Incident Overview

Date: Wednesday 22 December 1999
Aircraft Type: Boeing 747-2B5F (SCD)
Owner/operator: Korean Air
Registration Number: HL7451
Location: near Great Hallingbury – ÿ United Kingdom
Phase of Flight: Initial climb
Status: Destroyed, written off
Casualties: Fatalities: 4 / Occupants: 4
Component Affected: Aircraft ADI (Attitude Director Indicator) ? This is the primary component affected by the incident, as it was the source of the erroneous alerts and control input errors.Aircraft ADI (Attitude Director Indicator) ? This is the primary component affected by the incident, as it was the source of the erroneous alerts and control input errors.
Investigating Agency: AAIBAAIB
Category: Accident
A Boeing 747 HL-7451 aircraft experienced a series of critical events during its flight from Stansted to Milan-Malpensa. Initial issues with the Technical Log, including an unreliable ADI, led to a series of maneuvers and alerts. The aircraft then experienced a significant climb, resulting in a rapid descent and impact with the ground. The pilot’s response to the comparator warnings, combined with a misdirected maintenance activity, contributed to the incident. The aircraft?s ADI malfunction caused a series of erroneous alerts and a critical shift in flight control, ultimately leading to a dangerous situation.A Boeing 747 HL-7451 aircraft experienced a series of critical events during its flight from Stansted to Milan-Malpensa. Initial issues with the Technical Log, including an unreliable ADI, led to a series of maneuvers and alerts. The aircraft then experienced a significant climb, resulting in a rapid descent and impact with the ground. The pilot’s response to the comparator warnings, combined with a misdirected maintenance activity, contributed to the incident. The aircraft?s ADI malfunction caused a series of erroneous alerts and a critical shift in flight control, ultimately leading to a dangerous situation.

Description

Boeing 747 HL-7451 arrived at Stansted at 15:05 after a flight from Tashkent. Prior to leaving the aircraft, the flight engineer made an entry in the Technical Log stating “Captain’s ADI [Attitude Director Indicator] unreliable in roll’ he also verbally passed the details to the operator’s ground engineer who met the aircraft on arrival. During turnover repair works on the ADI were carried out. Some cargo was offloaded and other cargo loaded for the flight to Milan-Malpensa (takeoff weight was 548,352 lb including 68,300 lb of fuel) and a new crew boarded the aircraft. After a delay of an hour, because ATC had not received the flight plan, Flight 8509 was cleared to depart Stand Alpha 6 and taxi to runway 23 holding point at 18:25. Subsequently, at 18:36 KAL 8509 was cleared to takeoff with a reported surface wind of 190deg/18 kt. The Dover 6R Standard Instrument Departure called for a climb ahead to 1.5 miles DME, then a left turn onto the 158 inbound radial to the Detling VOR. Climbing through 900 feet, the ADI ‘Comparator’ buzzer sounded three times. Shortly afterwards, the warning sounded a further two times, coincident with the captain expressing concerns over his DME indication. Climbing through 1400 feet, ATC instructed the crew to contact ‘London Control’. And as the captain initiated the procedure turn to the left, the ‘Comparator’ warning sounded again some 9 times. The maximum altitude reached was 2,532 feet amsl. The aircraft then banked left progressively and entered a descent until it struck the ground in a approx. 40deg nose down pitch and 90deg bank to the left; the speed was high in the region of 250 to 300 kt. CAUSAL FACTORS: The following causal factors were identified: 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 approximately 90ø of left bank and there was no control input to correct the pitch attitude throughout theÿturn. 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 mis-directed maintenanceÿaction.

Source of Information

http://www.skybrary.aero/index.php/B742,_vicinity_Stansted_UK,_1999http://www.skybrary.aero/index.php/B742,_vicinity_Stansted_UK,_1999

Primary Cause

The pilots’ delayed and inadequate response to the comparator warnings, compounded by a misdirected maintenance activity and a failure to properly correct the ADI, caused the critical flight control errors that resulted in the aircraft?s descent and impact.The pilots’ delayed and inadequate response to the comparator warnings, compounded by a misdirected maintenance activity and a failure to properly correct the ADI, caused the critical flight control errors that resulted in the aircraft?s descent and impact.

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