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KE6316 MD-11F SHA ACCIDENT

KE6316 MD-11F SHA ACCIDENT. 신 지 수. General Information. Date : 1999. 4. 15 Place : SHA Injury to Person : 8 (3 crews, 5 civilians) killed 4 seriously injured 36 minor injured Damage to Airplane : Hull Loss A/C Type: MD-11F Year Built: 1992 Flight Time: 28,347 hrs

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KE6316 MD-11F SHA ACCIDENT

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  1. KE6316 MD-11F SHA ACCIDENT 신 지 수

  2. General Information • Date : 1999. 4. 15 • Place : SHA • Injury to Person : • 8 (3 crews, 5 civilians) killed • 4 seriously injured • 36 minor injured • Damage to Airplane : Hull Loss • A/C Type: MD-11F • Year Built: 1992 • Flight Time: 28,347 hrs • Flight Cycle: 4,463 • Engine: PW4460 x 3

  3. Conclusion of Accident Investigation • CAAC/KCAB/NTSB joint investigation concluded the probable cause of the accident for: • Flight Crew’s failure of altitude awareness • Confusion between Meter & Feet unit in ATC instructed Altitude • Insufficient Pre-departure preparation

  4. Findings • No Indication of : (No finding actually) • In-flight Fire • In-flight breakage of airplane • System Failure • Failure in Cargo loading • Bomb or DG Explosion in flight • Engine Failure • F/O’s wrong spoken word • Lateral deviation of Instrument departure • Dive to the ground from 4500 feet in 16 second • Crew expressed difficulty in control

  5. CAAC’s conclusion basically based upon: • Wrong spoken word of altitude unit • Stabilizer Trim moved toward AND • Simulator (FSB in Long Beach) evaluation • No Departure Briefing • Not enough operational experience in SHA

  6. Lack of Factual Evidences • FDR loss • Difficulty in defining position of flight control related items • Difficulty in Corroboration • No indication of system failure • No warning or alerts of system failure in CVR • No indication on the wreckage

  7. Factual Evidence vs Situational Evidence • Both requires : • Correlation • Corroboration • Correction • Ask 100 times “Why?” • Stronger supporting facts needed for analysis by situation evidence • Both must be feasible : “Make sense!”

  8. Other View • KAL analyzed different point of view: • Cockpit Noise Analysis including Engine Noise level • Flight Path Analysis • Focused on other clues

  9. Other Important Clues • Difficulty in Pitch Control • Unidentified Noises • Abrupt Nose up before Dive • Contamination in Elevator control valve

  10. Similar Incident or Accident worldwide • FeDex crash land in Newark • JAL pitch oscillation • CAL abrupt pitch oscillation

  11. Can human make that kind of control? • Dive to crash from 4500ft in 16 second with max 20 degrees nose up to max 50 degrees nose down • Physical limitation of human • Engine Noise(Throttle movement) • Pilots’ call out • Continuous Trimming down(beginning time)

  12. Investigation should be further reviewed • CVR analysis • A/C Stability & Pitch Control • Negative-G load stall • Engineering Simulation • EMI(Electro-magnetic Interference) • Flight Path analysis • Reason of Lateral deviation

  13. Administrational Litigation In Progress • Cargo Operation continues currently. 감사합니다.

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