1. KE6316 MD-11F SHA ACCIDENT 신 지 수신 지 수

2. 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

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

4. 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

5. 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

6. 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

7. 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!”

8. Other View KAL analyzed different point of view: –Cockpit Noise Analysis including Engine Noise level –Flight Path Analysis –Focused on other clues

9. Other Important Clues Difficulty in Pitch Control Unidentified Noises Abrupt Nose up before Dive Contamination in Elevator control valve

10. Similar Incident or Accident worldwide FeDex crash land in Newark JAL pitch oscillation CAL abrupt pitch oscillation

11. 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)

12. 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

13. Administrational Litigation In Progress Cargo Operation continues currently. 감사합니다.