Original subtitles

NARRATOR: A Boeing 747 slams into the English countryside.

GARY: Hello.

DAVID: It was like a battlefield.

STEVE: Complete and utter devastation.

SID: Where was this 747?

NARRATOR: Investigators have all the clues they need

to figure out what caused the accident.

STEVE: The aircraft took off with the same defect that it had arrived with.

NARRATOR: But they can't explain

why no one on board did anything to prevent it.

DAVID: They seem to be ignoring the alarms completely.

The first officer was about to die, and he didn't say anything.

How can this happen?

NARRATOR: The answer lies not at the crash site

but thousands of kilometers away,

buried in hundreds of years of history.

MAN (over radio): Mayday, mayday.

(theme music plays).

NARRATOR: Gary Dann is enjoying

the Christmas holiday at his home just north of London.

GARY (off-screen): I told you I don't like them.

It was a Christmas-y family get together.

We were just exchanging the presents and that's when I heard

the noise of the plane coming over.

It got louder and louder.

It was almost like the plane was going to take the chimneys off.

I felt and heard the noise that close to the, to the house.

NARRATOR: Living less than two kilometers from Stansted Airport,

Dann is used to hearing jets.

But not this close.

GARY (off-screen): I looked out the window, saw the plane coming over

with fire coming out of the engines.

As it came over it sort of banked heavily left

and then just kept banking and banking.

(explosion)

NARRATOR: A Korean Air 747 slams into

a forest in the village of Great Hallingbury.

GARY (off-screen): This was just a huge, huge explosion that you're watching

it happen with a plume of, of fire coming towards you.

I collected a torch and ran downstairs saying,

"The plane's gone down. We've got to go and help."

My brother and I ran outside and ran towards where it happened.

We were racing towards where

we could see the plume of smoke and fire because there was still

lots of aviation fuel popping around the area.

We ran and jumped into a very large crater just shouting out.

Hello.

You know any survivors please shout.

Hello.

Can anybody hear me?

DAVID (off-screen): The aircraft had created a 30 foot plus crater.

Wreckage was spread over at least half a mile.

It was like a battlefield.

GARY: We dialed 9-9-9.

A plane's gone down in Hatfield Forest in Great Hallingbury.

NARRATOR: It takes nearly half an hour for rescue workers to arrive.

They quickly determine that there are no survivors.

A multi-million dollar plane,

and thousands of kilograms of cargo are completely destroyed.

It's up to the UK's Air Accidents Investigation Branch to figure out why.

DAVID: This is a very sophisticated aircraft flown by a trained crew

and somehow they had lost control of this aircraft How can this happen?

NARRATOR: Stansted Airport on London's northeastern edge.

The airport is a major European hub for low cost passenger carriers

and cargo flights from around the world.

DAVID (off-screen): It really was buzzing.

Lots of people there queuing up, checking in, people arriving,

lots of meeters and greeters, lots of coaches.

So it really was a fairly busy hub just on that run-up to Christmas.

NARRATOR: Flight 8509 is a Korean Air cargo plane.

ANDREW (off-screen): The aircraft was a Boeing 747 freighter.

As the name suggests it was not configured with passenger seats

but the interior was full-up with freight.

NARRATOR: Departing from Seoul, South Korea

the jumbo jet stopped in Tashkent,

Uzbekistan before arriving at Stansted.

It will now continue on to Milan, Italy with a new captain and crew.

In the hold a load controller directs the offloading and on-loading of cargo.

He makes sure that the more than 63,000 kilograms of freight

is stowed safely and securely.

More than just stacking boxes, the job can have a critical effect on the flight

characteristics of the plane itself.

ANDREW: Loading the aircraft has to be done in a manner

that keeps the weight distribution within limits

so that you can't put all the heavy stuff in the back

and all the light stuff in the front, for example,

because it would tend to tip-up and make control difficult.

And that would be very dangerous.

NARRATOR: Captain Park Duk-kyu is a highly respected commander.

FIRST OFFICER (off-screen): Sir.

NARRATOR: And a former colonel in the Korean air force with

thousands of hours of flying time on the 747.

Park Hun-kyu is flight 8509's flight engineer responsible

for monitoring the aircraft's mechanical systems.

First Officer Yoon Ki-sik is new to the 747,

with 195 hours flying time on the aircraft.

DAVID: On this night there were the three crew and a Korean engineer.

NARRATOR: The engineer has overseen some minor maintenance work

on the aircraft and will

now accompany Flight 8509 back to Seoul.

PARK: All right, gentlemen,

if departure goes smoothly we may just make our scheduled time.

Let's proceed.

Stansted clearance delivery Korean Air 8509

requesting clearance to Milan.

CONTROLLER: Korean Air 8509 we have no flight plan.

Cannot clear you.

PARK: Copy that.

Stansted stand-by for flight plan.

NARRATOR: Every commercial airplane needs to file a flight

plan before it can leave the ground.

PARK: Contact our people and get them to re-file the flight plan.

Hurry up!

NARRATOR: Korean Air 8509 must wait while the document

detailing their planed route is filed.

ANDREW (off-screen): As far as the air traffic control system was concerned

it's just another airplane.

It has to obey all the same operational rules and procedures

as any other aircraft, passenger or freight.

CONTROLLER: Korean Air 8509 cleared to Milan via Dover-six-Romeo.

PARK: Korean Air 8509 cleared to Dover-six-Romeo

squawk two-two-three-zero.

NARRATOR: Now nearly an hour behind schedule

the crew gets clearance to taxi.

It's 6:25 p.m.

CONTROLLER: Korean Air 8509 line-up on runway two-three.

FIRST OFFICER: Position on hold runway two-three Korean Air 8509.

NARRATOR: Captain Park is well aware

they have no hope of arriving in Milan on time.

CONTROLLER: Korean 8509 clear takeoff runway two-three.

PARK: Finally.

FIRST OFFICER: 80 knots.

PARK: Roger.

FIRST OFFICER: V-1. Rotate.

NARRATOR: The plane takes off from Stansted Airport at 6:36 p.m.

FIRST OFFICER: Positive rate confirmed.

PARK: Gear up.

FIRST OFFICER: Gear up.

Passing 900 feet.

DAVID: The aircraft had taken off and climbed to about 2,500 feet.

ANDREW: Shortly after takeoff the aircraft was making a turn.

FIRST OFFICER: Left turn at 1.5 D-M-E.

PARK: Copy that. Left turn at 1.5 D-M-E.

DAVID (off-screen): The aircraft started its turn to the left.

FIRST OFFICER: Heading standby sir.

Heading 1-5-8.

(alarm beeping)

NARRATOR: The captain's artificial horizon tells him that the plane isn't turning.

ENGINEER: Bank's not working.

(alarm beeping).

Bank! Bank!

Look! Bank!

(explosion)

NARRATOR: For some reason, Flight 8509 has gone from

takeoff to total destruction in less than 60 seconds.

NARRATOR: Korean Air Flight 8509 lies in pieces just a

few kilometers from one of the busiest airports in the world.

SID: We had no wreckage really that was above knee height.

Where was this 747?

NARRATOR: After any major crash,

Britain's Air Accidents Investigation Branch

deploys a safety specialist to the site.

SID: I'd like to take a look around if I could.

NARRATOR: Sid Hawkins' job is to assess the level of danger at the crash site.

SID: One of the key things to do is to get investigators into site to, to start work.

And for somebody like me who's looking after their safety,

there's always a challenge for me to try and hold them at bay

until we've done our initial site assessment.

NARRATOR: His first concern: the 30 tons of fuel the 747 was carrying on takeoff.

SID: Is that fuel still on site?

If it is that poses quite an immediate hazard for the team there.

In addition to that what sort of cargo are we dealing with?

Are we dealing with just general cargo or are we dealing with dangerous goods?

Let's shut down the scene for the night.

It's too dark and dangerous.

Notify your people.

DAVID: There was no lighting,

and it actually was very, very dangerous for the investigators

and the rescue services.

NARRATOR: Investigation of the crash site will have to wait till morning.

But before they leave the area they make a key find,

one of the plane's two black boxes.

SID: This was crucial the discovery of, of the recorder on the day.

DAVID (off-screen): The cockpit voice recorder is extremely important

dealing with any accident where we have no crew that survived.

It tells us what they were saying.

It gives us an idea of the environment in the cockpit.

And it records the sounds from the cautions and warnings

that go off in the cockpit.

NARRATOR: But this black box has suffered extreme damage.

It's too soon to say whether the CVR holds valuable clues that could help explain

the sudden crash, or if the last recorded moments of Flight 8509

are gone for good.

ENGINEER (off-screen): Bank!

NARRATOR: Meanwhile the AAIB has begun work closer to the

Stansted terminal on the airport runway.

The team's operations investigator is David Miller.

DAVID: We'd been out on the runway having received a report from the airport

that the runway was covered in debris.

NARRATOR: With Miller at the airport is engineering investigator Steve Moss.

STEVE: The things that go through your mind are possibly what's known as

an uncontained engine failure which means that the engine has burst

and left bits on the runway.

NARRATOR: Investigators wonder if the plane actually began

to disintegrate on takeoff.

Among the small pieces of wreckage on the runway is

an especially chilling piece of evidence.

DAVID: Something that looked very much like a human jawbone.

STEVE: And of course then your mind starts to race.

What on earth's gone wrong?

You know has somebody been hit by the aircraft as it took off?

DAVID (off-screen): We wondered whether somebody had committed suicide,

had run towards the aircraft and thrown themselves into the

engine, affected its performance and that had brought it down.

We really didn't know.

NARRATOR: The runway investigation has stopped all

flights in and out of Stansted Airport.

The shutdown comes just days before Christmas.

DAVID (off-screen): The terminal was seething with people.

The pressure on us was tremendous to get that runway open.

REPORTER (over TV): Korean Airline representatives arrived

at Stansted Airport this morning.

They're here to talk to accident investigators

both to try to assess what's known about the crash

as well as to answer questions.

NARRATOR: And there are sure to be a lot of questions.

The destruction of Flight 8509 is the fifth major accident

for Korean Air in the past two-and a half years.

If the AAIB can figure out what happened near Stansted

they may be able to break this deadly pattern.

REPORTER (off-screen): Daylight and the remains of a 747 lying

in a path of destruction on the edge of an English village.

ANDREW (off-screen): It was a very confusing debris field.

It takes a while for, for one to absorb the scene

and to try and make sense of it all.

NARRATOR: By daylight they get their first good look at the point of impact,

a massive crater surrounded on all sides by scattered debris.

STEVE: In fact what we were seeing on the runway

was debris from the explosion which had

blown debris high into the air and had been carried downwind

and just happened to deposit on the runway.

NARRATOR: The far-flung wreckage also helped solve the mystery of

what seemed to be a jawbone on the runway.

DAVID: Closer examination the following morning revealed that

it actually was a bit of twisted plastic.

NARRATOR: Safety specialist Sid Hawkins now turns his attention

to the shattered remnants of the plane's cargo.

SID (off-screen): If you can imagine 40, 50 tons of cargo

almost all of it packed in, in cardboard boxes and the

explosion being so severe that every piece had been destroyed

then it gives you an indication really of just how severe this, this explosion was.

NARRATOR: He needs to know if any of it poses a risk to investigators.

SID (off-screen): We had a consignment of corrosive materials.

NARRATOR: Hawkins learns that Flight 8509 also carried military detonating cord,

two tons of whisky, color printer cartridges,

even an X-ray machine.

But he soon establishes that none of it poses a serious threat.

SID: We were able to determine that the dangerous goods from

this aircraft had all been destroyed.

NARRATOR: But there is one more significant risk Hawkins must assess,

one that stems from the design of the plane itself.

SID (off-screen): We know that this aircraft carries depleted uranium in

its tail section, both in the rudder and in the elevators.

NARRATOR: The 747-200 series uses depleted uranium

as ballast to improve stability in flight.

But tests show that none of the radioactive material has escaped.

SID (off-screen): You feel then that it's safe enough for the guys to start work.

NARRATOR: Meanwhile investigators are still trying to learn if the aircraft

broke-up before crashing.

WOMAN: I did see a glow which could have been the plane alight.

GARY: I noticed the engines were on fire before it hit.

I explained to the investigators that when I looked out the window

I saw the plane coming over

and then I saw flames coming out of an engine.

NARRATOR: Dann's observations raises the possibility

that the left side engines flamed out

causing the plane to roll to one side.

SID: It's safe.

But be careful down in through there.

NARRATOR: To determine if the plane hit the ground intact they

carry out what they call the four corners search.

STEVE: Have we got both wings?

Have we got the tail plane?

Have we got the fin and rudder?

And the answer, eventually, was yes we have.

And we were satisfied that there had not been a structural

failure of the aircraft in the air.

NARRATOR: While locating the four corners Investigators also

discover some very distinctive marks on the ground.

STEVE (off-screen): It was a long slender gash which was made by the wing

and then you could see where the nose had impacted further on.

From the shape of the ground marks you try and understand

what attitude the aircraft was in when it, when it hit the ground.

NARRATOR: The ground scar gives investigators a revealing

glimpse into the flight's final seconds.

ANDREW (off-screen): The aircraft struck the ground at high speed, steep left bank,

steep nose down and uh with an almighty amount of energy.

STEVE: Of course it could be that somehow or other the pilot's been misled by his

instruments and has become what we call disorientated.

NARRATOR: The team brings some of the aircraft's instruments

back to the AAIB labs for examination.

ANDREW: We found a few pieces of um the ADls.

NARRATOR: The ADI, or Attitude Director Indicator,

is a flight instrument that displays the plane's bank and pitch.

ANDREW: When you're flying at night, in cloud, there are no visual cues.

So he has an artificial horizon or an attitude direction

indicator in front of him.

DAVID (off-screen): Modern aircraft have three instruments, one in front

of each pilot and a standby one in the center panel.

So if one of them should fail the pilots can compare their instruments with

the standby instrument and see which two agree and which one disagrees.

ANDREW (off-screen): We found only fragments.

And we were able to forensically examine these.

NARRATOR: They discover that the captain's artificial horizon

seems to have malfunctioned.

It was showing the plane flying level at the point of impact.

That contradicts evidence found at the crash site.

But without the plane's flight data recorder

investigators can't explain the discrepancy.

DAVID: What we needed was that recorder to give us the

confirmation of the exact flight path of the aircraft.

NARRATOR: Pre-flight maintenance records

would normally shed some light on the situation,

but not in this case.

STEVE: The technical log from this flight was not available to us.

It had been destroyed in the uh impact and

unfortunately a copy was not left at Stansted.

It should have been.

NARRATOR: For more information

investigators interview the crew that flew the plane to Stansted

on the previous leg of the flight.

DAVID: I need you to walk me through exactly what happened.

They told us that when they departed from Tashkent the day before, in good weather,

in daylight conditions, they had to carry-out a turn to the left.

As the captain commenced the turn his artificial horizon,

did not work in roll.

NARRATOR: In the daylight the pilot was able to get

his bearings from the horizon outside.

DAVID: In order to resolve this issue

the captain selected number three as his source

and his instrument worked perfectly.

They continued the flight and landed uneventfully at Stansted.

NARRATOR: After landing, the inbound crew left the terminal

before the replacement crew arrived.

DAVID: And the normal practice is if a crew, inbound crew, were

to meet the outbound crew there would be a verbal handover.

A debrief, if you like, of the state of the aircraft.

NARRATOR: But that didn't happen.

Instead the only person that heard about the ADI problem

is the Korean Air maintenance engineer.

KIM: Okay. I'll have a look.

STEVE: Korean Airlines had dispatched an engineer to take

charge of any work that needed to be done on it.

NARRATOR: The Korean engineer didn't have the tools he needed for the job.

So he enlisted some local help.

KIM: I need you to remove the captain's ADI.

NARRATOR: The story of the repair only deepens the mystery.

The inbound crew knew they had a faulty instrument and they had it fixed.

And yet, on takeoff, Captain Park's artificial horizon did not work

according to the evidence found at the crash site.

The Korean engineer is dead.

The only person they can ask about the repair

is the British mechanic who helped him.

DAVID (off-screen): The locally based engineer told us he removed

the instrument from the panel, unplugged the wires at the back.

KIM: Alright that's our problem.

Can you reset the pin?

DAVID: And found what he believed to be a problem with

the connector pins at the back of the instrument.

He replaced the connector in the right way, put the instrument

back into the instrument panel and then carried out a test.

KIM: Looks good.

NARRATOR: As far as the engineer was concerned the problem was solved.

STEVE: Had the maintenance actions actually fixed the defect?

NARRATOR: They hope the answer will be found on the flight data recorder.

It has finally been recovered at the crash site.

DAVID: To find that in amongst all the wreckage at the bottom

of a 30 foot crater took a considerable effort.

It took 7 days to find it.

NARRATOR: But when they download the data something doesn't add up.

The readout is showing that the plane's roll angle never exceeded two degrees.

ANDREW: Clearly it had gone in

at a much steeper roll angle than that like 90 degrees.

So that set the alarm bells ringing.

Why should that occur?

NARRATOR: Why a Korean Air 747 crashed

just moments after takeoff from London's Stansted Airport

is a mystery investigators are only beginning to unravel.

NARRATOR: The flight data recorder from Korean Air 8509 reveals

that the faulty ADI reported by the previous crew

seems not to have been fixed after all.

They need to understand how the fault in the plane's

navigation system was for some reason misdiagnosed.

DAVID: How exactly did your crew report this problem?

NARRATOR: Upon landing the inbound crew's flight engineer noted the problem

with the ADI by entering a code in his technical log.

He then mentioned it to the maintenance engineer.

KIM: Okay. I'll have a look.

DAVID: The normal action is to take the code that's entered

and then look in the corresponding Fault Isolation Manual,

which has the same corresponding numbers.

And that would then tell him

what the fault was and what he had to do about it to fix it.

NARRATOR: But the Korean Air engineer

didn't have a copy of the Fault Isolation Manual.

Without it he couldn't correctly identify the proper repair.

Instead he tried to troubleshoot the problem as best he could.

KIM: Alright that's our problem.

ANDREW: This is when we go into the detailed evaluation

of the aircraft manuals, the component manuals,

right down to the wiring manuals.

NARRATOR: After an in-depth analysis of the plane's navigation system

they finally figure out what was wrong with the captain's artificial horizon.

It was being fed corrupt information.

The real problem lay deeper with a device

called an Inertial Navigation Unit or INU.

Units deep inside the airplane,

send pitch and roll data to the captain and first officer's ADI.

Investigators conclude that one of the INUs short circuited.

ANDREW: It simply ended up in corrupting the roll information that was fed to the,

both the flight data recorder and the captain's ADI.

NARRATOR: All the maintenance work done on Flight 8509 was misdirected.

What they had repaired was never the problem at all.

ANDREW: Really they were barking up the wrong tree.

KIM: I need you to remove the captain's ADI.

ANDREW: If the Fault Isolation Manual had been available they

might have deduced that the correct maintenance action

was to replace the number one INU not the captain's ADI.

STEVE: The rectification action was completely ineffective.

The aircraft took off with the same defect that it had arrived with.

DAVID: An instrument failure is a, is a rare occurrence.

However crews are trained to deal with it.

NARRATOR: Checking each of the three ADis should have allowed

the captain to identify the problem.

The recorded flight data shows that both the First Officer's ADI

and the backup instrument displayed the plane's correct bank angle.

Only the captain's artificial horizon was wrong.

How the crew dealt with that defect in the seconds after takeoff could be the key

to understanding why the flight ended in disaster.

Investigators finally have new insight into those crucial last moments.

FIRST OFFICER (off-screen): Sir.

NARRATOR: AAIB technicians have salvaged the recording from the badly damaged CVR.

(speaking Korean)

(alarm beeping)

DAVID (off-screen): One of the most important things that was on that recorder

was the sound of a warning horn going off in the cockpit

as the aircraft departed from Stansted.

(alarm beeping)

NARRATOR: But even more significant than the sound

of the alarm is what is not on the tape.

DAVID: They seem to be ignoring the alarms completely.

There was no discussion about the fault with the artificial horizon.

NARRATOR: The alarm is telling the pilots one of their ADis is malfunctioning.

They should check the third instrument to see which ADI is correct.

But the pilots remain strangely silent.

DAVID: The flight engineer saw the standby horizon,

looked at the other instruments,

and actually pointed out this problem to the captain.

ENGINEER (off-screen): Bank's not working.

DAVID (off-screen): But the captain did not respond to that,

either in words or deeds.

NARRATOR: Investigators are also troubled by the fact that the first officer

who had a working ADI did nothing to save the plane.

DAVID: Why didn't the first officer say anything?

Here he was in a situation where he was about to die.

He knew that the instruments were at fault.

The comparator buzzer was going off and he said nothing.

ENGINEER (off-screen): Bank! Bank!

STEVE: The copilot should have said to the captain

your ADI is not reading correctly.

DAVID: He should have forcefully said to the captain,

"Mine's correct. I have control."

FIRST OFFICER: I have control. I have control.

DAVID (off-screen): Let me take control.

FIRST OFFICER: I have control.

STEVE: The correct response to that would have been,

"Yes, you have control."

DAVID: But the copilot said nothing.

NARRATOR: The CVR also answers a lingering question concerning

some of the eyewitness accounts of the crash.

STEVE: The CVR gave no indication that there was a fire onboard the aircraft.

You would have heard an engine fire bell, which is a very distinctive warning.

And we didn't hear that.

NARRATOR: The fact that some witnesses were wrong doesn't surprise Moss.

STEVE: There's all sorts of things people can see

in, in bad weather conditions at night.

Reflections of the aircraft's lights or the navigation lights

sometimes can mislead people into thinking there's a fire there.

NARRATOR: Investigators now want to know more about the crew members

who let a minor malfunction lead to a catastrophic crash.

DAVID: We listened to the words on the tape.

But of course they were in Korean.

We had the translation in front of us

but it was very difficult to determine the tone

of what was said and how it was said.

And we had someone who spoke Korean listening to this conversation telling us

the social interaction between the two crew.

(speaking Korean)

NARRATOR: They can hear that prior to takeoff the captain

was becoming more and more agitated by the delays.

CONTROLLER: Korean Air 8509 please explain your delay.

PARK: Answer them!

They're asking how long the delay will be.

And make sure you understand what they're saying before you speak.

FIRST OFFICER: Stansted clearance standing by

for a new flight plan for Milan.

STEVE (off-screen): The captain was very overbearing.

He was very critical of the first officer.

DAVID: And the first officer was, was quite subservient in this conversation.

He did all the listening. The captain did all the talking.

So you'd say he's being condescending.

NARRATOR: Miller can't help but wonder what would have happened

if the captain had listened to the engineer's warning.

He wants to know if there was enough time to save the plane.

Using a flight simulator and data from the Flight Recorder

they recreate the entire flight.

The simulation reveals that impact with the ground was not inevitable.

DAVID: It was possible, just possible, to recover the aircraft

about 500 feet above the ground

doing about 260 knots at 80 degrees of bank.

If you knew what was happening you could have just recovered

that aircraft just skimming the ground in doing so.

NARRATOR: The results convince Miller and his team

that they need to better understand how

Korean Air trains its flight crews.

DAVID: It was obvious from this accident that the crew

interaction played a big part in this accident.

So we needed to go to Korea to see how the crew were trained.

NARRATOR: In Korea, Miller gets an opportunity to observe

Korean Air flight training first hand.

DAVID: There was definitely a hierarchy between pilots.

The captain was the supposedly the older, the wiser, the more experienced,

and the first officer was the younger, inexperienced apprentice.

Crews were working in a very procedural way.

There was not really much free thinking

to deal with an unusual situation.

NARRATOR: The crew dynamic observed in the Korean training session

is strikingly similar to what was recorded in the cockpit of Flight 8509.

Investigators dig into Captain Park's personal history.

DAVID: A lot of the captains in Korean Air were people that

had developed their skills in the military.

NARRATOR: Captain Park had been a colonel, a pilot with a distinguished career flying

small, lightweight fighter jets.

DAVID (off-screen): Korean culture at the time suggested that these pilots

needed to hold a position that was commensurate with

the rank that they had when they were in the military.

So it would be a great loss of face for a colonel in the

military to be given the job of a first officer.

He would go into the company as a captain.

NARRATOR: Park became a Captain

even though his experience was flying solo in fighter jets,

not as part of a crew on large commercial jets.

By piecing together the puzzle of miscommunications, unexpected glitches,

and crew dynamics investigators believe they finally understand

why Korean Air 8509 hit the ground less than 60 seconds

after lifting off from the runway.

PARK: This is inexcusable.

If we hit one more delay.

CONTROLLER: Korean 8509 clear takeoff runway two-three.

FIRST OFFICER: Clear for takeoff runway two-three.

Korean 8509 clear for takeoff.

PARK: Finally.

NARRATOR: A series of delays put flight 8509 behind schedule,

testing the patience of the captain.

The first officer remained quiet, trying to avoid conflict with a senior colleague.

DAVID: To operate any aircraft you need the crew to be working as a team.

You, you don't want an autocrat in one seat

and somebody who's very subservient in the other.

FIRST OFFICER: V-1. Rotate.

Positive rate confirmed.

PARK: Gear up.

FIRST OFFICER: Gear up.

STEVE: You have to have the crew talking to, to each other feeling free to comment

and criticize if necessary what the other's doing.

NARRATOR: The critical moment came

as the captain turned his control column to the left.

His artificial horizon didn't move.

DAVID: And that would have been very confusing.

He would have wondered why.

And in fact what he did was put more bank on,

and more bank and continued to increase the turn rate.

ENGINEER: Bank! Bank!

NARRATOR: The flight engineer knew that the aircraft was starting to bank

at an extreme angle but Captain Park ignored all warnings.

STEVE: In fact he had received a reprimand some months before

because he had not correctly followed an instrument departure procedure.

And we think that this was uppermost in his mind that he had to follow

the correct procedure to avoid getting

another wrap across the knuckles I suppose.

NARRATOR: To make matters worse, he had no visual reference,

and likely couldn't feel the drastic bank.

NARRATOR: Crews are trained to trust their instruments and not their senses.

Captain Park trusted his ADI in spite of overwhelming evidence that it was wrong.

DAVID (off-screen): The first officer should have said to the captain:

"Look at the warning buzzers going off."

It's very difficult to understand his reactions or lack of reactions.

But I think a lot of it is embedded within the culture, or was at that time.

NARRATOR: Fearing dishonor more than death itself,

the first officer did not dare criticize his captain,

or even attempt to correct his actions.

STEVE (off-screen): This crew were not operating as a crew.

They were operating as one man with a couple of assistants.

DAVID (off-screen): The aircraft just continued to roll to 30 degrees,

40, 50, 60, 70, 80,

90 degrees of bank.

NARRATOR: Investigators now suspect that the seeds of the deadly crash

were sown hundreds of years before the 747 ever left the ground.

FIRST OFFICER: Sir.

NARRATOR: For centuries a rigid class structure based

on social hierarchy defined Korean culture.

Investigators have come to see how the Korean military,

an honor bound institution, has strongly influenced commercial aviation.

It's now clear that strict adherence to cultural norms

put the crew of Korean Air 8509 in danger

from the moment they entered the cockpit.

DAVID: It's very difficult to overcome entrenched cultural values.

NARRATOR: The different stature of the two pilots was also

reinforced by a disparity in military rank.

DAVID (off-screen): We believe that the cultural values within which these

two people were raised was

overwhelming in this instance.

NARRATOR: The relationship between the two pilots was not that of equals.

Just two-and-a-half years earlier,

a Korean Air flight went down in the South Pacific

killing more than 200 people.

DAVID: Korean Air had been going through quite a rough patch.

One of their aircraft had been involved in an accident in Guam.

(screaming)

NARRATOR: Poor crew communication and long-standing rules of hierarchy

had also contributed to the crash in Guam.

DAVID (off-screen): Their reputation was not good.

Then this accident had come along.

NARRATOR: The U.S. military stops using Korean Air

to ferry its personnel in the Pacific region.

The airline comes under strict scrutiny around the world.

With the crash of flight 8509 Korean Air's reputation is in ruins.

REPORTER (over TV): At a news conference the Korean Airline officials

made the startling admission that military pilots,

many of whom were recruited by the airline,

sometimes take unnecessary risks.

NARRATOR: Despite all the negative publicity

for the struggling airline,

investigators see a way to help Korean Air overcome is safety problems.

STEVE: I think all accidents have a lesson or lessons to

be learned that will improve aviation safety.

NARRATOR: The AAIB recommends that all imported training

materials be modified to better accommodate Korean culture.

Korean Air's training programs are radically overhauled

to improve pilot performance

and foster a completely new culture within the cockpit.

DAVID: After the accident in 1999, Korean Air, I believe,

entered into a significant program to improve its safety record.

That company have introduced a much more rigorous process.

And they really have invested very, very heavily in the flight

safety aspects that came out of this accident.

STEVE: In this case the issues of communication,

the issues of how aircraft are maintained,

and also the very important conclusions regarding cockpit resource management.

DAVID: The statistics show that the safety record of Korean Air

since these events around 1999

is such that it is now regarded as a very safe airline.

NARRATOR: As a direct result of the crash of flight 8509

Korean Air has been completely transformed.

Since 1999 the airline has not had a single crash or fatality.

It has become one of the most highly regarded airlines in the world.

(music plays through credits)