All language subtitles for M.2003-S11E07-Bad.Attitude.Korean.Air.Cargo.Flight.8509.WEBDL-1080pEAC3.5.1h264-PiTBULL_track4_[eng]

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)