PAS 2018-Feeling and thinking inside the cockpit: Aviation accident paradigm 2

Korean Air 801:On August 6, 1997, about 0142:26 Guam local time, Korean Air flight 801 from Kimpo international airport to Seoul, Korea, a Boeing 747-3B5B (747-300), Korean registration HL7468,  , crashed at Nimitz Hill, Guam with 228 fatalities (228/254). According to the official accident report “probable cause of this accident was the captain’s failure to adequately brief and execute the non-precision approach and the first officer’s and flight engineer’s failure to effectively monitor and cross-check the captain’s execution of the approach”.  During deteriorating weather at the time of the approach the captain failed to properly react to the GPWS (ground proximity warning system) minimum callouts and crashed into terrain without a direct challenge from the rest of the flight crew to the captains improper actions and confusion. Moreover the ILS glide scope was down for maintenance and  crew was briefed about  it not working but captain was still questioning its operational status. Although the captain apparently became confused about the glideslope’s status, the flight crew had sufficient information to be aware that the glideslope was unusable for vertical guidance and should have ignored any glideslope indications while executing the non-precision localizer-only approach. The first officer and flight engineer failed to properly  challenge the captain’s performance, although they knew exactly what was causing the accident without reacting and exhibiting passiveness during captain’s fatal decisions without ever correcting him. The cultural effect of the Korean culture in the cockpit crew’s performance and its psychological effect  is directly implicated in this accident. At this point it should be noted that Korean Air had more plane crashes than almost any other airline in the world for a period at the end of the 1990s. Korean culture is characterized by a strict authoritarian and hierarchical culture were challenging superiors and elders is considered a    As a general point of reference about the Korean language, you speak to superiors and elders in an honorific form that requires more words and can be more oblique. Korea’s authoritarian structure, not surprisingly, is reflected in its industries including aviation, where co-pilots traditionally have not been encouraged to challenge senior pilots. But Boeing (BA, Fortune 500) and Airbus design modern, complex airplanes to be flown by two equals.

Fatigue: The days before the flight, during flight and the accumulation of the effects are characterised by moderate to severe fatigue of the captain due to operational reasons, inadequate rest time and disrupted sleep patterns. It should be noted that despite the fact that pilots tend to underestimate their fatigue and overestimate their abilities,  during flight captain Park was recorded saying “Eh…really…sleepy” at 0121 (NTSB, 2000).  Planning, executive functions, , monitoring, checklists, attention are the cognitive variables implicated whereas the psychological effect is affected by by fatigue, training, dynamics, communication, cultural factors, under reaction, passiveness, obedience to authority .

The official accident report concludes:

The National Transportation Safety Board determines that the probable cause of this accident was the captain’s failure to adequately brief and execute the nonprecision approach and the first officer’s and flight engineer’s failure to effectively monitor and cross-check the captain’s execution of the approach. Contributing to these failures were the captain’s fatigue and Korean Air’s inadequate flight crew training.

Press here for the Official Final Accident Report

Korean Air1Seat plan survivors Korean airKorean air2korean_air_801 distance

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