KE6316 MD-11F SHA ACCIDENT

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KE6316 MD-11F SHA ACCIDENT

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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

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Conclusion of Accident Investigation

• CAAC/KCAB/NTSB joint investigation concluded the
  probable cause of the accident for
• Flight Crews failure of altitude awareness
• Confusion between Meter Feet unit in ATC
  instructed Altitude
• Insufficient Pre-departure preparation

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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/Os wrong spoken word
• Lateral deviation of Instrument departure
• Dive to the ground from 4500 feet in 16 second
• Crew expressed difficulty in control

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CAACs 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

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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

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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!

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Other View

• KAL analyzed different point of view
• Cockpit Noise Analysis including Engine Noise
  level
• Flight Path Analysis
• Focused on other clues

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Other Important Clues

• Difficulty in Pitch Control
• Unidentified Noises
• Abrupt Nose up before Dive
• Contamination in Elevator control valve

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Similar Incident or Accident worldwide

• FeDex crash land in Newark
• JAL pitch oscillation
• CAL abrupt pitch oscillation

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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)

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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

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Administrational Litigation In Progress

• Cargo Operation continues currently.
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