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

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

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

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

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

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!”

Other View

• KAL analyzed different point of view:– Cockpit Noise Analysis including

Engine Noise level– Flight Path Analysis – Focused on other clues

Other Important Clues

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

valve

Similar Incident or Accident worldwide

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

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)

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

Administrational Litigation In Progress

• Cargo Operation continues currently.

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