All language subtitles for Air.Disasters.S03E09.Bad.Attitude.1080p.PMTP.WEB-DL.DDP2.0.H.264-maldini_track3_[eng]

A Boeing 747 slams
into the English countryside.

Hello!

It was like a battlefield.

Complete
and utter devastation.

Where was this 747?

Investigators
have all the clues they need

to figure out what caused
the accident.

The aircraft took off
with the same defect

that it had arrived with.

But they can't
explain

why no one on board
did anything to prevent it.

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?

The answer lies
not at the crash site

but thousands of miles away...

Buried in hundreds of years
of history.

Ladies and gentlemen,

we are starting our approach.

We lost both engines!

Put the mask over your nose.

Emergency descent.

Mayday, mayday.

Brace for impact!

I think I lost one.

Investigation starting...

He's gonna crash!

Gary Dann is enjoying
the Christmas holiday

at his home
just north of London.

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 house.

Living just a mile
and a half

from Stansted airport,

Dann is used to hearing jets.

But not this close.

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.

A Korean Air 747
slams into a forest

in the village
of Great Hallingbury.

This was just
a huge, huge explosion

that you're watching it happen

with a plume 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?

The aircraft had
created a 30-foot-plus crater.

Wreckage was spread
over at least half a mile.

It was like a battlefield.

We dialed 999.

A plane's gone down
in Hatfield Forest

in Great Hallingbury.

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 pounds of cargo

are completely destroyed.

It's up to the UK's air
accidents investigation branch

to figure out why.

This is a very
sophisticated aircraft

flown by a trained crew,

and somehow they had
lost control of this aircraft.

How can this happen?

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.

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.

Flight 8509 is
a Korean Air cargo plane.

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.

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 loading and offloading
of cargo.

He makes sure that the nearly
139,000 pounds 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.

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.

Captain Park Duk-Kyu
is a highly respected commander.

Sir.

And a former colonel
in the Korean Air Force

with thousands of hours
of flying time on the 747.

Park Duk-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.

On this night there were the
three crew

and a Korean engineer.

The engineer
has overseen

some minor maintenance work
on the aircraft

and will now accompany
flight 8509 back to Seoul.

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.

Korean Air 8509,
we have no flight plan.

Cannot clear you.

Copy that.

Stansted, stand by
for flight plan.

Every commercial airplane

needs to file a flight plan
before it can leave the ground.

Contact our people

and get them to re-file
the flight plan.

Hurry up!

Ground control, standing by
for new flight plan to Milan.

Korean Air 8509
must wait

while the document detailing
their planned route is filed.

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.

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

Korean Air 8509 cleared
to Dover-six-Romeo squawk 2230.

Now nearly an hour
behind schedule,

the crew gets clearance to taxi.

It's 6:25 p.m.

Korean Air 8509,
line up on runway 23.

Position on hold
runway 23, Korean Air 8509.

Captain Park is well aware

they have no hope of arriving
in Milan on time.

Korean 8509,
clear takeoff runway 23.

Finally.

80 knots.

Roger.

V-1.

Rotate.

The plane takes off
from Stansted airport

at 6:36 p.m.

Positive rate confirmed.

Gear up.

Gear up.

Passing 900 feet.

The aircraft
had taken off

and climbed to about 2,500 feet.

Shortly after takeoff
the aircraft was making a turn.

Left turn
at 1.5 D-M-E.

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

The aircraft started
its turn to the left.

Heading standby, sir.

Heading 1-5-8.

The captain's
artificial horizon

tells him that the plane
isn't turning.

Bank's not working.

Bank! Bank!

Look! Bank!

For some reason,
the 747 has gone

from takeoff
to total destruction

in less than 60 seconds.

Korean Air flight 8509
lies in pieces

just a few miles from one of the
busiest airports in the world.

We had no wreckage really that
was above knee height.

Where was this 747?

After any major
crash,

Britain's air accidents
investigation branch

deploys a safety specialist
to the site.

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

Sid Hawkins' job
is to assess the level of danger

at the crash site.

One of the key things to do

is to get investigators
into site 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.

His first concern:
The 33 tons of fuel

the 747 was carrying on takeoff.

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.

There was no lighting

and it actually was
very, very dangerous

for the investigators
and the rescue services.

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.

This was crucial,

the discovery of
the recorders on the day.

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.

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.

Bank!

Meanwhile the AAIB
has begun work

closer to the Stansted terminal
on the airport runway.

The team's operations
investigator is David Miller.

We had been out
on the runway

having received a report
from the airport

that the runway was covered
in debris.

With Miller
at the airport

is engineering investigator
Steve Moss.

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.

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.

Something that looked
very much like a human jawbone.

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?

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.

The runway investigation

has stopped all flights

in and out of Stansted airport.

The shutdown comes
just days before Christmas.

The terminal
was seething with people.

The pressure on us
was tremendous

to get that runway open.

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.

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.

Daylight,
and the remains of a 747

lying in a path of destruction

on the edge
of an English village.

It was
a very confusing debris field.

It takes a while for one
to absorb the scene

and to try and make sense
of it all.

By daylight they get
their first good look

at the point of impact...

A massive crater surrounded on
all Sides by scattered debris.

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.

The far-flung wreckage

also helped solve the mystery

of what seemed to be
a jawbone on the runway.

Closer examination
the following morning

revealed that it actually was
a bit of twisted plastic.

Safety specialist
Sid Hawkins

now turns his attention

to the shattered remnants
of the plane's cargo.

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.

He needs to know if any of it

poses a risk to investigators.

We had a consignment
of corrosive materials.

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.

We were able to determine

that the dangerous goods
from this aircraft

had all been destroyed.

But there is
one more significant risk

Hawkins must assess...

One that stems from the design
of the plane itself.

We know
that this aircraft

carries depleted uranium
in its tail section,

both in the rudder
and in the elevators.

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.

You feel then
that it's safe enough

for the guys to start work.

Meanwhile,

investigators
are still trying to learn

if the aircraft broke up
before crashing.

I did see a glow,

which could have been
the plane alight.

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.

Dann's observation
raises the possibility

that the left side engines
flamed out,

causing the plane
to roll to one side.

It's safe. But be careful down
in through there.

To determine if
the plane hit the ground intact,

they carry out what they call
the four corners search.

Have we got both wings?
Have we got the tail plane?

Have we got the fin, 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.

While locating
the four corners,

investigators also discover

some very distinctive marks
on the ground.

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 hit the ground.

The ground scar
gives investigators

a revealing glimpse into
the flight's final seconds.

The aircraft struck
the ground at high speed,

steep left bank,
steep nose down

and with an almighty
amount of energy.

Of course it could be
that somehow or other

the pilot's been misled
by his instruments

and has become what we call
disorientated.

The team brings back

some of the aircraft's
instruments

to the AAIB labs
for examination.

We found a few pieces
of the ADIs.

The ADI,
or attitude director indicator,

is a flight instrument

that displays the plane's
bank and pitch.

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.

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.

We found
only fragments.

And we were able to
forensically examine these.

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.

What we needed
was that recorder

to give us the confirmation

of the exact flight path
of the aircraft.

Pre-flight maintenance records

would normally shed some light
on the situation,

but not in this case.

The technical log
from this flight

was not available to us.

It had been destroyed
in the impact,

and unfortunately a copy
was not left at Stansted.

It should have been.

For more information,

investigators interview
the crew that flew the plane

to Stansted on the previous leg
of the flight.

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.

In the daylight
the pilot was able

to get his bearings
from the horizon outside.

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.

After landing,
the inbound crew

left the terminal before
the replacement crew arrived.

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.

But that
didn't happen.

Instead the only person who
heard about the ADI problem

is the Korean Air
maintenance engineer.

Okay.
I'll have a look.

Korean Airlines
had dispatched an engineer

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

The Korean engineer

didn't have the tools he needed
for the job.

So he enlisted some local help.

I need you to remove
the captain's ADI.

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.

The locally based
engineer told us

he removed the instrument
from the panel,

unplugged the wires at the back.

Alright,
that's our problem.

Can you reset the pin?

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.

Looks good.

As far as the
engineer was concerned,

the problem was solved.

Had the maintenance actions
actually fixed the defect?

They hope the answer
will be found

on the flight data recorder.

It has finally been recovered
at the crash site.

To find that
in amongst all the wreckage

at the bottom
of a 30-foot crater

took a considerable effort.

It took seven days to find it.

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.

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?

Why a Korean Air 747 crashed

just moments after takeoff
from London's Stansted airport

is a mystery investigators
are only beginning to unravel.

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.

How exactly did
your crew report this problem?

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.

Okay.
I'll have a look.

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.

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.

Alright,
that's our problem.

This is when we go
into the detailed evaluation

of the aircraft manuals,
the component manuals,

right down
to the wiring manuals.

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.

It simply ended up in
corrupting the roll information

that was fed to the,

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

All the maintenance
work done on flight 8509

was misdirected.

What they had repaired
was never the problem at all.

Really they were
barking up the wrong tree.

I need you to remove
the captain's ADI.

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.

The rectification action
was completely ineffective.

The aircraft took off

with the same defect
that it had arrived with.

An instrument failure
is a rare occurrence.

However, crews are trained
to deal with it.

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.

Sir.

AAIB technicians
have salvaged the recording

from the badly damaged CVR.

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.

But even more significant

than the sound of the alarm is
what is not on the tape.

They seem to be ignoring
the alarms completely.

There was no discussion
about the fault

with the artificial horizon.

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.

The flight engineer
saw the standby horizon,

looked at the other instruments,

and actually pointed out
this problem to the captain.

Bank's not working.

But the captain
did not respond to that,

either in words or deeds.

Investigators are
also troubled by the fact

that the first officer,
who had a working ADI,

did nothing to save the plane.

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.

Bank! Bank!

The copilot should have
said to the captain

your ADI is not reading
correctly.

He should have
forcefully said to the captain:

Mine's correct.
I have control.

Let me take control.

I have control.

The correct response
to that would have been:

Yes, you have control.

But the copilot
said nothing.

The CVR also answers
a lingering question

concerning some of
the eyewitness accounts

of the crash.

The CVR gave no indication

that there was a fire
on board the aircraft.

You would have heard
an engine fire bell,

which is a very distinctive
warning.

And we didn't hear that.

The fact that
some witnesses were wrong

doesn't surprise Moss.

There's all sorts
of things people can see

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.

Investigators
now want to know

more about the crew members

who let a minor malfunction lead
to a catastrophic crash.

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.

They can hear
that prior to takeoff

the captain was becoming more
and more agitated by the delays.

Korean Air 8509,
please explain your delay.

Answer them!

They're asking how long
the delay will be.

And make sure you understand
what they're saying

before you speak.

Stansted clearance,
standing by

for a new flight plan for Milan.

The captain
was very overbearing.

He was very critical
of the first officer.

And the first officer

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.

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.

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.

The results
convince Miller and his team

that they need
to better understand

how Korean Air trains
its flight crews.

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.

In Korea,
Miller gets an opportunity

to observe Korean Air
flight training first hand.

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.

The crew dynamic observed

in the Korean Air training
session

is strikingly similar
to what was recorded

in the cockpit of flight 8509.

Investigators dig into
captain Park's personal history.

A lot of the captains
in Korean Air

were people that had developed
their skills in the military.

Captain Park
had been a colonel,

a pilot with
a distinguished career

flying small,
lightweight fighter jets.

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.

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.

This is inexcusable.

If we hit one more delay.

Korean 8509,
clear takeoff runway 23.

Clear for takeoff
runway 23.

Korean 8509 clear for takeoff.

Finally.

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.

To operate any
aircraft,

you need the crew to be
working as a team.

You don't want an autocrat
in one seat

and somebody who's
very subservient in the other.

V-1.

Rotate.

Positive rate confirmed.

Gear up.

Gear up.

You have to have the crew
talking to each other,

feeling free to comment
and criticize if necessary

what the other's doing.

The critical moment came

as the captain turned
his control column to the left.

His artificial horizon
didn't move.

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.

Bank! Bank!

The flight engineer
knew that the aircraft

was starting to bank
at an extreme angle,

but captain Park
ignored all warnings.

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 rap
across the knuckles, I suppose.

To make matters
worse,

he had no visual reference

and likely couldn't feel
the drastic bank.

If the instrument is saying no,
you're straight and level,

then that's what you believe

even though the aircraft is
banked at quite a high angle.

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.

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.

Fearing dishonor
more than death itself,

the first officer did not dare
criticize his captain

or even attempt
to correct his actions.

This crew were not
operating as a crew.

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

The aircraft just
continued to roll to 30 degrees,

40, 50, 60, 70, 80,
90 degrees of bank.

Investigators now suspect

that the seeds of the deadly
crash were sown

hundreds of years before the 747
ever left the ground.

Sir.

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.

It's very difficult to overcome
entrenched cultural values.

The different stature
of the two pilots

was also reinforced
by a disparity in military rank.

We believe
that the cultural values

within which these two people
were raised

was overwhelming
in this instance.

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.

Korean Air had been going
through quite a rough patch.

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

Poor crew communication

and longstanding rules
of hierarchy

had also contributed
to the crash in Guam.

Their reputation
was not good.

Then this accident
had come along.

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.

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.

Despite all
the negative publicity

for the struggling airline,

investigators see a way
to help Korean Air

overcome its safety problems.

I think all accidents
have a lesson

or lessons to be learned

that will improve
aviation safety.

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.

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.

In this case the issues
of communication,

the issues of how aircraft
are maintained,

and also the very important
conclusions

regarding cockpit
resource management.

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.

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.