Edwin Alfonzo S.

Solano 04/15/2022
On-The-Job Training BSAET 4-1

Human Factors Report: Korean Air Cargo Flight 8509

Human Factors refer to the study of human capabilities and limitations in the
workplace. In the field of aviation, researchers tend to study the interaction of
maintenance personnel, the equipment they use, the written and verbal procedures and
rules they follow and more importantly the environment conditions in any system. The
study of human factor optimizes the relationship of maintenance personnel and systems
which can improve the safety, efficiency, and well-being. We all know that human
factors are one of the biggest factors that lead aircraft to accidents. Thus, through
aircraft investigation of the Korean Air Cargo Flight 8509 we can understand more how
related those errors such as mechanical errors and human errors had contribute the
most in accidents.

Days before Christmas, the Korean Air Cargo Flight 8509 crashes minutes after
takeoff. It was a Boeing 747-2B5F registered HL7451 and bound for Milano-Malpensa
Airport, that crashed due to instrument malfunction and pilot error on 22 December
1999 shortly after take-off from London Stansted Airport where the final leg of its route
from South Korea to Italy had begun. The aircraft crashed into Hatfield Forest near the
village of Great Hallingbury, close to but clear of some houses. All four crews on board
died due to plane crashed. One of the considered factors of the accident is the
mechanical error which showed that one of its Inertial Navigation Unit (INUs) had partly
failed, providing incorrect roll data to Captain’s attitude director indicator (ADI). The
investigation revealed that the captain entered a left bank as his attitude director
indicator froze and show no roll moment. As he continues to bank, his copilot’s ADI and
standby ADI both showed that the aircraft is banking excessively. It is also showed that
the ADI “comparator” buzzer sounded three times to alert all that there was a problem
with at least one of the ADI. These warning sounds alert them twice during the situation.

Page | 1
AVT 3226 – ON-THE-JOB TRAINING
The flight engineer did also call out the problem, but the captain ignored all the warnings
and the advice from the flight engineer. The next considering factor is the human error,
the pilots did not respond appropriately to the comparator warning during the climb after
take-off. The Pilots also disregarded the call-out of the situation from the flight engineer.
The first officer either did not monitor the aircraft attitude from his ADI display during the
climbing turn and revealed that he did not alert the Pilot in command to the excessive
attitude that developed. More importantly, the maintenance activity at Stansted was
misdirected, despite the fault of having been correctly reported using the Fault
Reporting Manual. Consequently, the aircraft was presented for service with the same
fault experience from the previous flights.

The failure in Crew Resource Management and the failure of both pilots to
recognize an Unusual Attitude killed them both and their two crew mates. British
Accident Investigation Board hints some answers for the reasons of the accidents. It
was also revealed on the Canadian TV series of aircraft investigations which is the
Mayday (Season 11 Episode 7) titled “Bad Attitude”, that these two Pilots have some
past disapproval and annoyance to each other. It was also showed in TV documentary
that during this flight a delayed flight clearance put the crew behind schedule and the
captain became irritated. No one on the crew dared increase that irritation. That’s why
they concluded that even if some simulator tests proved that the aircraft was
recoverable in that kind of situation, there was no recovery attempt was made by either
pilot.

Lastly, I learned in this aircraft investigation documentary that every flight crews
such as the pilots must understood that they need to stay calm on that kind of situation
to think and assess the situation. The Pilots of the Korean Air Cargo Flight 8509 might
have properly diagnosed the problem, being a pilot brings a several responsibilities,
among which is the need to stay sharp and avoid complacency to increase the safety of
the aircraft, reduce the human errors and to become efficient in the workplace.

Page | 2
AVT 3226 – ON-THE-JOB TRAINING
 Page | 3
AVT 3226 – ON-THE-JOB TRAINING