The crash of a Boeing 747 in Guam

Boeing 747-3B5 (registration number HL7468, serial number 22487, serial 605) was released in 1984 (the first flight was made on December 3 under test b / n N6069D). December 12 of the same year was transferred to Korean Air . Equipped with four twin - circuit turbofan engines Pratt & Whitney JT9D-7R4G2 . Overhaul took place on July 7, 1997, no malfunctions were found. He flew in the status of “ presidential plane ” and was one of the oldest aircraft of the airline. On the day of the disaster, it completed 8552 take-off and landing cycles and flew 50 105 hours ^{[1] [2]} .

The aircraft was controlled by an experienced crew, the composition of which was as follows:

• The aircraft commander (FAC) is Park Yong-cheol , cor. 42, 42, a 42-year-old. A very experienced pilot, worked at Korean Air for 9 years and 9 months (from November 2, 1987). He flew a Boeing 727 (first co-pilot, and then FAC). In the post of commander of the Boeing 747 - from August 20, 1995 (before that he had been managing it as a co-pilot). 8932 hours flew, 3192 of them on Boeing 747 (1718 of them as pic).
• The co - pilot is the 40-year-old Song Kyungho ( born Song Kyung-ho , cor. 송경호 ). An experienced pilot, worked at Korean Air for 3 years and 6 months (from January 10, 1994). In the position of co-pilot of the Boeing 747 - since July 23, 1995. 4066 hours flew, over 1560 of them on the Boeing 747.
• Flight Engineer - 57-year-old Nam Sokhun ( born Nam Seok-hoon , cor. 남석훈 ). He worked at Korean Air for 18 years and 2 months (since May 7, 1979). As a flight engineer, he flew the Boeing 727 and Airbus A300 . 13,065 hours flew, 1573 of them on the Boeing 747.

In the cabin, 20 stewardesses worked.

Prior Circumstances

According to Korean Air, the crew arrived at the center at 21:05 ^{[* 1]} (20:05 local time in Seoul). According to the original plan, the crew was to fly to Dubai ( UAE ). However, due to insufficient commander rest, the flight mission was changed and now the crew had a shorter KE801 flight to Aghanyu (Guam). Previously, the PIC flew along this route 9 times and knew it well enough. The crew collected the necessary documents and conducted independent training.

At 21:27 flight KE801 left the platform and at 21:53 took off from Gimpo airport and headed for Aganya. There were 254 people on board: 3 pilots, 20 flight attendants (6 of them flew in the cabin as passengers) and 231 passengers ^[3] .

According to the records of the voice recorder , the aircraft was controlled by the commander throughout the flight. At 01:03:18, when the plane was on the FL410 echelon (12,500 meters) and about 444 kilometers northwest of the Nimitz radio beacon, the co-pilot made contact with the approach manager of the Guam airport. At 01:05:00 the dispatcher gave instructions for approaching runway No. 6L and at 01:10:00 instructed to decrease to a height of 792 meters. In response, the second pilot confirmed the receipt of information and announced his readiness to begin the decline. Further, the commander gave the rest of the crew a brief briefing on the approach to the airport by ILS . Then at 01:13:33 he said that it was time to decrease, so the second pilot told the air traffic controller that flight 801 began to decline from 12,500 meters to 792 meters ^[4] .

Holocaust

In the process of decline, it turned out that in Guam, weather conditions are constantly deteriorating, at this time there was a rainy season. In addition, the directional radio beacon did not work, as it underwent maintenance, which greatly complicated landing. Based on the recording of the negotiations in the cockpit, the commander who had not had time to take a proper rest before departure was probably more worried that the parking in Guam on schedule was only 3.5 hours, after which they had a return flight. At 01:26:25, the flight engineer said he saw Guam. At 01:31:17 the aircraft crew reported that because of the cumulonimbus clouds, the crew went around the CHARLIE BRAVO landmark and requested a radar vector for landing on runway No. 6L ^[5] .

The dispatcher instructed to perform a left turn at 090 ° to enter the landing course. The airliner at this moment passed a height of 853 meters with 10 ° flaps and landing gear retracted. At 01:39:30, the second pilot reported that he was observing the capture of the glide path along the instruments (although the radio beacon did not work) ^[5] . Hearing from the second pilot that the glide path is working, the flight engineer expressed surprise and asked to double-check. But the PIC also said that the glide path was working, despite repeated warnings by the flight engineer that the glide path was faulty. At 01:40:13, approximately 16.7 kilometers from the threshold of the strip, the crew began to decline from a height of 804 meters. At 01:40:33 the plane passed a height of 731 meters, and after a few seconds the FAC still noticed that the glide path this time was not working accurately. At 01:40:42, the approach dispatcher instructed to switch to communication with the control tower, which the crew completed at 01:40:55. By that time, flight 801 was 12.6 kilometers from the runway (5.6 kilometers from VOR) and at an altitude of less than 610 meters ^[6] . At 01:41:01 the dispatcher allowed flight 801 to land, so at 01:41:14, when passing a height of 550 meters, the flaps were set to the landing position (30 °) and the landing gear was released. More radio messages from the board have not been received. At 01:41:42 flight 801 passed a height of 427 meters and the GPWS system worked in the cockpit. At 01:41:46, the commander asked if the glide path worked (no response from the co-pilot or flight engineer was found on the voice recorder) and gave the command to turn on the wipers ^[6] .

At 01:41:59, the airliner was at an altitude of 335 meters and 7.4 kilometers from the end of the runway, when the co-pilot, reading out the points on the control map, asked: Is it not observed [lane]? and after a couple of seconds, the GPWS system reported an altitude of less than 152 meters above the ground, which caused the flight engineer to cry out in amazement. A plane descending with a vertical speed of 426 m / min at 01:42:14 passed a height of 256 meters, and the GPWS issued a voice warning: Minimums minimums . After another 5 seconds, when passing a height of 222 meters, the second pilot said that he should go to the second circle , and after a second they both with the flight engineer reported that they did not see the lane. Then the helm was slightly pulled over, after which the liner slowly, at a speed of about 1 ° / sec, began to lift its nose, while continuing to decline ^[7] .

At 01:42:26, ​​6.1 kilometers from the end of runway No. 6L of Aghany Airport, flying at an altitude of 201 meters above sea level, flight KE801 crashed into a hill in Nimitz Hill and completely collapsed ^[7] . According to the surviving passengers, everything happened so quickly that they did not even have time to scream ^[8] .

Jet fuel spilled out of damaged fuel tanks ignited, causing an extensive fire that lasted for 8 hours. Due to the inaccessibility of the accident site and the blocking of the only small road leading to the crash site, rescuers were able to reach only a few hours later. The accident killed 228 people - 14 crew members (all 3 pilots and 11 stewardesses) and 214 passengers. Only 26 people survived - 23 passengers and 3 flight attendants ^[9] .

For 2019, this is the first and only disaster in the history of the Boeing 747-300 aircraft.

Investigation of the causes of the crash of flight KE801 took up the National Transport Safety Council (NTSB) .

Among the possible causes of the disaster were engine failures and bad weather conditions. At the time of landing, visibility was 1.6 kilometers.

The American National Aviation Safety Association issued a statement accusing the crew of the erroneous actions that led to the disaster. Korean Air has protested. According to her, on the day of the crash, the radar landing system did not work at Guam’s airport, which was supposed to warn pilots about the dangerous reduction of the aircraft. Korean experts found that a mistake was made in the compilation of the computer program of the guidance service. In addition, it turned out that the glide path drive (providing the correct trajectory of the aircraft landing) worked with the defect that day.

American experts claimed: the crew was warned about turning off the radar system and he had to focus on the readings of the instruments. The American side said that systems located on the ground could not cause a disaster.

The South Koreans called the main cause of the crash of flight 801 the difficult weather conditions in which the crash occurred, in particular heavy rain. They categorically rejected the suggestion that Flight 801 commander was inexperienced or tired during the flight.

The parties agreed only that at the time of the crash the plane was fully operational. Neither the records of the flight recorders, nor the actions of the crew indicated any kind of malfunction, because the HL7468 board served as one of the presidential planes for 6 years and looked after it more carefully.

The final report of the NTSB investigation was published on January 13, 2000.

The report says:

The National Transport Safety Council determines that the probable cause of this accident was the inability of the commander to properly inform and perform an inaccurate approach, as well as the inability of the co-pilot and flight engineer to effectively monitor and double-check the approach by the commander. This was facilitated by the commander’s fatigue and inadequate training of Korean Air’s flight personnel. This was facilitated by the Federal Aviation Administration’s deliberate prohibition of a minimum safe altitude warning system in Guam and the agency’s inability to properly manage the system.

Original text

The National Transportation Safety Board determines that the probable cause of this accident was the captain's failure to adequately brief and execute the non-precision approach and the first officer's and flight engineer's failure to effectively monitor and cross-check the captain's execution of the approach. Contributing to these failures were the captain's fatigue and Korean Air's inadequate flight crew training. Contributing to the accident was the Federal Aviation Administration's intentional inhibition of the minimum safe altitude warning system at Guam and the agency's failure to adequately manage the system.

One of the explanations for the disaster is given from the standpoint of sociology and cultural studies and lies in the specifics of Korean culture ^[10] . A number of cross-cultural studies in the field of aviation security have shown that one of the causes of such disasters is often the so-called “ power distance index ” in the cockpit ^{[11] [12] [13]} . According to the original sociologist Gert Hofstede ’s research in the 1970s, the Republic of Korea is a country with a high power distance index - in such cultures, the social hierarchy is of great importance, and as a result, it is not customary for them to object to elders - including, in the cockpit it is not customary to question the actions of the FAC ^[14] .

A number of cases have been recorded in the history of aviation ^[10] , when disasters occurred because pilots did not dare to object to the commander at the moment when he made a critical error for the flight, or insisted on his communication with airport air traffic controllers, etc. . This is exactly what happened on board flight KE801. According to the transcript and interpretation of the recording of the voice recorder, the statements of the co-pilot showed that he several times hinted to the commander about a mistake and could even manage to save the plane if he insisted on it or seized control, but the pilot did not dare to do so.

In detail from the point of view of the distance of power, the crash of flight 801 is described and analyzed in the chapter "The ethnic theory of plane crashes" in Malcolm Gladwell 's book "Geniuses and Outsiders" ^[15] .

• The crash of Korean Air flight 801 was shown in season 4 of the Canadian documentary television series Crash Investigation in the Blind Landing series (not to be confused with the eponymous series of season 12).
• The crash of flight 801 is shown in the American documentary television series MSNBC Why Planes Crash in the Crisis In The Sky series.
• It is also mentioned in the book by I. A. Muromov, “100 Great Plane Crashes,” in the chapter The Crash of a Boeing 747 on Guam Island .
• The catastrophe is discussed in detail in Malcolm Gladwell's book Geniuses and Outsiders as an example of the influence of a high power distance index on aviation security in different cultures ^[15] .

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Comments

Sources

• Description of the disaster on the Aviation Safety Network
• Aviation Accident Report - Controlled flight into terrain, Korean Air Flight 801, Boeing 747-300, HL7468 . NTSB .