WHY didn't he LISTEN?? | Korean Air Cargo 8509

Flying a passenger plane is a complex task that requires highly trained pilots working together to get hundreds of tons of metal and people into the air safely. The margin for error is small and when errors occur, they can be catastrophic when things go well. This complexity looks like a clock mechanism, each of the components interlocks perfectly and eliminates flight. The story of Korean Flight

8509

is dark and complex. Its cogs and wheels are psychological, technological and even cultural when the mechanism of this flight burst open just seconds after takeoff on December 22, 1999. It revealed deeper-rooted problems in the aviation industry, problems that should be addressed. address quickly.

This is the story of the Korean Air

8509

fight. It was 20 minutes 7:00 a.m. at Staned Airport, just northeast of London, when the airport slowly woke up to the 5,000 kilometers away, in Tashkent, Usbekistan, A Korean Air Cargo Boeing 747 was preparing to depart. On board were two pilots, a flight engineer and 33 tons of

cargo

. The 19-year-old had just arrived from Soul, South Korea, and would now be completing the final leg of his journey to the UK. He had received a clean bill of health in Tashkent and the flight was expected to depart safely. , but we wouldn't start the story here if that's what ended up happening just seconds later.

On takeoff, things would begin to go wrong on this flight, these small imperfections in the Mechanism would set in motion a chain of events that would ultimately doom the plane and its crew. At 12:29 local time, the captain lined up the huge plane and Runway 08. Left at Tashkent, the plan was to depart east into the wind and then, shortly after takeoff, make a 180 turn. ° to head west towards Europe, the captain pressed the accelerators for takeoff and the heavy plane began to accelerate within moments. he took to the sky as the captain was going up, he used this instrument here to make sure that he was putting the aircraft in the right position.

This instrument is known as ADI or attitude direction indicator, as its name indicates, it tells pilots their attitude, that is, their orientation. With respect to the Horizon, how much they are pointing up or down, this symbol here represents the plane, its nose here and its wings here while in the background the blue represents the sky and the brown represents the Earth at this moment while the plane ascended its wings. They were level and their nose was about 15° above the horizon if the plane turned to the right it would look like this on the left it would look like this 10° with the nose up it looks like this and 5° with the nose down it looks like this at night or in the clouds Pilots cannot see anything through their windows and depend completely on this instrument to indicate the orientation of their plane, for this reason the ADI is extremely important, which is why there are three in the cockpit, one for the captain, one for the first officer and a backup, each operating completely independently, so that a failure in one has no effect on the others shortly after takeoff, when the plane passed 1000 feet, the Captain began to turn gently to the right, but as he turned, something strange happened as the plane passed.

At 15° Bank, the captain's ADI froze, he still kept his control column to the right and could see out the window that his plane was clearly tilted even further, but his instrument had apparently stopped registering the bank. He checked the reserve ADI and the first one. The officer's ADI and both correctly indicated the bank of the aircraft. It wasn't just the captain who noticed this problem. The plane itself continually compares each Adis and recorded a disparity between the captain's instrument and the other two instruments. He placed a flag in front of the captain's ADI and an ARL warning sounded indicating that there was a disagreement between the instruments.

Following standard operating procedure for this exact situation, the captain handed control over to the first officer, who then began flying the aircraft as the The first officer continued the turn to the west. The captain began troubleshooting the problem on an airplane like the 747. The Adis received their information from a system of gyroscopes and accelerometers called Inus or inertial navigation units, there are three Inu on board Inu 1 Inu 2 and as you'd expect Inu 3 normally the captain's announcement receives data from inu1 the ADI of the first officer receives data from Inu 2 and the reserve ADI takes data from Inu 3 the captain could see that the reserve ADI and the first officer's ADI matched, it was just his that was giving a different reading, so his Inus probably They were working properly, while yours was probably defective.

If he wanted his ADI to work, he would need to feed data to one of the properly functioning Inus, so he switched his instrument to his alternate source. Using this switch here, the compass stabilization switch, this caused the data not to come from inu1 which was faulty but from Inu 3, within 5 seconds of pressing this switch the captain's ADI started working correctly again and the warnings disappeared when the first officer came out. Heading west, the captain regained control and continued climbing the plane after nearly two decades of flying and more than 15,000 flights. This plane wasn't exactly new.

Problems like this, although serious, were not a shock to the crew. What mattered in this outing. was that they dealt with the situation in a calm and systematic manner, after all, their role in the system was to use their training to quickly and safely troubleshoot problems that were sure to arise when operating a complex machine once the plane was in cruise. With the autopilot on, the captain began testing the system to see if the problem persisted. He turned the switch back to the normal position for a moment. It seemed to be working, but that was only because the plane was not making any turns.

As soon as the plane began making course changes on the route, the crew noticed that it was simply frozen at wing level. Interestingly, it had no problem knowing how much the nose was pointed up or down, but in turns it was unreliable, clearly it wasn't the ADI itself that was there. defective but the system that was supplying information to the inertial navigation unit the captain turned the switch back to the alternative position and again his instrument began taking data from Inu 3 for the remaining 7 hours the fight progressed normally through the north from Europe with the switch in the alternative position at 3:5 minutes local time the 747 landed at Stanstead the pilots parked at the gate and shut down the plane it would be too much to say that disaster had been averted there was no reason for there to be a problem with one of the aircraft's three attitude direction indicators should cause an accident, but aviation is a complex system.

Each component is linked together, if not by direct connection, then by just a few degrees of separation, we are about to see exactly how a failure occurs in one. Some of those components can propagate through the others and eventually stress the system to the breaking point, but first I want to say a quick word about the sponsor of this video, Opera. The new Opera web browser is truly a breath of fresh air in what has become a fairly stagnant browser space. Unlike many of today's browsers, it has fast features and is easy to use. One of my favorite features of the oper browser is the Island of Tabs feature.

I find it really useful because when I'm browsing the web and opening a lot of tabs, I can organize them into islands. grouped by common themes, so here I have an Island tab for some of the things I'm studying as part of my flight training here I have an Island tab for the food I wanted to make and here I have I got an Island tab for my work in green . Aviation I can expand and collapse these tabs however I want, which makes it much easier to stay organized and productive. It's also great to know that with the built-in ad blocker and VPN I can keep my data safe online with just one click.

The sidebar here is really useful. It has WhatsApp, Instagram and Facebook Messenger built in, making it easier to stay connected with friends and family. Opera even has its own AI ARA browser. This is helpful because every time I have a question that Google can't answer. just ask ARA oper really feels like the future of the web everything I need is there in the browser click my link in the video description to download Opera it's free, it's fast and it just works now let's get back to the video Once which the pilots had parked at the gate, the captain returned the alt compass stabilization switch to Norm as part of his duties after shutting down the aircraft, the flight engineer recorded the malfunction in the technical log book which included a reference code and the phrase Captain's ADI on the screen. unreliable has gyro flag in view, displays fine when alternate attitude is selected Ed with that the flight crew packed their briefcases and headed towards the gate where the aerial stairs had now stopped, they will rest in London for the day while another crew who had been staying in a nearby hotel would take the plane to its next destination, Milan, upon leaving the crew they met a Korean Airlines ground engineer, Kim Iluk, despite having their usual base in Moscow, Kim he had to fly to Stanstead because Korean Air had no permanent staff.

Engineering support: A similar situation existed in Milan, which meant Kim would remain on board for the next flight. His role in both Stanstead and Milan will be to take charge and coordinate with local mechanics to quickly resolve any issues that arose during the previous flight. As the outgoing crew was leaving the plane, the flight engineer told Kim about the problem with the captain's ADI. He also mentioned that the problem was resolved when the captain changed the attitude and compass stabilization switch to alt. The flight crew then left for their hotel with no idea that the first steps towards disaster had already been taken, when the new crew for the flight to Milan headed to the airport, Kim and the local engineer in Stanstead began preparing the 747 for their flight, they did an extensive walk around the plane to ensure that the plane was physically fit to fly and also supervised the loading and refueling, once this was done they went to the cockpit to solve the problem written on the technical record.

This is where things started to go wrong for fight 8509 when Kim opened the technical log and read the combat engineer's entry, he couldn't tell what the code the combat engineer had written referred to so he knew exactly what it meant, you would need to get an engineering manual known as fim or fault isolation. manual, but since there was no permanent Korean maintenance station at Stanstead, there was no fim for the plane, Kim's personal copy was still in Moscow, this simple error would prove crucial, because if Kim had managed to obtain fault isolation. In the manual, you would have seen the procedure that told you to replace inu1 or, if that was not possible due to a shortage of spare parts, change the captain's compass stabilization switch to alt as the captain had done on the previous flight, like Kim did.

I couldn't determine what the code meant. He had nothing to go on except what the flight engineer had written. Kim decided to remove the ADI and check for loose connections or corrosion. While he got to work, the incoming crew headed to the plane. and it was an experienced crew. The captain of the incoming flight was Park Duk C, aged 57. He had more than 13,000 flight hours, more than 8,000 of which were on the Boeing 747 before joining Korean Air. Captain Park had flown fighter jets for South Korean Air. Strength It was not uncommon for Korean Air pilots to have a military background and Captain Park's career was similar to that of many of his colleagues as a result of this military culture being deeply ingrained within Korean Air at all levels.

This culture would continue. Playing a vital role in the outcome of Flight 8509, the first officer was Yun Kei sik Yun, 33, a new employee with only 1,400 total hours, of which only 200 were on the 747, giving him a lot of less experience than Captain Park. Before starting on the 747 I had flown the 100, a much smaller aircraft, the jumbo jet was something of an adjustment and despite being fully qualified to fly it I was still learning a lot about the ins and outs that went along with the two pilots. . He was 38 years old. Engineer Parun C, like the captain, was very experienced with more than 8,000 total flight hours under his belt, more than half of which were executed by the 747 while the pilot settled on the ground.

The engineer haddetermined that a damaged connecting pin was the likely culprit for the captain's ADI malfunction. He enlisted the help of an engineer who was qualified to perform the repair and together they fixed the pin and reinserted the ADI into the instrument panel. Once that was completed the first officer carried out a test of the instrument quite safely when he pressed this test button here the instrument performed its full range of motion up and down and left and right everything seemed normal the The test also checked whether the comparator warning was working to determine if the computers would notice if there was a disparity between the captains' and first officers' instruments.

Naturally, the test showed that the comparator was working, but for the crew or engineers, the test was a total waste of time. There was never any problem with the ADI or the comparator, the problem was entirely with the Inu, which fed the ADI its data, it would turn completely left or right if the Inu just told it to, but the UI was broken and was unable to do so. All the test did was show that the ADI could spin freely, which it always was able to do anyway, but without full knowledge of what had originally gone wrong, the crew were now lulled into a false sense of security, as They knew their instrument had been fixed and the pilots made final preparations for departure.

Darkness was taking hold and in a few moments the crew would be taking off from Stanstead just before the 5 o'clock mark. The crew had completed their checks and the plane had been loaded with

cargo

and fuel. Its takeoff weight would be more than half a million. pounds, 68,000 of which was fuel after a delay, flight 8509 was finally issued clearance to Milan, the trip was scheduled to last 2 hours, the crew had missed their original departure time and the pushback team originally assigned to Their flight was serving another plane with the clock ticking, the pilots had to wait another 30 minutes.

Before a pushback crew was available on A4 6, the foot bar was engaged and the huge plane began to back away from the base, finally the plane was on its way, but just when the crew thought their problems were over, There was a call from the The ground crew was unable to push the heavy 747 any further. The rearward thrust lacked the necessary power because the 747 was now between the parking stand and the taxiway. The crew was unable to taxi to the runway from the current position, as a result, they had to wait. for an officer to guide the plane, this caused an additional delay, it was almost as if fate itself was intervening trying to prevent the plane from departing, but at 6:25 minutes, fate let flight 8509 be cleared to taxi to runway 23 at Stanstead.

As far as the crew was concerned, the Mechanism was running slowly, they had no idea that the problem lurking just below the surface was much more serious and had nothing to do with the faulty instrument or the delays or the weather after all the delays and problems. With the push back, Captain Park was growing impatient between the first officer's radio transmissions to air traffic control, the captain began to admonish him in a fit, dissatisfied with the way Yun was handling the radio calls. Park said, make sure you understand what Ground Control says. Before speaking in complete contravention of Korean Air's standard operating procedures, Park began taking care of the radio work himself while testing the plane, now having taken the first officer out of the loop, taking on most of the work himself. the cockpit, this crew wasn't a team as if that wasn't enough during the taxi when air traffic control called the plane and the first officer

didn

't answer the captain scolded him for not answering Yun was damned if he did and damned if he

didn

't The highly unpleasant work environment caused directly by Park's attitude toward his inexperienced first officer was a symptom of the high power distance culture prevalent in South Korean society.

In 1998, a group of New Zealand pilots conducted a safety audit report on Korean Air that revealed significant problems with the airline. The report uncovered a widespread level of complacency, arrogance and incompetence in all sections of the airline's operations. The airline's flight operations between 1970 and 1999 Korean Air had 16 incidents and aircraft accidents that caused nearly 700 casualties. The report suggested that the airline's organizational culture that is heavily influenced by South Korea's national culture played a role. important in these incidents when flight 8509 took to the runway that night, the worst elements of this culture were on display. Captain Park continued to braid his less experienced first officer, who became increasingly resigned and less willing to challenge the captain for his mistakes or for breaking the Sops.

It wasn't that the captain was having a bad day; the attitude he displayed was endemic. within the airline but then another instrument began to have problems as the flight continued his taxi to Park on the runway he noticed that his instrument that showed the distance from the plane to the radio beacons showed an incorrect value; the display should have read close to zero because the beacon was at the airport; However, it showed a distance of 399 nautical miles, this was another source of frustration for the captain, he needed to use his distance from that beacon to judge where he should take his first turn after takeoff, if his distance measuring equipment did not work, How would you know when to turn?

The captain was especially concerned about this because there was an active noise monitoring program in operation around the standard airport if he stayed off the designated departure route his bosses back in Korea would receive a noise complaint that would not reflect well on him, but there was a simple solution to this problem according to the pilot's charts. He could use a different beacon to guide his turn rather than relying on his ranging equipment to begin the turn at a certain distance from the beacon. They could begin the turn once they are in a certain direction, all they would have to do was tune their navigation radios to that beacon and turn at the point described on the chart, perhaps this is something the first officer would have mentioned in a more positive work environment, but given how things had gone so far, what were the chances of the captain?

He would be receptive to me mentioning this as the plane approached the runway. The combat engineer provided the first good news for the crew. The instrument finally seemed to be working. This would be the last good news for flight 8509, halfway there, 6 behind. schedule Air Traffic Control cleared the fight for takeoff the fight engineer pushed the throttles to the takeoff position and the 747 began its slow acceleration down the runway in a few moments the imperfections in the Mechanism would come together there was no turning back now the captain lifted the plane into the sky and it disappeared into the low clouds above the airport the first officer made the standard call as the plane passed 900 feet but seconds later the alert system that compares the two pilots Adis activated indicating that there were more than a difference of 4dre between the captains and the first officers AI the problem that the plane had suffered in the last leg returned but this time for some reason neither the pilots nor the flight engineer responded to the warning at that moment the captain said again that his distance measuring equipment was not working, he was obsessed with this, determined to make the turn at the correct point, which had to be less than a minute after takeoff, 1.5 thousand from the mark, he confirmed with the first officer that the exit procedure required them to turn. on a heading of 158° when they were 1 and 1/2 thousand from the radio beacon again, the comparator warning sounded this time for 1 second but the crew still did not respond to this alert, their attention was completely focused on the point at which that they needed to start their turn shortly, this point had already been reached, the captain now started to turn the plane to the left again, this time the comparator warning was activated, after a few seconds the pilots canceled the warning, but for some reason They did not investigate further.

The captain's ADI shows a different reading than the first officers, since they were in a turn close to the ground, now would be a good time to check, but the crew was distracted, their attention focused on the departure procedure and on Try to complete the turn successfully. They did not notice the growing discrepancy between the captain's ADI and the first officers as Park turned the 747 to the left. His ADI indicated that the plane was still flying with the wings level, naturally he believed that his instrument was something all pilots are trained to do. It's not likely that he ever encountered an ADI failure in his thousands of hours of flying, as a result he continued to hold his control column further and further to the left to get the stubborn airplane to roll.

The first officer could see on his instrument that the plane was clearly already turning left and this turn was increasing even though the captain could not see outside and had not yet thought to compare his own instrument with the backup one, there was still a clue that something was off his ADI. They have been providing false information, but his flight director here was still working as the plane passed the desired trajectory of 158°, the flight director began demanding a right bank and pitch. The pilots were supposed to follow the combat director in this case. The fact that he was giving Park instructions that were very different from what he expected, which was a left turn, should have clued him in to the fact that something was a mistake, but the captain ignored these signals and the 747 It faithfully followed its control inputs and continued to increase its roll to the left.

Its ADI simply indicated that the airplane was wings level. On this flight, it was not the captain who first noticed the problem but the flight engineer who had been monitoring it. He closes the exit from his seat behind the two pilots. and he had noticed that according to the captain's ADI the airplane was not turning in line with its control input he told the captain the bank does not accept the captain did not respond when the airplane passed 30° of the bank the flight engineer made the standard call Bank bank this call was intended to draw the captain's attention to the holding attitude indicator so he could see that his own ADI had failed.

Park did not, so he was hell-bent on successfully completing the exit procedure he had started. to disconnect from everything else, crucially, at no point did the young first officer with a fully functioning ADI challenge the captain's actions, did he not respond to the comparator's warning or the warnings of the fight engineers, it is possible that with only 195 hours in the 747, who is He was unaware of the meaning of the comparative warnings, but most likely after being repeatedly reprimanded by the captain for his incompetence at the beginning of the flight, he did not wish to become more angry with him.

Ironically, it was the captain's own lack of faith in the first officer's decision. competition that led the first officer to retire and become a less effective pilot under normal circumstances, the correct thing for the first officer to do would be to immediately alert the captain about the extreme bank angle of the aircraft and, if that did not work, he would have to take the control of himself, the situation was now deteriorating rapidly, the plane was close to the ground and its turn had become so tight that it was beginning to descend. Park was still holding his control column to the left long after he should have released it and even though his ADI indicated the wings were level, the plane was now pitching over 45°, then 50, then 60 as the bank angle approached. at 80°, the 747's wings could no longer maintain lift and the plane began to descend rapidly even now with the plane screaming toward Park was obsessed with making sure he had met the requirement to begin a turn at 1 1/2 miles. 2 of the radio beacon.

He asked the first officer to request a Radar Vector from Air Traffic Control, but he never had the opportunity to do so. By doing this, the aircraft was now completely on its side and its nose was pitched more than 30° below the horizon. The sound of wind blowing through the cockpit as it plummeted to the ground was only interrupted by the combat engineer saying "boy Bank Split Second later." the plane hit the ground there were no survivors from takeoff to impact it took only 56 seconds Korean Air's response to this incident was profound the airline completely modernized its crew resource management training program, which was the first timesignificantly updated in almost 15 years, never Once again, a power imbalance in the cockpit would cause an accident, but they didn't stop there and Korean Air began training its pilots more frequently in SC unusual attitude scenarios and in failures of instruments if the captain of Flight 8509 had recognized that his ADI had failed even relatively late in the shift.

I would have been able to recover the plane. The airline also made changes to the way it conducted its maintenance, relying less on contractors and expanding its engineering bases to have permanent staff at almost all of its destinations. Hundreds of other smaller changes were implemented over the following months and years, completely transforming the culture within the airline. The year 2024 marks the 25th anniversary of the loss of flight 8509. It is thanks to these changes that in those 25 years not a single Korean airline plane crashed causing deaths. This has been the trend in the industry as a whole, which is why aviation remains by far the safest way to travel.