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B742, vicinity Stansted UK, 1999

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Summary
On 22 December 1999, a KAL Boeing 747 freighter crashed shortly after take-off from Stansted UK, following an ADI malfunction.
Event Details
When December 1999
Actual or Potential
Event Type
Loss of Control
Day/Night Night
Flight Conditions IMC
Flight Details
Aircraft BOEING 747-200
Operator Korean Air
Domicile South Korea
Type of Flight Public Transport (Cargo)
Origin Stansted
Intended Destination Milan/Malpensa Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed No
Flight Phase Take Off
TOF
Location - Airport
Airport vicinity Stansted
General
Tag(s) Inadequate Airworthiness Procedures
HF
Tag(s) Data use error,
Inappropriate crew response (technical fault),
Ineffective Monitoring,
Procedural non compliance,
Spatial Disorientation
LOC
Tag(s) Flight Management Error,
Extreme Bank
EPR
Tag(s) RFFS Procedures
AW
System(s) Indicating / Recording Systems
Contributor(s) Component Fault in service,
Pilot verbal-only defect communication
Outcome
Damage or injury Yes
Aircraft damage Hull loss
Fatalities Most or all occupants (4)
Causal Factor Group(s)
Group(s) Aircraft Operation,
Aircraft Technical
Safety Recommendation(s)
Group(s) Aircraft Operation,
Aircraft Airworthiness
Investigation Type
Type Independent

Description

On 22 December 1999, a KAL Boeing 747 freighter crashed shortly after take-off from Stansted UK, following an ADI malfunction.

Synopsis

The following is an extract taken from the Synopsis from the AAIB Accident Report:

"…The aircraft arrived at Stansted Airport after a flight from Tashkent, Uzbekistan. Prior to leaving the aircraft, the flight engineer made an entry in the Technical Log to the effect that the captain's Attitude Director Indicator (ADI) was "unreliable in roll"; he also verbally passed the details to the operator's ground engineer who met the aircraft on arrival. This fault had been detected after takeoff from Tashkent. The inbound flight crew then left the aircraft without meeting the outbound crew who were due to operate…later that day.

…[The aircraft departed Stansted at 1836 hrs, bound for Milan] The Tower controller considered that the takeoff was normal and the aircraft disappeared from sight as it entered the cloud base at about 400 ft121.92 m
agl. At 1838 hrs, as the aircraft indicated altitude passed 1,400 ft426.72 m
, [the aircraft] was transferred to "London Control" on frequency 118.82 MHz. The crew had been cleared for a departure procedure, which required a left turn at 1.5 nm2,778 m
2.778 km
9,114.173 ft
from the Stansted DME…No radio calls were heard from the aircraft subsequent to the frequency transfer instruction…

Investigations revealed that, throughout the accident flight, the captain's ADI indicated the correct pitch attitude but that the roll attitude remained at wings level indication. Radar and Flight Data Recorder data showed that the aircraft commenced a turn to the left but that this turn was continuous until impact with the ground. At impact, the aircraft was assessed to be pitched approximately 40° nose down, banked close to 90° to the left and with a speed in the region of 250 kt463 km/h
128.5 m/s
to 300 kt555.6 km/h
154.2 m/s
.

The investigation identified the following causal factors [including]:

  • The pilots did not respond appropriately to the comparator warnings during the climb after takeoff from Stansted despite prompts from the flight engineer.
  • The commander, as the handling pilot, maintained a left roll control input, rolling the aircraft to approximately 90° of left bank and there was no control input to correct the pitch attitude throughout the turn.
  • 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…."

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