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Cette fois ca se passe apres le decollage de l’aeroport de Stansted ….l’avion decroche et s’ecrase. CDB face a un horizon en panne alors que les 2 autres fonctionnaient normalement, que faisait le copilote The captain's attitude director indicator (ADI) showed a correct pitch reading for the 747 during departure from London Stansted, but falsely showed the aircraft as being wings-level when it was actually in a dangerously steep left bank, says the UK Air Accidents Investigation Branch's (AAIB) report.A fault in the ADI, correctly reported by a crew who had flown the aircraft to Stansted, was not rectified by the KAL ground engineer, who was among the four crew members killed in the accident. Crew must check the weather of all en route suitable, emergency, destination and alternate airfields. Relate available runways and weather from these fields to landing minima and crosswind limits to check if these fields are usable. This should be a check item and crew must not accept a flight director giving erroneous information.
Jeppesens should be held at dispatch in an easily accessible area for all the crew to use.4. The names and locations of all active volcanoes must be published in an Operations bulletin. During descent FO confused aircraft call signs the crew responded to a radar vector given to another aircraft.
The proximity of these volcanoes must be noted on the en route weather chart so the flight crew can note proximity to flown track.
Fuel policy should be reviewed to ensure it complies with the appropriate regulations and all dispatchers must be familiar with the updated regulations. Despite visual conditions crew did not look out and see that the current heading would not take aircraft to the airfield. This must NOT be a regurgitation of the Jeppesen manual but rather important pilot and operational information specific to the route.7. The incident caused by similar sounding call signs, lack of situational awareness, crew not looking out, crew not speaking up, incorrect radio procedures and implicitly trusting ATC.9.
Radio and navigation instruments on the checklist must NOT be completed until it is actually set for the approach.
If, in the opinion of the dispatcher an unreasonable decision has been made, this information should be reported to the Chief pilot of the fleet who may at a later stage choose in to discuss this with the Captain at a convenient time.
As the dispatcher has no 747 command experience, he can not possibly make an informed decision about the fuel requirements. Management should in turn set up an extra fuel tracking system to monitor extra uplifts so they can be controlled.9. It is not necessary to use it for every landing and considerable cost savings can be made here with reduced brake and tire wear.12. Very important with non-ISA conditions and heavy weights, especially on the A model aircraft. Performance manuals should be kept at all out stations so crew can check take off data taking into account temperature, baro corrections etc.Before Start Operations1. Approach checklist must be done at the correct time and the checklist must not be continued if an item is not complete.18.
Also suggest Korean Air can save a huge amount of money by placing manuals on each aircraft instead of a full set for each crew member. If anti ice is required during the descent it is a satisfactory procedure to ask the FE to set the required minimum thrust for the PF.
When deicing is required and requested before take off, the Captains judgement is constantly put in question by the ground and dispatch crew saying that it isn't necessary. In many cases this is far too early at Radio and Nav instruments will NOT be set for the approach.20. Outer marker height call is to check for glide slope functionality and ensure the correct QNH is set. They do it in record time and would not pick up any problems because of the rush they are in.4.
Customizing All Korean Air plates just for a company frequency and route is costly and ineffective. When getting on board, the FO must ensure that ALL en route emergency, suitable and alternate Jeppesen plates are in the manuals for the flight. Crews do not check on board manuals to make sure that the alternate plates are there in case of a diversion, en route and destination.7. This attitude may have had a contributory factor to the Guam accident due to the trained mind set.
There must be a list of what Jeppesen plates are in the alternate manuals and this must be cross-referenced with the Korean Air approved suitable and emergency approved airfields. Crews must be trained, in the event of a malfunction of the primary approach aid on any approach, an IMMEDIATE missed approach is necessary. Reestablish situational awareness, find out the problem, re brief and then re a enter the safety window. The Boeing manual stipulates that the Flight Engineer starts the INS's and loads the present position. This is not even removed, so if the mask is required in an emergency, the chances are that oxygen may be unavailable.13. The crews were trying to fly an instrument approach off the QUIET BRIDGE visual approach plate for 28R.
FE's seen turning oxygen switch on but no oxygen mask check or check that oxygen valve is open.14.
NOBODY was looking out, the pilots were all head down trying to read the plate and program the AFCS. The flight engineer saw the problem but would NOT make any input to bring this to their attention.(CRM-all crew MUST be involved) Just by looking out of the window a clear deviation away from the field would have been noted. Many portable oxygen bottles did not have full face masks, and most were not connected to them. A full inspection of all emergency and fire fighting equipment should be done to bring this up to standard.
The deviation was sufficiently large to cause the tower to panic and ask the crew if they had the field in sight. All crew should have continuity training on all on board emergency and safety equipment.16.
The ensuing communications resulted in an unstable approach due to late configuration of the aircraft. The crew must be aware that once a visual approach is accepted by the crew, the most important instruments on the approach on a wide body jet are the WINDOW and the VSI. Non standard modifications have been made to oxygen panels and pins have been place on some of the emergency diluter levers. Aims monitoring program must be implemented and management trained to use it as a positive safety tool and not for retribution.28. If a diversion is required, the Captain makes the decision to divert, NOT the dispatcher as is currently the case. The altitude select switch on the 747 classic is one switch that can KILL if it is mishandled.20. The Korean crew ask for permission to divert from their dispatcher and will divert where the dispatcher tells them to go. Crew unaware of pitch bar graduations for the flight director for setting 3-engine target attitude after take off. Communications are difficult as often many aircraft are trying to contact the dispatcher at the same time.
Pitch bar for rotation attitude must be accurately set with respect to 2 degrees per notch.21.
With a foreign Captain on board, the FO and FE consult with the dispatcher in Korean and the Captain does not know what they are saying. The crew is then divided as the Captain will want to go with his plan having assessed all the options. The rest of the crew will actively oppose the Captain in diverting to his intended airfield of diversion if it is not the same as that of the dispatcher for fear of upsetting the dispatcher. It should be a normal crew function to change unserviceable light bulbs on the flight deck.
He may offer alternatives that may assist the company and provide weather, but the decision lies with the Captain and his crew alone. Take off alternate should be discussed and included in the take off briefing when appropriate.25. Captains says during take off briefing that if there an emergency after take off with the FO flying, he will immediately assume control.
Assuming that ALL FO's are current, competent and trained to Captains standards with respect to flying ability, there are substantially better methods of handling emergencies to manage risk and correctly use resources.26. An instrument check should be coordinated by both pilots prior to start to cross check instruments. Crew did non-precision LOC DME approach with ALT SEL switch off to minimize switching requirement at ALT capture. Crews are using rudder, rudder trim or and aileron trim for landing and pitch trim for the flare. Engine out procedure should be written on the take off card and also placed on the appropriate page in the performance manual.
All crew must review engine out procedure and minimum safe height for acceleration with an engine out.31. Crews are taught to use rudder on final approach for directional control, rudder and aileron trim for handling cross winds and trimming for the flare.
Engine out flight path is seldom reviewed for Seoul runway 32 or for any runway for that matter.32. There are unknown techniques for the correct handling of these situations and may be the root cause of the considerable pod damage that occurs.6. Boeing normal checklist has had many changes that result in flow breakdown and ultimately violations.
On investigation it was found that the call originated because a B 727 did a wheels up landing some years ago. This will also resolve the confusion that arises with respect to checklist responses in the cockpit.36. The correct procedure would have been to educated crew into not pulling the aural warning CB and not adding in a highly disruptive call. Standard phraseology for pushback procedure must be developed and taught to Cockpit and ground crew. Monitoring the VSI is extremely important on wide body jets and is largely ignored by Korean crew. The aircraft thus would not STOP in time in an RTO and would not clear the required obstacles in the event of a go decision with an engine out. This should be looked into as fuel savings can be made here but the data used must be correct.40.
Captain did not disengage auto brake on runway.Aircraft came to a stop and could not taxi off the runway.
There are cultural problems here with Korean tradition and respect for their senior that must be overcome through out the operation.41.
Crews are unsure of how to calculate bug speeds on the approach - half the wind plus the gust as additives.14.
He took over tiller and armed body gear at 80 knots and started turning off the runway causing terrific airframe and tire side loads and cause pax. After start with many crews Captain speaks to ground, FE does after start checks, FO reads after start checklist by himself. Management must be trained in the appropriated management of handling of crews with respect to the go arounds.

Flying and directional control uncomfortable due to instability with the crew not sure who was flying. After start the when FO reads the checklist he MUST check, aileron and rudder rim are zero.7. While departing Anchorage recently, 4.00 am, OAT 9C, rain and wind, the Captain briefed that he required nacelle anti ice after start.
FE's must make calls on pressure altimeter and altimeter bugs must be placed on pressure altimeters.19. The FE said it was not required and that using the nacelle anti ice with the TAT at 12C, would damage the engines.
The FE informed the Captain that he was a professional of many years, and that he was right as this was his job, and the Captain was wrong to require it.
Captain over pattered the FO so much on the approach, the FO was having difficulty concentrating on the flying.21. A monitored coupled approach policy will stop unsafe maneuvers close to the ground and also help eradicate pod contact.22. With an OAT of 9C and visible moisture present, icing conditions indeed existed and nacelle anti ice was required. The Captain explained that use of anti ice above 10C does not damage engines as far as he was aware and it is always better to err on the side of safety in such matters.
KAL crew that have been questioned about diversion fuel requirements to Cheju from Seoul and all came up with the figure of 30000 lbs. The Captain had to demand the anti ice be turned on after start in the interests of safety. Sadly CRM was compromised as a result and there was the minimum of communication and input from the FE on the remainder of the flight.
This is NOT the correct procedure and anti ice must be left on until just before shutdown to protect the engine. The Boeing manual clearly covers this.The weatherman is already forecasting the coming winter may indeed be a severe one. The Boeing adverse weather procedures must be known, understood and applied by all crew before the winter season sets in. This lack of understanding is probably not localized only to the FE's only but may be through out the airline.• There is little understanding of the meaning of TAT, SAT, and OAT and Boeing anti ice procedures.
There should be a company policy that mandates that a full emergency must be declared when fuel gets down to e.g.
A check of landing fuel in the fuel logs on Korean Air aircraft will reveal that many flights land with less that the company minimum fuel.
As the auditors are not and have not been trained as a flight engineer, it is neither fair or professional to undertake an audit of a position that I am not qualified for. If an aircraft is operating on a re file flight plan, it is good airmanship to advise ATC that you are operating on minimum reserves. It MUST stay on after landing while taxiing in icing conditions and can be turned off before engine shutdown.Taxi and before Take off1. Likewise if you are below minimum reserves, ATC must be advised so priority can be given for the approach.25. Crews are NOT supporting each other with wind and drift angle callouts on final approach.28. Pilots must NOT have armrests down for take off as they may restrict movement in the case of an RTO or engine out.5. Crew must have feet correctly positioned on rudder pedals for the RTO and must ensure on rudder check that full deflection is possible with current rudder pedal and seat settings to ensure full braking is available.6. Some Captains assume control at 80 knots with all thrust reversers coming out, some at 60 knots etc. True professionals fight off complacency as it there is nothing more dangerous than a complacent crewmember.7. Boeing checklist - Compare checklist with standard Boeing checklist and make appropriate changes to avoid violations, e.g. In some cases crews have attempted to turn off at up to 80 knots with heavy braking causing extreme airframe side loading and potential tire damage. This causes distraction and unnecessary cockpit chatter when anticipation take off clearance. Unquestionably the correct decision with 360 passengers on board and with airmanship and safety in mind!Engineering boarded the flight on the return to the ramp and castigated the crew for not having dispatched with the door open light on. This riled the crew to the extent that during the taxi and climb the FE spent most of the time writing up a report in his defense.
The action of the ground crew was unacceptable and definitely compromised flight safety for the remainder of the flight.10. When disembarking the freighter, the correct steps must be used and they must be correctly positioned.
Gear lever to off at 1500 ft when climb thrust is set, NOT immediately after gear retracts.
They are difficult to manage because of the gradient and the crew bags that are carried.11. Passenger Aid units must be made available at Cheju and other airfield for incapacitated passengers. It is not satisfactory that they get carried down the stairs as it increases the chance of a fall with all the incumbent liability.General Standards1.
SOP's ensure a level of operation that is standard and well inside the operating envelope of the aircraft.
They must consider the implications of the effect of wind on the RTO, Pax evacuation, vortices and drift after take off.3.
Captains hands alone must be on throttles for take off at 80 knots so he alone will reject the take off.There is tremendous confusion here. A thorough understanding of the checklist and how to manage it is the foundation of a safe operation.3.
This is because there is no standardization and simulator training is different to the actual procedure.
Korean crews generally only carry an envelope with the required charts and plates for the route flown.
As a result FO's are doing the whole take off and handling the thrust levers to V1 or BOTH pilots AND the FE have their hands on the thrust levers for the whole take off. There could be considerable problems here if something non-standard occurs and original destination is changed. This must be addressed urgently as confusion here with an RTO could well result in a runway excursion or overrun. Current procedures require that the individual crew members operate totally independently of each other. Reduced thrust is currently set at the FE's discretion somewhere between Max and reduced thrust.5. Crew must announce all changes in frequencies, headings, altitude, courses and switch positions.5.
All operational communications in the cockpit when operating with a foreign Captain must be in English. This is good airmanship with respect to other foreign carriers operating in Korea as well.6. Any CB that is pulled must only be done with the permission of the Captain and after all crew have discussed the implications thereof.7. PNF doing the radio often does not wait long enough for ATC to respond after a request is made.
This results in the PNF transmitting the request again, just as ATC is responding and transmitting a response. After TO check list must be read in full and acknowledged by the return of the take off card to the FE.10. Never just accept a clearance unless you are totally happy that the clearance is reasonable.9. Crews must be aware of altitude restrictions on departure, particularly out of Seoul and Tashkent. Just because you are cleared to a level does not mean that the restriction is cancelled.Climb and Cruise1. FE on leaving the cockpit must inform the crew of the position of ignition, antic ice, air-conditioning and fuel system.
Crews (both cockpit and ground) smoke cigarettes on the ground while refueling and during the taxi.
When this comes to the attention of the local authority, it will have serious implications for Korean Air.11. Hand flying the aircraft to cruise altitude in busy airspace is not good risk management as it significantly increases cockpit workload.
When hand flying, it is mandatory that the PF calls for all AFCS changes to be done by the PNF so as not to disrupt scan.7. This is just about the position that the crew wish to eat, and they always eat at the same time. Crew do not make pilot reports PIREPS regarding significant weather and turbulence to ATC.8. An emergency here could have serious consequences if all the crew aren't totally prepared.13. If a Trans Pacific operation for example, has an emergency descent with hydraulic complications and the gear is selected down for the descent, it may not be possible to retract it.
It should be considered to set 1 white bug at V2 + 100 during the cruise so the crew always have a reference for drift down. CB's should NEVER be pulled on a normally operating system unless the Captain has given his permission to do so. Recently a pressurization 115V auto controller CB was pulled by the FE for demonstration purposes while at F370 without consulting or advising the crew.
KAL flight operations seem to totally dictated to by the commercial department without due consideration being given to flight safety.
The system could not be reset and the pressurization had to be controlled in manual for the remainder of the flight. NO NEW airport should be operated into unless the standards department of flight operations has done a full and thorough investigation into it and EVALUATED it. Commercial departments relate only to the bottom line and this is NOT always the cheapest way in the long run.
KAL should really look into this, as LUFTHANSA will surely have done their homework and had their flight operations evaluate the operation. All crew, at each waypoint must discuss in detail, the fuel variances and at re dispatch point all crew must be aware of fuel state, destination and en route weather. The re file point is currently not even mentioned and it is a MAJOR event in operational safety on long range operations.14.
While the wearing of golf gloves on both hands while flying may have advantages, it does pose some problems. Altitude capability performance must be cross-checked before departure and ESPECIALLY before changing altitudes. The current pilot check list altitude capability chart is inadequate and the figures for the A engine should be rechecked.
Under no circumstances should the FE give weather avoidance instructions to the FO in Korean when flying with a Foreign Captain. Crew do not know which winds are true and which are magnetic on METARs and TAFS and tower reports.22.

When an altitude change is required, the figures must be checked by two crew members before initiating the climb.15. Suggested autopilot usage - When flying manually, PF calls for all changes and settings required. The FE must report to the Captain immediately when something abnormal appears on his panel. Once autopilot engaged PF may make own MCP selections until on intercept headings for a monitored approach or cat 11 approach. AP must be used as soon as possible after take off and until final approach for risk management. They must not hesitate to ask ATC to say again and must NOT say roger unless they fully understand the communication. When executing a climb from the cruise, landing lights should be turned on to improve safety.19. Crew must continue to ask ATC to say again until the clearance is fully understood and read back correctly. It would be a good policy if a crew member walked around the freight compartment on a regular basis, (eg.
On flights such as SEL ANC LAX this requires the crew operating second to get into the seat at TOD for Anchorage. Sennheiser or equivalent high quality head sets to be used in the cockpit to improve communications.27. Crew read newspapers through out the flight, often with the newspapers held up in such a way that if a warning light came on, it would not be noticed.22. Limited knowledge is evident on aircraft performance, specifically take off and landing performance.
It must be obtained and related to notams and the appropriate Jeppesen plates for that route. If an emergency occurs in the cruise that requires and immediate landing, crew will not have the necessary information at their disposal unless this procedure is followed. Shoulder harnesses must be worn till top of climb and from top of descent, as well as when required.29. Constantly check en route weather for diversion airfields weather as well as weather at destination and alternate. Take off and landing briefing must be updated and must provide a logical flow without regurgitating too much info so that the important information is lost.
Crew must keep a log of other aircraft on the same and opposing tracks and constantly update them relative to their own position.24. They must include strict and vigilant awareness of Grid MORA, Sector safe altitude and initial approach altitudes. Crew must always be aware of 1 and 2 engine out performance with respect to optimum altitudes, grid mora's and MEA's.
Planning must be done for go around and missed approach, diversion fuel requirement, and routing.
Medical department must get involved with crew training with respect to Medical emergency training and management of incapacitated crew members. Crew must be aware of the doctors bag contents and trained in the management of in flight medical emergencies. Tropopause layer also be inserted in the flight plan for assisting in optimum level selections.28. Korean Air cabin service is of the highest standard as far as presentation and appearance is concerned from a passenger's point of view.33. The wisdom of automatically updating an INS 2 hours after take off before checking its accuracy needs to be reviewed.
English standard needs to be improved to enhance safety with ATC and ground communications.
Many of the world best airlines (Swissair, KLM, Saudi, Lufthansa, SAS, Air France, Finnair etc.) have English as a second language, but within the airline it is the primary language. The RNP 10 checklist in the cockpit has some of the update coordinates INCORRECTLY printed. For RNP 10, an INS accuracy checklist should be designed to record VOR position, triple mix position and individual position of all 3 INS's and then relate them to each other. The Korean FO's often ask the Foreign Captains to complete a report after landing whenever they get a leg.
It is unfair on the FO's to be assessed by someone who is unqualified and unaware of the reason for the documentation.39.
Crew baggage often left unattended at the gates of overseas airports while crew look at shops.40.
The ground handlers in Anchorage have brought to the attention of the auditors that on occasions on the freighters are departing with more crew and extra crew than there are seats on the aircraft.
These call signs can be confused because of their similarity but are especially confusing to crew because they can also be confused with the numbers given in VHF frequency changes. When ATC or PA chime interrupts a checklist being read, hold the check list until the communication is complete and then continue with the checklist.
Currently, the crew member reading the checklist ignores the ATC call and continues with the checklist with nobody listening or responding.43.
Crew members with poor English skills should be placed on domestic service as they become a major liability on the long-range aircraft. A training method of evaluation should be adopted that has the capability of allowing positive reinforcement into the assessment. In the interim any fatigued crewmember must report to the Captain he is fatigued and the Captain can keep an eye on the panel while the FE takes a break.50.
Extra crew talking in the cockpit in terminal areas is unacceptable but occurs all the time.52. Maintenance on all Korean Air aircraft is generally excellent and aircraft seldom carry inop. Crew will pass on snags, engineering will repair them and nothing will be written in the tech log.
It has been suggested that KAL may using some Captains over the age of 60 years (western age) to operate flights to Moscow and Tashkent.
Apart from the liability issue using Captains over 60 to non published or authorized destinations, the Korean MOT have recently announced that the Company and its management will now be held responsible for non compliance of regulations, not just the pilot as has previously been the case. This matter should be investigated, and should it indeed be taking place, the issue and the policy should be urgently reviewed to protect KAL's interests.55.
The Jeppesen department and the route clearance unit (RCU - route audio visual center) should be open 24 hours a day, 7 days a week. If the full Jeppesen series is eventually kept on board, the requirement for the Jepp office to stay open falls away.56. All Flight plans must also include performance degradation to ensure flight planning accuracy. This accuracy must be improved to avoid diversions.Management feedback from the crewsKorean Air crew were very open about pointing out areas of concern for the good of the company.
There is tremendous good will within the company and the staff are very keen to see things improve. There is a great deal of ill feeling from the Korean crew regarding the payment of flying hours. Thus, through no fault of their own, they are seriously financially disadvantaged relative to the 747 400 crews. There is a low level of self esteem and moral present throughout the flight operations division.3. The flight operations department appears to have poor communications between management and the staff. The Foreign Captains especially, source most of the company information via the rumor network.
It appears that the silent, secret dis information technique is a current management style.The recent tragedy involving the Swiss Air accident highlights the incredible success Delta and Swiss Air had using rapid, high quality and open communication techniques.
This can only be resolved by clear, honest and open communication throughout the company.5.
All Korean Aircrew spoken to expressed major aggravation regarding conditions of service, flight and duty time and salary.6. However, if they go to management to make a suggestion there is fear of termination or suspension of promotion.
They would like to consolidate on a few routes.• Non military Korean FO's are frustrated that military FO's with Colonel rank can go from direct entry FO to 747 400 Captain in 3 years as they carry their military rank into Korean Air to assist them in promotion. This process typically takes 10 years on various aircraft types, operating in a good training environment, with good Captains as role models, to be achieved.• Normal command time in most major carriers is 10-15 years. This is deemed by the industry as the required experience level necessary to become a Captain. Career path may be short haul FO to develop flying skills, long range FO, short range Captain and then long range Captain (over the 10 to 15 year period). Korean Air's expansion over the past few years has been extraordinary and has resulted in crew promotion well beyond safe experience levels.
Military flying experience holds NO credit in airline operations as the are so totally different. Ironically the Foreign Captains generally rate the Cheju First Officers very highly.• Crews complain of their dislike of the physical and verbal abuse that goes on in the simulator during training. The moment a voice is raised in training, the student is lost, training stops and some form of conditioning takes over.
Quality training takes place in a caring environment, with knowledgeable instructors and where all present have a mutual respect for each other.• The upgrade system is dishonest and unfair. Military status and NOT competence means everything.• First Officers can suddenly find their career comes to a halt for no apparent reason.
They say there may be a secret reporting system and they are too afraid to ask why their promotion has been stopped.• Crew members, particularly on the 744, 777 and A330 are expected to socialize with the Captain on layovers. The resentment is a substantial cause of communications breakdown on the flight deck and obviously is an obstacle to any form of CRM development. This concept is not understood or applied by KAL military pilots as it is seen to consistently conflict with "Korean procedure" ?
The only time it is acceptable to have two Captains in the operating seats is when one is an IP.9. The FE, in the FO's eyes is more senior than a Foreign Captain or for that matter a new Korean Captain on the fleet. The quality of the KAL hotels for the crew has constantly been dropping over the past year. This has now reached a stage that adequate rest can no longer be taken before a scheduled international departure, so flight safety will be an issue here.11. Pilot incapacitation occurs more frequently than any other emergency and this is little acknowledged.12.
There is far too much content in the simulator training and the emphasis is to get through the syllabus rather than giving quality training.

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