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NARRATOR: A Boeing 747 slams
into the English countryside.
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00:00:07,541 --> 00:00:08,742
GARY: Hello.
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00:00:09,710 --> 00:00:10,928
DAVID: It was like
a battlefield.
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00:00:11,011 --> 00:00:13,814
STEVE: Complete and
utter devastation.
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00:00:15,182 --> 00:00:17,618
SID: Where was this 747?
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00:00:18,585 --> 00:00:20,805
NARRATOR: Investigators have all
the clues they need
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00:00:20,888 --> 00:00:23,183
to figure out what caused the accident.
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STEVE: The aircraft took off with
the same defect that it had arrived with.
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00:00:29,796 --> 00:00:31,482
NARRATOR: But they can't explain
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00:00:31,565 --> 00:00:34,251
why no one on board
did anything to prevent it.
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DAVID: They seem to be
ignoring the alarms completely.
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The first officer was about to
die, and he didn't say anything.
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How can this happen?
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NARRATOR: The answer lies not
at the crash site
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but thousands of kilometers away,
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buried in hundreds of years of history.
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MAN (over radio):
Mayday, mayday.
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(theme music plays).
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{\an8}NARRATOR: Gary Dann is enjoying
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the Christmas holiday
at his home just north of London.
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GARY (off-screen): I told
you I don't like them.
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It was a Christmas-y family get together.
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We were just exchanging the
presents and that's when I heard
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the noise of the plane coming over.
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It got louder and louder.
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{\an8}It was almost like the plane was
going to take the chimneys off.
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{\an8}I felt and heard the noise that
close to the, to the house.
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NARRATOR: Living less
than two kilometers from Stansted Airport,
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Dann is used to hearing jets.
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But not this close.
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GARY (off-screen): I looked out
the window, saw the plane coming over
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with fire coming out of the engines.
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As it came over it sort of
banked heavily left
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and then just kept banking and banking.
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(explosion)
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NARRATOR: A Korean Air 747 slams into
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a forest in the village
of Great Hallingbury.
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GARY (off-screen): This was just a huge,
huge explosion that you're watching
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it happen with a plume of,
of fire coming towards you.
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I collected a torch and
ran downstairs saying,
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"The plane's gone down.
We've got to go and help."
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My brother and I ran outside and
ran towards where it happened.
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We were racing towards where
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we could see the plume of smoke
and fire because there was still
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lots of aviation fuel
popping around the area.
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We ran and jumped into a very
large crater just shouting out.
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Hello.
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You know any survivors please shout.
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00:03:12,426 --> 00:03:13,660
Hello.
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Can anybody hear me?
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DAVID (off-screen): The aircraft had
created a 30 foot plus crater.
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Wreckage was spread over
at least half a mile.
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It was like a battlefield.
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GARY: We dialed 9-9-9.
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A plane's gone down in Hatfield
Forest in Great Hallingbury.
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NARRATOR: It takes nearly half an hour
for rescue workers to arrive.
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They quickly determine that
there are no survivors.
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A multi-million dollar plane,
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and thousands of kilograms of
cargo are completely destroyed.
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It's up to the UK's Air Accidents
Investigation Branch to figure out why.
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{\an8}DAVID: This is a very sophisticated
aircraft flown by a trained crew
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{\an8}and somehow they had lost control of this
aircraft How can this happen?
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00:04:11,919 --> 00:04:15,214
NARRATOR: Stansted Airport on
London's northeastern edge.
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The airport is a major European hub
for low cost passenger carriers
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and cargo flights from around the world.
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DAVID (off-screen):
It really was buzzing.
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Lots of people there queuing up,
checking in, people arriving,
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lots of meeters and
greeters, lots of coaches.
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So it really was a fairly busy hub just on
that run-up to Christmas.
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NARRATOR: Flight 8509 is
a Korean Air cargo plane.
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00:04:49,489 --> 00:04:52,777
ANDREW (off-screen): The aircraft was
a Boeing 747 freighter.
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{\an8}As the name suggests it was not
configured with passenger seats
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{\an8}but the interior was full-up with freight.
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NARRATOR: Departing from Seoul,
South Korea
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the jumbo jet stopped in Tashkent,
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00:05:07,007 --> 00:05:09,309
Uzbekistan before arriving at Stansted.
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It will now continue on to Milan, Italy
with a new captain and crew.
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In the hold a load controller directs
the offloading and on-loading of cargo.
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He makes sure that the more
than 63,000 kilograms of freight
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00:05:29,796 --> 00:05:31,932
is stowed safely and securely.
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More than just stacking boxes, the job
can have a critical effect on the flight
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00:05:38,539 --> 00:05:40,774
characteristics of the plane itself.
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00:05:42,009 --> 00:05:43,961
ANDREW: Loading the aircraft
has to be done in a manner
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00:05:44,044 --> 00:05:46,914
that keeps the weight distribution
within limits
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00:05:47,047 --> 00:05:49,467
so that you can't put all the heavy stuff
in the back
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and all the light stuff in the front,
for example,
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because it would tend to tip-up
and make control difficult.
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And that would be very dangerous.
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NARRATOR: Captain Park Duk-kyu
is a highly respected commander.
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00:06:08,302 --> 00:06:10,304
FIRST OFFICER (off-screen): Sir.
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NARRATOR: And a former colonel
in the Korean air force with
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00:06:13,407 --> 00:06:16,310
thousands of hours of
flying time on the 747.
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00:06:20,414 --> 00:06:25,152
Park Hun-kyu is flight 8509's
flight engineer responsible
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for monitoring the aircraft's
mechanical systems.
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00:06:29,957 --> 00:06:33,327
First Officer Yoon Ki-sik
is new to the 747,
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with 195 hours flying
time on the aircraft.
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00:06:39,700 --> 00:06:44,371
DAVID: On this night there were
the three crew and a Korean engineer.
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00:06:45,939 --> 00:06:48,759
NARRATOR: The engineer has
overseen some minor maintenance work
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on the aircraft and will
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00:06:50,410 --> 00:06:53,547
now accompany Flight 8509 back to Seoul.
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PARK: All right, gentlemen,
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if departure goes smoothly we may just
make our scheduled time.
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Let's proceed.
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Stansted clearance delivery
Korean Air 8509
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requesting clearance to Milan.
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CONTROLLER: Korean Air 8509
we have no flight plan.
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Cannot clear you.
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PARK: Copy that.
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Stansted stand-by for flight plan.
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{\an8}NARRATOR: Every commercial
airplane needs to file a flight
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00:07:24,111 --> 00:07:26,229
{\an8}plan before it can leave the ground.
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00:07:26,813 --> 00:07:29,733
{\an8}PARK: Contact our people and get them to
re-file the flight plan.
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Hurry up!
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NARRATOR: Korean Air 8509
must wait while the document
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00:07:37,624 --> 00:07:39,993
detailing their planed route is filed.
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00:07:43,897 --> 00:07:45,883
ANDREW (off-screen): As far as the
air traffic control system was concerned
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it's just another airplane.
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It has to obey all the same
operational rules and procedures
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as any other aircraft,
passenger or freight.
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00:07:55,442 --> 00:07:59,746
CONTROLLER: Korean Air 8509 cleared
to Milan via Dover-six-Romeo.
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00:08:01,148 --> 00:08:04,451
PARK: Korean Air 8509 cleared to
Dover-six-Romeo
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00:08:04,585 --> 00:08:06,753
squawk two-two-three-zero.
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00:08:07,487 --> 00:08:09,840
NARRATOR: Now nearly
an hour behind schedule
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the crew gets clearance to taxi.
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00:08:12,759 --> 00:08:14,428
It's 6:25 p.m.
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CONTROLLER: Korean Air 8509
line-up on runway two-three.
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FIRST OFFICER: Position on hold
runway two-three Korean Air 8509.
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NARRATOR: Captain Park is well aware
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they have no hope of arriving in Milan
on time.
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CONTROLLER: Korean 8509 clear
takeoff runway two-three.
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PARK: Finally.
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FIRST OFFICER: 80 knots.
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PARK: Roger.
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FIRST OFFICER: V-1. Rotate.
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00:08:57,171 --> 00:09:01,341
NARRATOR: The plane takes off
from Stansted Airport at 6:36 p.m.
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00:09:04,111 --> 00:09:05,930
FIRST OFFICER: Positive
rate confirmed.
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00:09:06,013 --> 00:09:07,114
PARK: Gear up.
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00:09:07,247 --> 00:09:08,600
FIRST OFFICER: Gear up.
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00:09:09,616 --> 00:09:11,285
Passing 900 feet.
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00:09:11,418 --> 00:09:16,557
DAVID: The aircraft had taken off
and climbed to about 2,500 feet.
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00:09:17,758 --> 00:09:20,978
ANDREW: Shortly after takeoff
the aircraft was making a turn.
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00:09:21,061 --> 00:09:23,238
FIRST OFFICER: Left
turn at 1.5 D-M-E.
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00:09:23,730 --> 00:09:27,401
PARK: Copy that. Left
turn at 1.5 D-M-E.
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00:09:28,836 --> 00:09:32,223
DAVID (off-screen): The aircraft
started its turn to the left.
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00:09:32,306 --> 00:09:33,691
FIRST OFFICER:
Heading standby sir.
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00:09:33,774 --> 00:09:35,776
Heading 1-5-8.
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00:09:36,710 --> 00:09:40,047
(alarm beeping)
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00:09:40,414 --> 00:09:44,735
NARRATOR: The captain's artificial horizon
tells him that the plane isn't turning.
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00:09:44,818 --> 00:09:46,203
ENGINEER: Bank's not working.
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00:09:46,286 --> 00:09:49,289
(alarm beeping).
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00:09:49,423 --> 00:09:51,225
Bank! Bank!
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00:09:55,195 --> 00:09:56,930
Look! Bank!
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00:10:07,508 --> 00:10:11,178
(explosion)
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00:10:13,113 --> 00:10:16,283
NARRATOR: For some reason,
Flight 8509 has gone from
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00:10:16,416 --> 00:10:20,487
takeoff to total destruction
in less than 60 seconds.
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00:10:23,991 --> 00:10:27,594
NARRATOR: Korean Air Flight
8509 lies in pieces just a
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00:10:27,728 --> 00:10:31,258
few kilometers from one of the
busiest airports in the world.
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00:10:34,034 --> 00:10:37,154
SID: We had no wreckage really
that was above knee height.
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00:10:37,237 --> 00:10:39,673
Where was this 747?
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00:10:41,475 --> 00:10:43,358
NARRATOR: After any major crash,
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00:10:43,477 --> 00:10:46,380
Britain's Air Accidents
Investigation Branch
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00:10:46,513 --> 00:10:48,699
deploys a safety specialist to the site.
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00:10:48,782 --> 00:10:50,868
SID: I'd like to take a
look around if I could.
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00:10:50,951 --> 00:10:55,473
NARRATOR: Sid Hawkins' job is to assess
the level of danger at the crash site.
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00:10:55,556 --> 00:11:00,498
{\an8}SID: One of the key things to do is to get
investigators into site to, to start work.
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00:11:00,694 --> 00:11:03,581
{\an8}And for somebody like me who's looking
after their safety,
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00:11:03,664 --> 00:11:06,984
there's always a challenge for me to try
and hold them at bay
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00:11:07,067 --> 00:11:09,656
until we've done
our initial site assessment.
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00:11:10,337 --> 00:11:15,475
NARRATOR: His first concern: the 30 tons
of fuel the 747 was carrying on takeoff.
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00:11:16,643 --> 00:11:18,579
SID: Is that fuel still on site?
171
00:11:18,712 --> 00:11:22,816
If it is that poses quite an immediate
hazard for the team there.
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00:11:22,950 --> 00:11:26,520
In addition to that what sort
of cargo are we dealing with?
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00:11:26,653 --> 00:11:31,183
Are we dealing with just general cargo
or are we dealing with dangerous goods?
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00:11:32,426 --> 00:11:34,612
Let's shut down the scene for the night.
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00:11:34,695 --> 00:11:36,313
It's too dark and dangerous.
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00:11:36,396 --> 00:11:38,198
Notify your people.
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00:11:39,633 --> 00:11:41,218
DAVID: There was no lighting,
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00:11:41,301 --> 00:11:43,854
{\an8}and it actually was very, very
dangerous for the investigators
179
00:11:43,937 --> 00:11:46,440
{\an8}and the rescue services.
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00:11:48,008 --> 00:11:52,244
NARRATOR: Investigation of the crash site
will have to wait till morning.
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00:11:52,980 --> 00:11:56,783
But before they leave the
area they make a key find,
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00:11:56,917 --> 00:11:59,253
one of the plane's two black boxes.
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00:12:01,588 --> 00:12:06,159
SID: This was crucial the discovery of, of
the recorder on the day.
184
00:12:08,128 --> 00:12:10,514
DAVID (off-screen): The cockpit
voice recorder is extremely important
185
00:12:10,597 --> 00:12:14,668
dealing with any accident where
we have no crew that survived.
186
00:12:15,302 --> 00:12:17,404
It tells us what they were saying.
187
00:12:17,538 --> 00:12:20,624
It gives us an idea of the
environment in the cockpit.
188
00:12:20,707 --> 00:12:25,045
And it records the sounds from
the cautions and warnings
189
00:12:25,179 --> 00:12:27,481
that go off in the cockpit.
190
00:12:27,881 --> 00:12:30,668
NARRATOR: But this black box
has suffered extreme damage.
191
00:12:30,751 --> 00:12:36,089
It's too soon to say whether the CVR holds
valuable clues that could help explain
192
00:12:36,223 --> 00:12:41,562
the sudden crash, or if the last
recorded moments of Flight 8509
193
00:12:41,695 --> 00:12:43,297
are gone for good.
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00:12:43,597 --> 00:12:45,245
ENGINEER (off-screen): Bank!
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00:12:51,171 --> 00:12:54,258
NARRATOR: Meanwhile the AAIB
has begun work closer to the
196
00:12:54,341 --> 00:12:56,810
Stansted terminal on the airport runway.
197
00:12:59,046 --> 00:13:02,549
The team's operations
investigator is David Miller.
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00:13:04,218 --> 00:13:08,372
DAVID: We'd been out on the runway having
received a report from the airport
199
00:13:08,455 --> 00:13:11,124
that the runway was covered in debris.
200
00:13:12,593 --> 00:13:17,005
NARRATOR: With Miller at the airport is
engineering investigator Steve Moss.
201
00:13:18,065 --> 00:13:21,285
{\an8}STEVE: The things that go through
your mind are possibly what's known as
202
00:13:21,368 --> 00:13:24,455
{\an8}an uncontained engine failure which means
that the engine has burst
203
00:13:24,538 --> 00:13:26,640
and left bits on the runway.
204
00:13:27,174 --> 00:13:29,927
NARRATOR: Investigators wonder if
the plane actually began
205
00:13:30,010 --> 00:13:31,678
to disintegrate on takeoff.
206
00:13:32,145 --> 00:13:35,649
Among the small pieces of
wreckage on the runway is
207
00:13:35,782 --> 00:13:38,194
an especially chilling piece of evidence.
208
00:13:38,886 --> 00:13:42,357
DAVID: Something that looked
very much like a human jawbone.
209
00:13:46,827 --> 00:13:48,979
STEVE: And of course then
your mind starts to race.
210
00:13:49,062 --> 00:13:50,381
What on earth's gone wrong?
211
00:13:50,464 --> 00:13:54,053
You know has somebody been hit
by the aircraft as it took off?
212
00:13:55,302 --> 00:13:57,621
DAVID (off-screen): We wondered whether
somebody had committed suicide,
213
00:13:57,704 --> 00:14:01,141
had run towards the aircraft
and thrown themselves into the
214
00:14:01,275 --> 00:14:06,480
engine, affected its performance
and that had brought it down.
215
00:14:06,980 --> 00:14:08,649
We really didn't know.
216
00:14:11,318 --> 00:14:13,304
NARRATOR: The runway
investigation has stopped all
217
00:14:13,387 --> 00:14:15,856
flights in and out of Stansted Airport.
218
00:14:16,990 --> 00:14:19,638
The shutdown comes just
days before Christmas.
219
00:14:21,161 --> 00:14:24,181
DAVID (off-screen): The terminal
was seething with people.
220
00:14:24,264 --> 00:14:28,869
The pressure on us was tremendous to
get that runway open.
221
00:14:30,270 --> 00:14:31,922
REPORTER (over TV): Korean
Airline representatives arrived
222
00:14:32,005 --> 00:14:34,174
at Stansted Airport this morning.
223
00:14:34,308 --> 00:14:36,977
They're here to talk
to accident investigators
224
00:14:37,110 --> 00:14:39,296
both to try to assess what's known
about the crash
225
00:14:39,379 --> 00:14:41,315
as well as to answer questions.
226
00:14:42,482 --> 00:14:45,236
NARRATOR: And there are sure
to be a lot of questions.
227
00:14:45,319 --> 00:14:50,090
The destruction of Flight 8509
is the fifth major accident
228
00:14:50,224 --> 00:14:53,160
for Korean Air in the past
two-and a half years.
229
00:14:55,796 --> 00:14:59,399
If the AAIB can figure out
what happened near Stansted
230
00:14:59,533 --> 00:15:02,603
they may be able to break
this deadly pattern.
231
00:15:04,605 --> 00:15:07,658
REPORTER (off-screen): Daylight
and the remains of a 747 lying
232
00:15:07,741 --> 00:15:11,153
in a path of destruction on the
edge of an English village.
233
00:15:13,380 --> 00:15:16,033
ANDREW (off-screen): It was a
very confusing debris field.
234
00:15:16,116 --> 00:15:19,786
{\an8}It takes a while for, for one to absorb
the scene
235
00:15:19,920 --> 00:15:22,289
{\an8}and to try and make sense of it all.
236
00:15:24,958 --> 00:15:29,370
NARRATOR: By daylight they get their first
good look at the point of impact,
237
00:15:29,530 --> 00:15:33,534
a massive crater surrounded on
all sides by scattered debris.
238
00:15:35,002 --> 00:15:37,321
STEVE: In fact what we were
seeing on the runway
239
00:15:37,404 --> 00:15:39,706
was debris from the explosion which had
240
00:15:39,840 --> 00:15:44,645
blown debris high into the air
and had been carried downwind
241
00:15:44,778 --> 00:15:47,614
and just happened to
deposit on the runway.
242
00:15:49,416 --> 00:15:52,436
NARRATOR: The far-flung wreckage
also helped solve the mystery of
243
00:15:52,519 --> 00:15:54,990
what seemed to be a jawbone on the runway.
244
00:15:56,490 --> 00:15:59,677
DAVID: Closer examination the
following morning revealed that
245
00:15:59,760 --> 00:16:03,764
it actually was a bit of twisted plastic.
246
00:16:09,970 --> 00:16:12,890
NARRATOR: Safety specialist Sid
Hawkins now turns his attention
247
00:16:12,973 --> 00:16:15,679
to the shattered remnants
of the plane's cargo.
248
00:16:16,443 --> 00:16:20,147
SID (off-screen): If you can
imagine 40, 50 tons of cargo
249
00:16:20,280 --> 00:16:23,617
almost all of it packed in,
in cardboard boxes and the
250
00:16:23,750 --> 00:16:27,171
explosion being so severe that
every piece had been destroyed
251
00:16:27,254 --> 00:16:32,092
then it gives you an indication really of
just how severe this, this explosion was.
252
00:16:33,660 --> 00:16:37,014
NARRATOR: He needs to know if any of it
poses a risk to investigators.
253
00:16:37,097 --> 00:16:41,401
SID (off-screen): We had a consignment of
corrosive materials.
254
00:16:42,736 --> 00:16:47,541
NARRATOR: Hawkins learns that Flight 8509
also carried military detonating cord,
255
00:16:49,176 --> 00:16:54,047
two tons of whisky,
color printer cartridges,
256
00:16:55,349 --> 00:16:56,884
even an X-ray machine.
257
00:16:59,219 --> 00:17:02,867
But he soon establishes
that none of it poses a serious threat.
258
00:17:04,291 --> 00:17:07,077
SID: We were able to determine
that the dangerous goods from
259
00:17:07,160 --> 00:17:09,337
this aircraft had all been destroyed.
260
00:17:09,897 --> 00:17:13,751
NARRATOR: But there is one more
significant risk Hawkins must assess,
261
00:17:13,834 --> 00:17:16,776
one that stems from the
design of the plane itself.
262
00:17:17,304 --> 00:17:20,858
SID (off-screen): We know that this
aircraft carries depleted uranium in
263
00:17:20,941 --> 00:17:24,545
its tail section, both in the
rudder and in the elevators.
264
00:17:25,812 --> 00:17:29,550
NARRATOR: The 747-200 series
uses depleted uranium
265
00:17:29,683 --> 00:17:32,186
as ballast to improve stability in flight.
266
00:17:33,487 --> 00:17:37,624
But tests show that none of
the radioactive material has escaped.
267
00:17:39,293 --> 00:17:43,047
SID (off-screen): You feel then that it's
safe enough for the guys to start work.
268
00:17:43,130 --> 00:17:46,016
NARRATOR: Meanwhile investigators
are still trying to learn if the aircraft
269
00:17:46,099 --> 00:17:47,901
broke-up before crashing.
270
00:17:48,702 --> 00:17:53,507
WOMAN: I did see a glow which could have
been the plane alight.
271
00:17:55,008 --> 00:17:57,862
GARY: I noticed the engines
were on fire before it hit.
272
00:17:57,945 --> 00:18:00,531
I explained to the investigators that when
I looked out the window
273
00:18:00,614 --> 00:18:02,916
{\an8}I saw the plane coming over
274
00:18:03,050 --> 00:18:05,786
{\an8}and then I saw flames
coming out of an engine.
275
00:18:07,621 --> 00:18:10,374
NARRATOR: Dann's observations raises
the possibility
276
00:18:10,457 --> 00:18:12,610
that the left side engines flamed out
277
00:18:12,693 --> 00:18:15,362
causing the plane to roll to one side.
278
00:18:19,666 --> 00:18:21,001
SID: It's safe.
279
00:18:21,401 --> 00:18:23,578
But be careful down in through there.
280
00:18:25,372 --> 00:18:28,225
NARRATOR: To determine if the
plane hit the ground intact they
281
00:18:28,308 --> 00:18:31,132
carry out what they call
the four corners search.
282
00:18:32,412 --> 00:18:33,931
STEVE: Have we got both wings?
283
00:18:34,014 --> 00:18:35,433
Have we got the tail plane?
284
00:18:35,516 --> 00:18:37,340
Have we got the fin and rudder?
285
00:18:37,918 --> 00:18:41,355
And the answer, eventually,
was yes we have.
286
00:18:41,488 --> 00:18:43,908
And we were satisfied that
there had not been a structural
287
00:18:43,991 --> 00:18:46,050
failure of the aircraft in the air.
288
00:18:47,060 --> 00:18:49,680
NARRATOR: While locating the
four corners Investigators also
289
00:18:49,763 --> 00:18:52,766
discover some very distinctive
marks on the ground.
290
00:18:55,302 --> 00:18:59,090
STEVE (off-screen): It was a long slender
gash which was made by the wing
291
00:18:59,173 --> 00:19:03,110
and then you could see where the
nose had impacted further on.
292
00:19:04,978 --> 00:19:09,283
From the shape of the ground marks you try
and understand
293
00:19:09,416 --> 00:19:13,240
what attitude the aircraft was in when it,
when it hit the ground.
294
00:19:13,854 --> 00:19:16,207
NARRATOR: The ground scar
gives investigators a revealing
295
00:19:16,290 --> 00:19:18,643
glimpse into the flight's final seconds.
296
00:19:23,697 --> 00:19:27,785
ANDREW (off-screen): The aircraft struck
the ground at high speed, steep left bank,
297
00:19:27,868 --> 00:19:33,473
steep nose down and uh with
an almighty amount of energy.
298
00:19:38,212 --> 00:19:42,299
STEVE: Of course it could be that somehow
or other the pilot's been misled by his
299
00:19:42,382 --> 00:19:45,519
instruments and has become
what we call disorientated.
300
00:19:48,755 --> 00:19:50,975
NARRATOR: The team brings some
of the aircraft's instruments
301
00:19:51,058 --> 00:19:53,560
back to the AAIB labs for examination.
302
00:19:54,795 --> 00:19:59,333
ANDREW: We found a few
pieces of um the ADls.
303
00:20:02,236 --> 00:20:05,272
NARRATOR: The ADI,
or Attitude Director Indicator,
304
00:20:05,439 --> 00:20:09,145
is a flight instrument that displays
the plane's bank and pitch.
305
00:20:12,045 --> 00:20:15,900
ANDREW: When you're flying at night,
in cloud, there are no visual cues.
306
00:20:15,983 --> 00:20:20,120
So he has an artificial horizon
or an attitude direction
307
00:20:20,254 --> 00:20:22,322
indicator in front of him.
308
00:20:24,491 --> 00:20:28,668
DAVID (off-screen): Modern aircraft have
three instruments, one in front
309
00:20:28,762 --> 00:20:32,165
of each pilot and a standby
one in the center panel.
310
00:20:33,033 --> 00:20:38,772
So if one of them should fail the pilots
can compare their instruments with
311
00:20:38,906 --> 00:20:43,024
the standby instrument and see which two
agree and which one disagrees.
312
00:20:44,211 --> 00:20:45,963
ANDREW (off-screen): We
found only fragments.
313
00:20:46,046 --> 00:20:48,815
And we were able to
forensically examine these.
314
00:20:51,151 --> 00:20:53,871
NARRATOR: They discover that the captain's
artificial horizon
315
00:20:53,954 --> 00:20:56,657
seems to have malfunctioned.
316
00:20:56,957 --> 00:21:00,487
It was showing the plane flying
level at the point of impact.
317
00:21:01,562 --> 00:21:04,445
That contradicts evidence
found at the crash site.
318
00:21:06,600 --> 00:21:09,736
But without the plane's
flight data recorder
319
00:21:09,870 --> 00:21:12,873
investigators can't explain
the discrepancy.
320
00:21:13,941 --> 00:21:16,594
DAVID: What we needed was
that recorder to give us the
321
00:21:16,677 --> 00:21:19,847
confirmation of the exact
flight path of the aircraft.
322
00:21:21,381 --> 00:21:23,067
{\an8}NARRATOR: Pre-flight maintenance records
323
00:21:23,150 --> 00:21:25,803
{\an8}would normally shed some light
on the situation,
324
00:21:25,886 --> 00:21:27,387
{\an8}but not in this case.
325
00:21:29,056 --> 00:21:32,243
STEVE: The technical log from this flight
was not available to us.
326
00:21:32,326 --> 00:21:35,329
It had been destroyed in the uh impact and
327
00:21:35,462 --> 00:21:40,033
unfortunately a copy was
not left at Stansted.
328
00:21:40,367 --> 00:21:41,802
It should have been.
329
00:21:43,237 --> 00:21:44,622
NARRATOR: For more information
330
00:21:44,705 --> 00:21:48,058
investigators interview the crew
that flew the plane to Stansted
331
00:21:48,141 --> 00:21:50,141
on the previous leg of the flight.
332
00:21:52,312 --> 00:21:55,232
DAVID: I need you to walk me
through exactly what happened.
333
00:21:55,315 --> 00:22:00,621
They told us that when they departed from
Tashkent the day before, in good weather,
334
00:22:00,754 --> 00:22:04,519
in daylight conditions, they had
to carry-out a turn to the left.
335
00:22:07,728 --> 00:22:11,632
As the captain commenced the
turn his artificial horizon,
336
00:22:11,765 --> 00:22:14,034
did not work in roll.
337
00:22:15,602 --> 00:22:17,488
NARRATOR: In the daylight
the pilot was able to get
338
00:22:17,571 --> 00:22:19,807
his bearings from the horizon outside.
339
00:22:21,208 --> 00:22:23,677
DAVID: In order to resolve this issue
340
00:22:23,810 --> 00:22:26,747
the captain selected number three
as his source
341
00:22:26,880 --> 00:22:29,583
and his instrument worked perfectly.
342
00:22:30,417 --> 00:22:34,888
They continued the flight and
landed uneventfully at Stansted.
343
00:22:36,557 --> 00:22:39,477
NARRATOR: After landing, the
inbound crew left the terminal
344
00:22:39,560 --> 00:22:41,678
before the replacement crew arrived.
345
00:22:43,130 --> 00:22:47,701
DAVID: And the normal practice
is if a crew, inbound crew, were
346
00:22:47,835 --> 00:22:51,605
to meet the outbound crew there
would be a verbal handover.
347
00:22:51,738 --> 00:22:54,875
A debrief, if you like, of
the state of the aircraft.
348
00:22:55,742 --> 00:22:57,294
NARRATOR: But that
didn't happen.
349
00:22:57,377 --> 00:23:00,781
Instead the only person that
heard about the ADI problem
350
00:23:00,914 --> 00:23:03,450
is the Korean Air maintenance engineer.
351
00:23:04,284 --> 00:23:05,932
KIM: Okay. I'll have a look.
352
00:23:07,821 --> 00:23:11,491
{\an8}STEVE: Korean Airlines had
dispatched an engineer to take
353
00:23:11,625 --> 00:23:16,029
charge of any work that
needed to be done on it.
354
00:23:17,397 --> 00:23:21,285
NARRATOR: The Korean engineer didn't have
the tools he needed for the job.
355
00:23:21,368 --> 00:23:23,237
So he enlisted some local help.
356
00:23:23,904 --> 00:23:26,434
KIM: I need you to
remove the captain's ADI.
357
00:23:26,940 --> 00:23:30,352
NARRATOR: The story of the
repair only deepens the mystery.
358
00:23:31,211 --> 00:23:35,447
The inbound crew knew they had a faulty
instrument and they had it fixed.
359
00:23:36,049 --> 00:23:40,254
And yet, on takeoff, Captain Park's
artificial horizon did not work
360
00:23:40,387 --> 00:23:43,270
according to the evidence found at
the crash site.
361
00:23:44,458 --> 00:23:46,260
The Korean engineer is dead.
362
00:23:47,728 --> 00:23:50,397
The only person they can ask about
the repair
363
00:23:50,531 --> 00:23:53,200
is the British mechanic who helped him.
364
00:23:53,500 --> 00:23:56,687
DAVID (off-screen): The locally based
engineer told us he removed
365
00:23:56,770 --> 00:24:01,608
the instrument from the panel,
unplugged the wires at the back.
366
00:24:03,510 --> 00:24:05,262
KIM: Alright that's our problem.
367
00:24:05,345 --> 00:24:06,813
Can you reset the pin?
368
00:24:06,947 --> 00:24:11,218
DAVID: And found what he
believed to be a problem with
369
00:24:11,351 --> 00:24:14,175
the connector pins at the
back of the instrument.
370
00:24:15,255 --> 00:24:19,726
He replaced the connector in the
right way, put the instrument
371
00:24:19,860 --> 00:24:23,964
back into the instrument panel
and then carried out a test.
372
00:24:28,068 --> 00:24:29,837
KIM: Looks good.
373
00:24:30,737 --> 00:24:34,796
NARRATOR: As far as the engineer
was concerned the problem was solved.
374
00:24:39,479 --> 00:24:44,051
STEVE: Had the maintenance
actions actually fixed the defect?
375
00:24:45,953 --> 00:24:50,040
NARRATOR: They hope the answer will
be found on the flight data recorder.
376
00:24:50,123 --> 00:24:52,888
It has finally been
recovered at the crash site.
377
00:24:54,595 --> 00:24:57,515
DAVID: To find that in amongst
all the wreckage at the bottom
378
00:24:57,598 --> 00:25:00,701
of a 30 foot crater took
a considerable effort.
379
00:25:01,668 --> 00:25:03,437
It took 7 days to find it.
380
00:25:07,307 --> 00:25:11,061
NARRATOR: But when they download the data
something doesn't add up.
381
00:25:11,144 --> 00:25:15,674
The readout is showing that the plane's
roll angle never exceeded two degrees.
382
00:25:16,917 --> 00:25:18,502
ANDREW: Clearly it had gone in
383
00:25:18,585 --> 00:25:22,422
at a much steeper roll angle
than that like 90 degrees.
384
00:25:23,056 --> 00:25:25,109
So that set the alarm bells ringing.
385
00:25:25,192 --> 00:25:26,560
Why should that occur?
386
00:25:30,230 --> 00:25:34,001
NARRATOR: Why a
Korean Air 747 crashed
387
00:25:34,134 --> 00:25:38,038
just moments after takeoff from
London's Stansted Airport
388
00:25:38,172 --> 00:25:41,842
is a mystery investigators are
only beginning to unravel.
389
00:25:47,381 --> 00:25:51,118
NARRATOR: The flight data recorder from
Korean Air 8509 reveals
390
00:25:51,251 --> 00:25:54,922
that the faulty ADI reported
by the previous crew
391
00:25:55,055 --> 00:25:57,350
seems not to have been fixed after all.
392
00:25:58,559 --> 00:26:00,945
They need to understand how
the fault in the plane's
393
00:26:01,028 --> 00:26:04,398
navigation system was for
some reason misdiagnosed.
394
00:26:05,432 --> 00:26:08,491
DAVID: How exactly did your
crew report this problem?
395
00:26:08,635 --> 00:26:12,423
NARRATOR: Upon landing the inbound crew's
flight engineer noted the problem
396
00:26:12,506 --> 00:26:15,565
with the ADI by entering a code
in his technical log.
397
00:26:19,146 --> 00:26:21,866
He then mentioned it to
the maintenance engineer.
398
00:26:21,949 --> 00:26:23,597
KIM: Okay. I'll have a look.
399
00:26:27,688 --> 00:26:31,491
{\an8}DAVID: The normal action is to take
the code that's entered
400
00:26:31,625 --> 00:26:36,396
{\an8}and then look in the corresponding
Fault Isolation Manual,
401
00:26:36,530 --> 00:26:39,433
which has the same corresponding numbers.
402
00:26:40,634 --> 00:26:42,569
And that would then tell him
403
00:26:42,703 --> 00:26:46,874
what the fault was and what he
had to do about it to fix it.
404
00:26:49,676 --> 00:26:51,429
{\an8}NARRATOR: But the Korean Air engineer
405
00:26:51,512 --> 00:26:54,336
didn't have a copy
of the Fault Isolation Manual.
406
00:26:55,749 --> 00:26:59,220
{\an8}Without it he couldn't correctly
identify the proper repair.
407
00:27:00,521 --> 00:27:04,110
Instead he tried to troubleshoot
the problem as best he could.
408
00:27:04,458 --> 00:27:06,341
KIM: Alright that's our problem.
409
00:27:11,932 --> 00:27:14,885
ANDREW: This is when
we go into the detailed evaluation
410
00:27:14,968 --> 00:27:17,938
of the aircraft manuals,
the component manuals,
411
00:27:18,071 --> 00:27:20,307
right down to the wiring manuals.
412
00:27:22,276 --> 00:27:25,729
NARRATOR: After an in-depth analysis
of the plane's navigation system
413
00:27:25,812 --> 00:27:30,283
they finally figure out what was wrong
with the captain's artificial horizon.
414
00:27:31,585 --> 00:27:33,762
It was being fed corrupt information.
415
00:27:36,089 --> 00:27:39,359
The real problem lay deeper with a device
416
00:27:39,493 --> 00:27:42,563
called an Inertial Navigation Unit or INU.
417
00:27:43,430 --> 00:27:45,499
Units deep inside the airplane,
418
00:27:45,632 --> 00:27:50,170
send pitch and roll data to the
captain and first officer's ADI.
419
00:27:52,873 --> 00:27:56,677
Investigators conclude that one
of the INUs short circuited.
420
00:27:58,045 --> 00:28:02,199
{\an8}ANDREW: It simply ended up in corrupting
the roll information that was fed to the,
421
00:28:02,282 --> 00:28:06,153
{\an8}both the flight data recorder
and the captain's ADI.
422
00:28:07,754 --> 00:28:12,626
NARRATOR: All the maintenance
work done on Flight 8509 was misdirected.
423
00:28:13,961 --> 00:28:16,961
What they had repaired was
never the problem at all.
424
00:28:17,331 --> 00:28:19,083
ANDREW: Really they were
barking up the wrong tree.
425
00:28:19,166 --> 00:28:21,218
KIM: I need you to
remove the captain's ADI.
426
00:28:21,301 --> 00:28:25,539
ANDREW: If the Fault Isolation
Manual had been available they
427
00:28:25,672 --> 00:28:28,942
might have deduced that the
correct maintenance action
428
00:28:29,076 --> 00:28:34,414
was to replace the number one
INU not the captain's ADI.
429
00:28:36,683 --> 00:28:39,970
STEVE: The rectification action
was completely ineffective.
430
00:28:40,053 --> 00:28:44,391
{\an8}The aircraft took off with the same defect
that it had arrived with.
431
00:28:47,461 --> 00:28:50,181
DAVID: An instrument failure
is a, is a rare occurrence.
432
00:28:50,264 --> 00:28:53,100
However crews are trained to deal with it.
433
00:28:55,335 --> 00:28:58,055
{\an8}NARRATOR: Checking each of the
three ADis should have allowed
434
00:28:58,138 --> 00:29:00,256
{\an8}the captain to identify the problem.
435
00:29:03,810 --> 00:29:07,298
The recorded flight data shows
that both the First Officer's ADI
436
00:29:07,381 --> 00:29:11,264
and the backup instrument displayed
the plane's correct bank angle.
437
00:29:13,420 --> 00:29:16,223
Only the captain's
artificial horizon was wrong.
438
00:29:18,825 --> 00:29:23,864
How the crew dealt with that defect in
the seconds after takeoff could be the key
439
00:29:23,997 --> 00:29:27,134
to understanding why the
flight ended in disaster.
440
00:29:29,536 --> 00:29:33,654
Investigators finally have new insight
into those crucial last moments.
441
00:29:33,774 --> 00:29:35,092
FIRST OFFICER (off-screen): Sir.
442
00:29:35,175 --> 00:29:39,940
NARRATOR: AAIB technicians have salvaged
the recording from the badly damaged CVR.
443
00:29:44,418 --> 00:29:49,122
(speaking Korean)
444
00:29:49,656 --> 00:29:51,558
(alarm beeping)
445
00:29:51,692 --> 00:29:54,311
DAVID (off-screen): One of the most
important things that was on that recorder
446
00:29:54,394 --> 00:29:58,599
was the sound of a warning horn
going off in the cockpit
447
00:29:58,732 --> 00:30:01,027
as the aircraft departed from Stansted.
448
00:30:10,177 --> 00:30:13,947
(alarm beeping)
449
00:30:14,081 --> 00:30:15,800
NARRATOR: But even more
significant than the sound
450
00:30:15,883 --> 00:30:18,285
of the alarm is what is not on the tape.
451
00:30:19,219 --> 00:30:22,239
DAVID: They seem to be
ignoring the alarms completely.
452
00:30:22,322 --> 00:30:26,264
There was no discussion about the fault
with the artificial horizon.
453
00:30:28,495 --> 00:30:32,850
NARRATOR: The alarm is telling the pilots
one of their ADis is malfunctioning.
454
00:30:32,933 --> 00:30:36,816
They should check the third instrument
to see which ADI is correct.
455
00:30:38,438 --> 00:30:40,733
But the pilots remain strangely silent.
456
00:30:44,578 --> 00:30:47,498
DAVID: The flight engineer saw
the standby horizon,
457
00:30:47,581 --> 00:30:49,100
looked at the other instruments,
458
00:30:49,183 --> 00:30:52,242
and actually pointed out
this problem to the captain.
459
00:30:52,419 --> 00:30:53,671
ENGINEER (off-screen):
Bank's not working.
460
00:30:53,754 --> 00:30:55,606
DAVID (off-screen): But the captain
did not respond to that,
461
00:30:55,689 --> 00:30:57,257
either in words or deeds.
462
00:30:59,826 --> 00:31:03,848
NARRATOR: Investigators are also troubled
by the fact that the first officer
463
00:31:03,931 --> 00:31:06,931
who had a working ADI did nothing
to save the plane.
464
00:31:07,434 --> 00:31:09,587
DAVID: Why didn't the first officer
say anything?
465
00:31:09,670 --> 00:31:14,208
Here he was in a situation
where he was about to die.
466
00:31:14,942 --> 00:31:17,744
He knew that
the instruments were at fault.
467
00:31:18,512 --> 00:31:21,915
The comparator buzzer was
going off and he said nothing.
468
00:31:22,916 --> 00:31:24,769
ENGINEER (off-screen):
Bank! Bank!
469
00:31:24,852 --> 00:31:27,705
STEVE: The copilot should have
said to the captain
470
00:31:27,788 --> 00:31:30,357
your ADI is not reading correctly.
471
00:31:30,524 --> 00:31:33,627
DAVID: He should have
forcefully said to the captain,
472
00:31:33,760 --> 00:31:36,096
"Mine's correct. I have control."
473
00:31:36,230 --> 00:31:38,048
FIRST OFFICER: I have control.
I have control.
474
00:31:38,131 --> 00:31:40,426
DAVID (off-screen):
Let me take control.
475
00:31:48,642 --> 00:31:50,577
FIRST OFFICER: I have control.
476
00:31:52,112 --> 00:31:53,631
STEVE: The correct response
to that would have been,
477
00:31:53,714 --> 00:31:55,215
"Yes, you have control."
478
00:31:56,984 --> 00:31:59,102
DAVID: But the copilot said nothing.
479
00:32:00,621 --> 00:32:03,541
NARRATOR: The CVR also answers
a lingering question concerning
480
00:32:03,624 --> 00:32:06,213
some of the eyewitness
accounts of the crash.
481
00:32:06,727 --> 00:32:11,198
STEVE: The CVR gave no indication that
there was a fire onboard the aircraft.
482
00:32:11,431 --> 00:32:15,753
You would have heard an engine fire bell,
which is a very distinctive warning.
483
00:32:15,836 --> 00:32:17,471
And we didn't hear that.
484
00:32:18,839 --> 00:32:23,016
NARRATOR: The fact that some witnesses
were wrong doesn't surprise Moss.
485
00:32:24,344 --> 00:32:26,564
STEVE: There's all sorts of things
people can see
486
00:32:26,647 --> 00:32:28,942
in, in bad weather conditions at night.
487
00:32:29,049 --> 00:32:33,187
Reflections of the aircraft's
lights or the navigation lights
488
00:32:33,320 --> 00:32:37,026
sometimes can mislead people into thinking
there's a fire there.
489
00:32:41,428 --> 00:32:44,515
NARRATOR: Investigators now want to know
more about the crew members
490
00:32:44,598 --> 00:32:47,968
who let a minor malfunction lead to
a catastrophic crash.
491
00:32:57,010 --> 00:32:59,296
DAVID: We listened to
the words on the tape.
492
00:32:59,379 --> 00:33:00,798
But of course they were in Korean.
493
00:33:00,881 --> 00:33:03,058
We had the translation in front of us
494
00:33:03,283 --> 00:33:05,970
but it was very difficult
to determine the tone
495
00:33:06,053 --> 00:33:08,172
of what was said and how it was said.
496
00:33:08,255 --> 00:33:11,942
And we had someone who spoke Korean
listening to this conversation telling us
497
00:33:12,025 --> 00:33:14,595
the social interaction
between the two crew.
498
00:33:15,429 --> 00:33:19,399
(speaking Korean)
499
00:33:20,400 --> 00:33:22,086
NARRATOR: They can hear that
prior to takeoff the captain
500
00:33:22,169 --> 00:33:25,205
was becoming more and more
agitated by the delays.
501
00:33:26,473 --> 00:33:29,591
CONTROLLER: Korean Air 8509
please explain your delay.
502
00:33:30,377 --> 00:33:31,678
PARK: Answer them!
503
00:33:31,812 --> 00:33:33,664
They're asking how long the delay will be.
504
00:33:33,747 --> 00:33:37,571
And make sure you understand what they're
saying before you speak.
505
00:33:39,119 --> 00:33:41,305
FIRST OFFICER: Stansted clearance
standing by
506
00:33:41,388 --> 00:33:43,271
for a new flight plan for Milan.
507
00:33:43,991 --> 00:33:46,010
STEVE (off-screen): The
captain was very overbearing.
508
00:33:46,093 --> 00:33:50,130
He was very critical of the first officer.
509
00:33:50,631 --> 00:33:54,685
DAVID: And the first officer was, was
quite subservient in this conversation.
510
00:33:54,768 --> 00:33:57,054
He did all the listening.
The captain did all the talking.
511
00:33:57,137 --> 00:33:59,940
So you'd say he's being condescending.
512
00:34:01,875 --> 00:34:04,428
NARRATOR: Miller can't help but
wonder what would have happened
513
00:34:04,511 --> 00:34:07,629
if the captain had listened
to the engineer's warning.
514
00:34:07,948 --> 00:34:11,419
He wants to know if there was
enough time to save the plane.
515
00:34:12,886 --> 00:34:16,356
Using a flight simulator and data from
the Flight Recorder
516
00:34:16,490 --> 00:34:18,692
they recreate the entire flight.
517
00:34:21,094 --> 00:34:25,153
{\an8}The simulation reveals that impact
with the ground was not inevitable.
518
00:34:28,368 --> 00:34:32,673
DAVID: It was possible, just possible,
to recover the aircraft
519
00:34:32,806 --> 00:34:35,142
about 500 feet above the ground
520
00:34:35,275 --> 00:34:39,379
doing about 260 knots
at 80 degrees of bank.
521
00:34:39,780 --> 00:34:42,733
If you knew what was happening
you could have just recovered
522
00:34:42,816 --> 00:34:45,758
that aircraft just skimming
the ground in doing so.
523
00:34:47,287 --> 00:34:49,673
NARRATOR: The results convince Miller
and his team
524
00:34:49,756 --> 00:34:51,375
that they need to better understand how
525
00:34:51,458 --> 00:34:53,861
Korean Air trains its flight crews.
526
00:34:55,229 --> 00:34:57,648
DAVID: It was obvious from
this accident that the crew
527
00:34:57,731 --> 00:35:00,050
interaction played a big
part in this accident.
528
00:35:00,133 --> 00:35:03,663
So we needed to go to Korea to
see how the crew were trained.
529
00:35:06,540 --> 00:35:09,393
NARRATOR: In Korea, Miller gets
an opportunity to observe
530
00:35:09,476 --> 00:35:12,079
Korean Air flight training first hand.
531
00:35:17,985 --> 00:35:21,162
DAVID: There was definitely
a hierarchy between pilots.
532
00:35:23,457 --> 00:35:26,877
The captain was the supposedly the older,
the wiser, the more experienced,
533
00:35:26,960 --> 00:35:31,832
and the first officer was the younger,
inexperienced apprentice.
534
00:35:34,134 --> 00:35:38,038
Crews were working in
a very procedural way.
535
00:35:38,172 --> 00:35:41,141
There was not really much free thinking
536
00:35:41,275 --> 00:35:45,812
to deal with an unusual situation.
537
00:35:48,882 --> 00:35:52,236
NARRATOR: The crew dynamic observed
in the Korean training session
538
00:35:52,319 --> 00:35:56,757
is strikingly similar to what was recorded
in the cockpit of Flight 8509.
539
00:35:59,526 --> 00:36:02,703
Investigators dig into
Captain Park's personal history.
540
00:36:07,034 --> 00:36:10,737
DAVID: A lot of the captains
in Korean Air were people that
541
00:36:10,871 --> 00:36:13,841
had developed their
skills in the military.
542
00:36:16,844 --> 00:36:21,232
NARRATOR: Captain Park had been a colonel,
a pilot with a distinguished career flying
543
00:36:21,315 --> 00:36:23,383
small, lightweight fighter jets.
544
00:36:24,551 --> 00:36:29,122
DAVID (off-screen): Korean culture
at the time suggested that these pilots
545
00:36:29,256 --> 00:36:33,961
needed to hold a position
that was commensurate with
546
00:36:34,094 --> 00:36:37,212
the rank that they had when
they were in the military.
547
00:36:37,798 --> 00:36:41,602
So it would be a great loss
of face for a colonel in the
548
00:36:41,735 --> 00:36:44,500
military to be given the
job of a first officer.
549
00:36:45,105 --> 00:36:47,875
He would go into the company as a captain.
550
00:36:49,443 --> 00:36:50,861
NARRATOR: Park became a Captain
551
00:36:50,944 --> 00:36:54,548
even though his experience was
flying solo in fighter jets,
552
00:36:54,848 --> 00:36:57,554
not as part of a crew on
large commercial jets.
553
00:37:06,493 --> 00:37:11,064
By piecing together the puzzle
of miscommunications, unexpected glitches,
554
00:37:11,198 --> 00:37:15,736
and crew dynamics investigators
believe they finally understand
555
00:37:15,869 --> 00:37:20,541
why Korean Air 8509 hit the
ground less than 60 seconds
556
00:37:20,674 --> 00:37:22,674
after lifting off from the runway.
557
00:37:23,510 --> 00:37:24,962
PARK: This is inexcusable.
558
00:37:25,045 --> 00:37:26,680
If we hit one more delay.
559
00:37:28,215 --> 00:37:31,302
CONTROLLER: Korean 8509 clear
takeoff runway two-three.
560
00:37:31,385 --> 00:37:33,104
FIRST OFFICER: Clear for
takeoff runway two-three.
561
00:37:33,187 --> 00:37:36,123
Korean 8509 clear for takeoff.
562
00:37:36,590 --> 00:37:37,891
PARK: Finally.
563
00:37:38,592 --> 00:37:42,496
NARRATOR: A series of delays
put flight 8509 behind schedule,
564
00:37:42,629 --> 00:37:44,747
testing the patience of the captain.
565
00:37:46,166 --> 00:37:50,990
The first officer remained quiet, trying
to avoid conflict with a senior colleague.
566
00:37:53,040 --> 00:37:57,678
DAVID: To operate any aircraft you need
the crew to be working as a team.
567
00:37:58,512 --> 00:38:02,883
You, you don't want an
autocrat in one seat
568
00:38:03,016 --> 00:38:05,603
and somebody who's very
subservient in the other.
569
00:38:05,686 --> 00:38:07,621
FIRST OFFICER: V-1. Rotate.
570
00:38:12,259 --> 00:38:14,094
Positive rate confirmed.
571
00:38:14,895 --> 00:38:16,163
PARK: Gear up.
572
00:38:16,296 --> 00:38:17,649
FIRST OFFICER: Gear up.
573
00:38:18,198 --> 00:38:23,837
STEVE: You have to have the crew talking
to, to each other feeling free to comment
574
00:38:23,971 --> 00:38:26,874
and criticize if necessary
what the other's doing.
575
00:38:28,876 --> 00:38:30,261
NARRATOR: The critical moment came
576
00:38:30,344 --> 00:38:33,403
as the captain turned
his control column to the left.
577
00:38:33,614 --> 00:38:35,749
His artificial horizon didn't move.
578
00:38:37,150 --> 00:38:38,803
DAVID: And that would
have been very confusing.
579
00:38:38,886 --> 00:38:40,337
He would have wondered why.
580
00:38:40,420 --> 00:38:44,992
And in fact what he did
was put more bank on,
581
00:38:45,125 --> 00:38:49,696
and more bank and continued
to increase the turn rate.
582
00:38:50,931 --> 00:38:52,633
ENGINEER: Bank! Bank!
583
00:38:53,967 --> 00:38:57,288
NARRATOR: The flight engineer knew that
the aircraft was starting to bank
584
00:38:57,371 --> 00:39:01,775
at an extreme angle but Captain Park
ignored all warnings.
585
00:39:03,477 --> 00:39:07,915
STEVE: In fact he had received
a reprimand some months before
586
00:39:08,048 --> 00:39:12,225
because he had not correctly followed
an instrument departure procedure.
587
00:39:12,452 --> 00:39:15,606
{\an8}And we think that this was uppermost in
his mind that he had to follow
588
00:39:15,689 --> 00:39:18,358
{\an8}the correct procedure to avoid getting
589
00:39:18,492 --> 00:39:20,963
another wrap across the knuckles
I suppose.
590
00:39:22,095 --> 00:39:25,216
NARRATOR: To make matters worse,
he had no visual reference,
591
00:39:25,299 --> 00:39:27,770
and likely couldn't feel the drastic bank.
592
00:39:34,875 --> 00:39:39,287
NARRATOR: Crews are trained to trust
their instruments and not their senses.
593
00:39:39,479 --> 00:39:44,185
{\an8}Captain Park trusted his ADI in spite of
overwhelming evidence that it was wrong.
594
00:39:45,853 --> 00:39:47,605
{\an8}DAVID (off-screen): The first officer
should have said to the captain:
595
00:39:47,688 --> 00:39:49,983
"Look at the warning
buzzers going off."
596
00:39:53,327 --> 00:39:58,265
It's very difficult to understand
his reactions or lack of reactions.
597
00:39:59,032 --> 00:40:03,570
But I think a lot of it is embedded within
the culture, or was at that time.
598
00:40:05,372 --> 00:40:08,025
NARRATOR: Fearing dishonor
more than death itself,
599
00:40:08,108 --> 00:40:11,411
the first officer did not dare
criticize his captain,
600
00:40:11,645 --> 00:40:13,940
or even attempt to correct his actions.
601
00:40:14,248 --> 00:40:17,067
STEVE (off-screen): This crew
were not operating as a crew.
602
00:40:17,150 --> 00:40:21,121
They were operating as one man
with a couple of assistants.
603
00:40:22,189 --> 00:40:25,943
{\an8}DAVID (off-screen): The aircraft just
continued to roll to 30 degrees,
604
00:40:26,026 --> 00:40:29,429
{\an8}40, 50, 60, 70, 80,
605
00:40:29,563 --> 00:40:31,098
90 degrees of bank.
606
00:40:33,667 --> 00:40:37,521
NARRATOR: Investigators now suspect that
the seeds of the deadly crash
607
00:40:37,604 --> 00:40:41,642
were sown hundreds of years before the 747
ever left the ground.
608
00:40:42,943 --> 00:40:44,478
FIRST OFFICER: Sir.
609
00:40:48,248 --> 00:40:51,001
NARRATOR: For centuries
a rigid class structure based
610
00:40:51,084 --> 00:40:54,555
on social hierarchy
defined Korean culture.
611
00:40:55,389 --> 00:40:58,566
Investigators have come to see how
the Korean military,
612
00:40:58,659 --> 00:41:02,863
an honor bound institution, has strongly
influenced commercial aviation.
613
00:41:05,365 --> 00:41:08,735
It's now clear that strict adherence to
cultural norms
614
00:41:08,869 --> 00:41:11,438
put the crew of Korean Air 8509 in danger
615
00:41:11,638 --> 00:41:14,474
from the moment they entered the cockpit.
616
00:41:15,843 --> 00:41:20,247
DAVID: It's very difficult
to overcome entrenched cultural values.
617
00:41:21,548 --> 00:41:23,834
NARRATOR: The different stature
of the two pilots was also
618
00:41:23,917 --> 00:41:26,587
reinforced by a disparity
in military rank.
619
00:41:27,754 --> 00:41:31,408
DAVID (off-screen): We believe that
the cultural values within which these
620
00:41:31,491 --> 00:41:35,095
two people were raised was
621
00:41:35,229 --> 00:41:37,931
overwhelming in this instance.
622
00:41:39,600 --> 00:41:43,836
NARRATOR: The relationship between
the two pilots was not that of equals.
623
00:41:46,874 --> 00:41:48,692
Just two-and-a-half years earlier,
624
00:41:48,775 --> 00:41:51,228
a Korean Air flight
went down in the South Pacific
625
00:41:51,311 --> 00:41:53,514
killing more than 200 people.
626
00:41:54,882 --> 00:41:58,685
DAVID: Korean Air had been going
through quite a rough patch.
627
00:41:59,620 --> 00:42:03,268
One of their aircraft had been
involved in an accident in Guam.
628
00:42:03,390 --> 00:42:05,626
(screaming)
629
00:42:06,059 --> 00:42:10,114
NARRATOR: Poor crew communication
and long-standing rules of hierarchy
630
00:42:10,197 --> 00:42:12,699
had also contributed to the crash in Guam.
631
00:42:15,068 --> 00:42:17,788
DAVID (off-screen): Their reputation
was not good.
632
00:42:17,871 --> 00:42:19,871
Then this accident had come along.
633
00:42:21,708 --> 00:42:24,261
NARRATOR: The U.S. military
stops using Korean Air
634
00:42:24,344 --> 00:42:26,933
to ferry its personnel
in the Pacific region.
635
00:42:27,948 --> 00:42:31,243
The airline comes under strict
scrutiny around the world.
636
00:42:34,388 --> 00:42:39,393
With the crash of flight 8509 Korean Air's
reputation is in ruins.
637
00:42:40,460 --> 00:42:42,279
REPORTER (over TV): At a news conference
the Korean Airline officials
638
00:42:42,362 --> 00:42:44,582
made the startling admission
that military pilots,
639
00:42:44,665 --> 00:42:46,917
many of whom were
recruited by the airline,
640
00:42:47,000 --> 00:42:49,002
sometimes take unnecessary risks.
641
00:42:51,004 --> 00:42:53,090
NARRATOR: Despite all
the negative publicity
642
00:42:53,173 --> 00:42:54,975
for the struggling airline,
643
00:42:55,175 --> 00:42:59,293
investigators see a way to help Korean Air
overcome is safety problems.
644
00:43:02,382 --> 00:43:07,087
STEVE: I think all accidents
have a lesson or lessons to
645
00:43:07,221 --> 00:43:10,724
be learned that will
improve aviation safety.
646
00:43:12,726 --> 00:43:15,579
{\an8}NARRATOR: The AAIB recommends
that all imported training
647
00:43:15,662 --> 00:43:19,399
materials be modified to better
accommodate Korean culture.
648
00:43:22,669 --> 00:43:25,790
Korean Air's training programs
are radically overhauled
649
00:43:25,873 --> 00:43:27,521
to improve pilot performance
650
00:43:27,741 --> 00:43:30,918
and foster a completely new culture
within the cockpit.
651
00:43:33,780 --> 00:43:37,551
DAVID: After the accident in 1999,
Korean Air, I believe,
652
00:43:37,684 --> 00:43:41,588
entered into a significant program
to improve its safety record.
653
00:43:42,289 --> 00:43:45,642
That company have introduced
a much more rigorous process.
654
00:43:46,260 --> 00:43:50,697
And they really have invested
very, very heavily in the flight
655
00:43:50,831 --> 00:43:53,479
safety aspects that came
out of this accident.
656
00:43:53,734 --> 00:43:56,737
STEVE: In this case the
issues of communication,
657
00:43:56,870 --> 00:44:01,575
the issues of how aircraft are maintained,
658
00:44:02,276 --> 00:44:07,247
and also the very important conclusions
regarding cockpit resource management.
659
00:44:08,415 --> 00:44:12,119
{\an8}DAVID: The statistics show that
the safety record of Korean Air
660
00:44:12,252 --> 00:44:15,255
since these events around 1999
661
00:44:15,389 --> 00:44:18,625
is such that it is now regarded
as a very safe airline.
662
00:44:20,928 --> 00:44:24,298
NARRATOR: As a direct result
of the crash of flight 8509
663
00:44:24,431 --> 00:44:27,167
Korean Air has been
completely transformed.
664
00:44:28,569 --> 00:44:33,373
Since 1999 the airline has not
had a single crash or fatality.
665
00:44:34,408 --> 00:44:38,350
It has become one of the most
highly regarded airlines in the world.
666
00:44:42,482 --> 00:44:44,284
(music plays through credits)