters
32:38are they asking us to?
32:40yes, they're telling us to climb
32:45it seems like they're so preoccupied getting the plane to turn left
32:49they forgot to climb
32:51especially since the controller told them
32:53twice
32:58then investigators hear a warning
33:00telling 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
33:23he'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
33:55f-f-fifteen hundred feet, sir
33:58f-f-fifteen
34:04they're talking in terms of feet
34:05even though the controller's instructions were in meters
34:10investigators now realize
34:11the controller and the pilots are using different altitude measurements
34:17weren't they trained to use metric?
34:20should be
34:21well, let's check
34:23certainly, the more training you have
34:26that would have helped greatly
34:27in terms of sorting out the meters versus feet
34:32I see, thank you for your time
34:34they look deeper into the training procedures for Korean Air pilots
34:39Korean Air says the Seoul to Shanghai route
34:42is the only one where their pilots need to use metric
34:45what kind of training do they have?
34:47they require their pilots to watch a single training video
34:50to learn metric conversion
34:53according to the pilot records
34:54the captain had only flown into Shanghai
34:57once prior
34:59the first officer had never flown there before
35:02which means the first officer
35:04would have watched the training video for the first time
35:07only that morning
35:12the first officer
35:13investigators conclude that the pilots of flight 6316
35:16confused metric and Imperial
35:19fifteen
35:21because they were inadequately prepared for the flight
35:25for the pilots to operate in a metric environment
35:27this 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 4500 feet or 1500 meters
35:58the first officer leads the captain to believe they should be much lower at 1500 feet
36:04the captain thinking that they have blown through their clearance would be extremely alarmed
36:10because now there is a very strong potential for a traffic conflict
36:1550
36:18I'm too high
36:21descend, descend, descend
36:23descend
36:24the quickest response is to push forward on the controls
36:33wait
36:34wait, wait, wait, wait, wait, wait
36:35just a moment
36:37the 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
36:56and simultaneously is trimming the horizontal stabilizer
37:02which relieves the control column pressure
37:04but the combination of these things put the aircraft into a dive
37:08for which it's almost impossible to recover
37:12during the descent
37:13the first officer suddenly recognizes the seriousness of their situation
37:18wait, wait, pitch
37:19oh, oh, oh, okay, okay
37:23but by the time the pilots realize the danger
37:27nose 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
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's trying to cover up his mistakes
38:22on one hand
38:23on one hand
38:23the captain knows
38:24it is dangerous when they're overshooting the altitude
38:28how far did it tell us to climb?
38:31on the other hand
38:32the 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?
39:09yes, 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 it tell us to climb?
39:311,500 feet sir
39:33oh
39:35oh
39:41wait
39:42wait 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 recognize his mistake was feet and meters we don't know
39:55just a moment
40:02in the right
40:03wait 2,500 feet
40:11wait until thebour
40:13wait pitch
40:195,000 feet in the way
40:22wait 11,500 feet just outside and etc
40:24wait, wait, wait
40:28clearly there should have been some input some effort for the first officer to try to
40:35slow things down
40:43in my opinion the first officer was speaking but he wasn't speaking up
40:49wait wait wait wait just a moment he gave little hints that things were going wrong to the captain
40:56but it was apparent that the pilots were not on the same page
41:07at the end of the day the captain caused the dive
41:13he overreacted the rate of descent was so high that now it became very difficult to recover
41:22once you got down to the lower altitudes and probably they didn't realize the trouble they
41:28were in until they could see breaks in the clouds and see the ground
41:42in their final report investigators conclude that confusion over the metric system
41:48led the first officer to relay the wrong altitude
41:52how far did they tell us to climb
41:58that mistake caused the captain to overcompensate
42:03wait wait wait just a moment and push the aircraft into a fatal dive
42:12we can look at this as a training accident as much as anything else the way the pilots were trained
42:20at that time resulted in a series of decisions and actions that put the airplane 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
42:51it's part of the fabric that holds a safe flight together
42:55and that includes things like a pre-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
43:36losing control of a big airplane is very unusual
43:41and hopefully we won't see it again
43:43you
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