Korean Air Cargo Flight 8509 (December 22, 1999)

Date: December 22, 1999
Crew: 4
Fatalities: 4
Cause: "1. The pilots did not respond appropriately to the comparator warnings during the climb after takeoff from Stansted despite prompts from the flight engineer --- 2. The commander, as the handling pilot, maintained a left roll control input, rolling the aircraft to approximate 90 degrees to left bank and there was no control input to correct the pitch altitude through the turn. --- 3. The first officer either did not monitor the aircraft attitude during the climbing turn or, having done so, did not alert the commander to the extreme unsafe attitude that developed. --- 4. The maintenance activity at Stansted was misdirected, despite the fault having been correctly reported using the Fault Reporting Manual. Consequently the aircraft was presented for service with the same fault experienced on the previous sector; the No 1 INU roll signal driving the captain's ADI was erroneous. --- 5. The agreement for local engineering support of the Operator's engineering personnel, was unclear on the division of responsibility, resulting in erroneous defect identification, and misdirected maintenance action."


Legend:
CAM     Cockpit area microphone or sound source
RDO     Radio transmission from accident aircraft
TWR     Stansted Tower
GPWS    Ground Proximity Warning System
-1      Voice identified as captain
-2      Voice identified as first officer
-3		Voice identified as flight engineer
-4		Voice identified as ground engineer
*       Unintelligible word
@       Non-pertinent word
&       Third-party personal name
#       Expletive
( )     Questionable insertion
(( ))   Editorial insertion
[ ]     Spoken in Korean
...     Pause
Times are expressed in UTC. Exact tenths of a second are estimated based on time difference of when FDR and CVR stopped recording.


---


1836:33.5	TWR		Korean eight five zero nine surface wind one nine zero one eight knots clear take off runway two three

1836:39.5	RDO-2	Clear to take off runway two three Korean Air eight five zero nine
			CAM-1	Cham
			CAM-1	[It is strange the surface looks damp but is slippery]
			TWR		((other ATC transmissions))
			CAM-1	[Cha-gulo gab ni da now rolling]
			CAM-1	Body gear steering
			CAM-3	Body gear steering
			CAM-3	Compass cross check

1837:07.1	CAM-3	Time check three seven
			CAM		((sound of engine power increasing))
			CAM-3	Before takeoff checklist complete
			CAM-3	Stabilised
			CAM-1	Set take off thrust
			CAM-3	Set
			CAM-3	(reduced) thrust

1837:19.1	CAM-3	Check
			CAM		((sound of switch))

1837:24.6	CAM-2	Eighty knots
			CAM-1	Roger

1837:32.1	TWR		((other ATC transmissions))
			CAM-2	V one rotate

1837:34.8	CAM		((sound of noise, possibly banging door))

1837:39.5	CAM-2	V two

1837:39.9	CAM		((sound of two noises, possibly trim movement))

1837:40.9	CAM		((sound of click))

1837:41.7	CAM		((sound of seat moving))

1837:43.5	CAM-2	Positive climb
			CAM-1	Gear up
			CAM-2	Gear up
			CAM-1	Set IAS
			CAM-2	IAS

1837:50.6	CAM-1	[Oh]
			CAM-1	[Il jeom one decimal]
			CAM-1	[I didn't expect this]

1837:55.1	CAM-2	Passing nine hundred feet

1837:57.1	CAM		((sound of warning for 1.7s, sounding three times))

1837:00.6	CAM-1	[We should turn at one point five DME]

1837:03.5	CAM-2	Yes sir

1837:06.3	CAM-1	[DME not working]
			CAM		((sound of warning for 1.1s, sounding twice))

1837:07.5	CAM-2	[One five eight]
			CAM-1	Eh?

1837:08.9	CAM-2	Heading standby sir

1837:10.9	CAM-2	Heading one five eight

1837:13.1	CAM		((sound of warning for 6s, sounding nine times, cut off at tenth chime))

1837:15.5	TWR		Korean eight five zero nine contact London one one eight decimal two good night

1837:16.2	CAM-3	[Bank an meog ne] bank is not working

1837:20.1	CAM-3	Bank bank

1837:21.5	RDO-2	One one eight eight two Korean Air eight five zero nine

1837:25.4	CAM-1	[Ya (eh you)]
			CAM		((sound of two clicks))

1837:26.8	CAM-3	Standby indicator [(do) also not working]

1837:28.5	CAM-?	[Oh]
			CAM		((sound of mechanical noise))

1837:30.1	CAM-1	Request radar vector

1837:32.1	CAM-1	[Ya (eh you)]

1837:32.6	CAM		((possibly static noise))

1837:33.3	CAM-?	**

1837:33.7	CAM		((sound of increasing wind noise))

1838:35.5	CAM-3	[Oy bank]

1838:37.0			((end of recording))