All language subtitles for Mayday.S26E10.Mixed.Measures.1080p.AMZN.WEB-DL.DDP5.1.H.264-Kitsune_track3_[eng]

Korean Air Flight 6316,

now turn left direct
to November, Hotel, Whiskey.

Where is it?

The pilots of Korean
Air 6316 struggle to navigate

in the skies above Shanghai,
China.

Keep turning left.
Keep turning.

Keep turning?

The controller
really needs the aircraft

to be going on the expected
path.

- But seconds later...
- Nose up. Nose up. Nose up.

...the M-D-11-F
crashes near a residential
neighbourhood.

The impact registered
the equivalent

of a 1.6 earthquake.

When investigators
reconstruct the flight
in a simulator...

Start the dive in three,
two, one, go.

...they come
to a shocking realization.

The data showed
that the upset was caused
by a pilot input.

And that becomes the mystery.

It's a mild and
overcast spring day

at Hongqiao International
Airport in Shanghai, China.

Korean Air Flight 6316
is being prepared for departure.

The cargo plane is loaded
with 86 tons of non-hazardous
materials.

Checklist beacon light.

Before Start checklist, sir.

The Captain
is 54-year-old Hong Sung Sil...

Captain Hong is a very
experienced pilot

with 13,000 flight hours
and a very good safety record.

...today his First
Officer is 35-year-old
Park Bon-Suk.

First Officer Park
is less experienced than
the captain

but also has an excellent
safety record.

- Doors and windows?
- Closed and locked.

Korean Air is South
Korea's flag carrier.

Its headquarters is located
at Gimpo International Airport
in Seoul.

In 1999 Korean Air is one
of the top three passenger
airlines in Asia.

And its cargo division is top
three in the world.

Its routes covered Asia,
South America and Europe.

Hey, guys. Any issues
or concerns?

All good so far.

Also on board
is 48-year-old Flight Technician
Park Byong-Ki.

The flight tech is a mechanic
onboard who is not a part
of the flight crew.

His job is just to make sure
this aircraft

has no mechanic issue
and will take off safely.

Engine ignition?

Standby. Fuel panel, auto.

Air panel, auto.

Before start checks complete.

Before the aircraft
can begin taxiing to the runway,

it must be pushed into position
on the taxiway.

Captain,
can you release
the parking brake?

Okay, brake released.

All aircraft are parked
facing terminal

or the cargo apron, which means
the aircraft has no ability
to reverse by themselves.

So it's a need to have a tow
truck to push them back onto
the taxiway.

But as Flight
6316 is being pushed back...

Uh, something's not right.

...the Captain
notices something amiss.

Why is that brake temperature
light on?

It seems this brake
isn't released.

The captain
noticed there is a caution

that shows there is a high
temperature on one
of the brakes.

It doesn't mean this brake
is failing.

It just means this brake
is hotter than the others.

Yeah, when we landed
that brake temp showed up.

In some rare conditions,
the hot brake

can lead to fire in flight.

But at this point, the hot brake
is not a serious issue.

You just keep an eye on it.

It's dropping down now.

I wonder what's gonna happen
when we take off.

Captain, cleared
to start engines 3-1-2.

Roger, starting number three.

The pilots
are flying a McDonnell Douglas
M-D-11-F.

The MD-11
is a large, wide-body aircraft.

This is a very high-performance
airplane.

And once you understand
the MD-11,

it is a very pleasurable
airplane to fly,

but it does require the pilots
to be on top of their game.

Hongqiao tower,
Korean Air 6316 request taxi.

Korean Air 6316 taxi
via kilo-seven tango-zero
for runway 1-8.

The aircraft begins
taxiing to runway 1-8.

- Right side clear?
- Right side clear.

Left side clear.

So many airlines
at this airport.

It's 77. It's normal now.

The elevated brake
temperature has returned
to normal.

Korean Air
6316 clear for takeoff.

Clear for take off 6316.
Confirming, we're clear
for takeoff.

Check thrust.

Thrust is set. Eighty knots...

V1...

Rotate.

Just after 4pm,
they lift off from Shanghai.

Positive climb.

Gear up.

The flight from
Shanghai to Seoul is expected
to take two hours.

Shortly after takeoff,
the controller provides

the pilots with their climb-out
instructions.

Korean Air, 6316,
now turn left direct to November

Hotel Whiskey, then climb
and maintain 1,500 metres.

The M-D-11
is to continue climbing and turn
left to intercept N H W.

N-H-W, or November Hotel
Whiskey, is

a ground-based navigation
beacon that assists pilots

in guiding their plane
through the skies.

Okay, direct November Hotel
Whiskey.

And say again altitude?

Reconfirming the altitude
instruction is smart.

Every aircraft have their
assigned route

or assigned altitude by the ATC.

So that is very important
to hold this altitude

to avoid the conflicts
with others.

But as the pilots
confirm their instructions,

the controller notices the plane
has yet to turn towards

the N-H-W navigation fix.

Flight 6316 turn left
direct to November Hotel
Whiskey,

then climb and maintain
1,500 metres.

The controller
can see on the radar scope

that the aircraft
is not turning left.

And so is reminding the crew
that they need to turn left

by reissuing the clearance.

But as
the controller repeats
his instructions...

I don't see NHW.

...the navigation
fix does not appear

on the Captain's display screen.

Where is it?

Uh, here. Keep turning left.

Keep turning.

- Keep turning?
- Yes, keep turning more.

As the pilots
continue their turn,

the controller realizes
the plane isn't climbing.

Korean Air 6316,
climb and maintain 1,500 metres.

Are they asking us to--

Yes, they're...
they're telling us to climb.

The aircraft
hasn't even reached

the initial altitude
that they were cleared to.

So this is a way to remind
the crew,

we need to get moving,
we need to climb.

Just as Flight
6316 nears its assigned
altitude...

...it disappears from the radar.

The plane is diving
uncontrollably towards

the ground, too fast to be
picked up by radar.

The controller is unaware
of its descent.

Korean Air 6316,
do you read?

Wait, wait... pitch

Korean Air 6316,
radio check.

Korean Air Flight
6316 bursts throh
the clouds above Shanghai...

Terrain. Terrain.

Nose up. Nose up. Nose up.

Pull up. Pull up.

...and slams into
the ground seven miles

from the airport...

...less than two-and-a-half
minutes after takeoff.

At the speed
they hit the ground,

the impact was so severe
that it registered

the equivalent
of a 1.6 earthquake.

The aircraft
crashes in Xinzhuang

on the outskirts of the town's
residential area.

The accident claims the lives
of both pilots and the Flight
Technician.

Five civilians are killed,
40 more are injured.

The investigation into
the crash is handled jointly
by the three countries involved.

Representatives from the Korean
Civilian Aviation Bureau

are onsite on behalf
of the airline.

With the crash occurring
on Chinese soil,

the investigation is led
by the Civil Aviation
Administration of China.

And as the plane
is manufactured in the U-S,

an American investigator
from the National Transportation
Safety Board joins the team.

What'd you find?

The debris trail runs nearly
two kilometres. Fan pattern.

Typically, on impact,
as the airplane hits the ground,

all of a sudden pieces will
start coming apart.

The biggest pieces will keep
going straight.

The other pieces will start
fanning out. They'll spread.

They had to impact
at a relatively shallow angle

to make that pattern.

But as investigators
continue to analyze
the crash site,

they learn that critical
evidence has been destroyed.

Not much left
of the Flight Data Recorder.

One of the major
tools in a modern aircraft

accident investigation
is the flight data recorder.

More modern ones can record
thousands of parametres:

angle of attack, airspeed,
engine parametres.

The lack of a flight data
recorder during an investigation
is a major blow.

Police say some of the cargo
has been stolen

from the crash site.

In the chaos,
some of the local residents

decided to help themselves
to some of the cargo.

This creates a situation where
investigators might not find

critical parts that they need
to solve the accident.

Has anyone found the Cockpit
Voice Recorder?

Hopefully that wasn't
stolen too.

If you don't have a flight data
recorder and you don't have

a cockpit voice recorder,
you really have to go
back to the basics

to try to figure out
what happened.

Investigators start
by examining "impact scars"

left by the engines
to determine at what attitude

the plane struck the ground.

The ground slopes 30 degrees
down from the horizontal.

Slope is the same
for the other ground scar.

And wings were level.

The aircraft
engines are very heavy.

They'll make their own craters.

So you look at the angle
the engines are in,

that gives you a very good idea
of the pitch angle at impact.

Because those parts are
basically going to try

to just bore a hole
into the dirt.

So the aircraft takes off.

Roughly three minutes later,
it crashes in a dive 30 degrees
nose down, with wings level.

So what caused the dive?

The ground information
tells you

how the airplane went down.

We don't know why it went down.

And that takes
a lot more effort.

We need to test
for explosives.

Get at least a dozen specimens
from the wreckage

and send those samples
to the lab for testing.

Chinese authorities
wonder if an act of terrorism
could have caused the accident.

In any
investigation, anything could
have happened.

And one of those events could
have been sabotage or a bomb.

So it's important
in investigations to rule out

something like that,
as soon as possible.

As police look for
evidence of explosives,

investigators interview
the Air Traffic Controller.

Anyone who talked
to the crew is a witness
to the investigation.

And the controller is the last
person to talk to the crew.

So it was very important to get
his impressions, what he did,

what he's hearing back from
the pilots and understand what
was happening that night.

To start, what stood out
to you about the flight?

Takeoff seemed normal.

But afterwards, the pilots
struggled to maintain
the flight plan.

Turn left direct
to November Hotel Whiskey.

Then climb and maintain
1,500 metres.

They eventually made their turn.
But I had to remind them.

After that?

As they corrected their turn,
I noticed they were still
too low.

So I told them to climb.

Korean Air 6316, climb
and maintain 1,500 metres.

I had to remind them a second
time, before they started
to climb.

I thought they were off safely.

The next thing I knew, the plane
disappeared from radar.

The air traffic
controller sees the aircraft
climbing.

Everything looks normal
and fine,

and then all of a sudden,
things go very wrong.

Korean Air 6316,
do you read?

Korean Air 6316,
radio check.

- Is that the radar data?
- Yes.

It looks like your
communication was by the book.

Thank you.

Looking at the radar
recordings is very important,

especially if you haven't looked
at the cockpit voice recorder
or the FDR.

This gives you an initial
framework to work with.

Can the radar data
provide any clues?

The plane climbs
to 1,371 metres or 4,500 feet.

Roughly 16 seconds later,
it impacts the ground.

That's a descent rate
of roughly...

...17,000 feet per minute.

We have a saying in aviation
called 'the minute to die rule',

which means that if your rate
of descent in feet per minute

is greater than your altitude,
that's a dangerous situation.

Flight 6316's
rate of descent

was more than three times
greater than their altitude.

Pull up.

It's virtually impossible
to recover the aircraft.

What would cause
the plane to descend at such
an incredible speed?

Maybe there was a problem
with the aircraft.

I'll pull the maintenance
records.

During
the initial stages
of the investigation,

the investigators will look
at all of the maintenance
records of the aircraft.

Any write-ups of issues
on handling,

delayed maintenance
for some reason...

anything at all that would give
a clue to what could have
happened here.

Here's something.

Investigators
examine maintenance records

of Korean Air Flight 6316,

looking for clues to explain
why a modern jetliner

plunged from the sky so soon
after takeoff.

On May 25, 1996, the aircraft
experienced a tail strike
at LAX.

The incident required a repair
that took 63 days to complete?

That was
an interesting finding because

if the repairs to the aircraft
from the tail strike

are not done properly, it can
cause that area to detach

in flight and in the process
damage the pitch controls
of the airplane.

And we've seen that before.

In 1978, a Japan
Airlines Boeing 747

suffered a tail strike while
landing at Osaka.

A faulty repair led
to an explosive decompression

seven years later, tearing off
the tail and killing 520 people.

If that's what happened here,
that could explain everything.

Did poor maintenance
cause the plane's tail to break
apart mid-flight?

Well, here's the vertical
stabilizer.

Investigators find
pieces of Korean Air Flight
6316's tail section

in the wreckage.

With all the pieces
of the tail this close to the
main crash site,

it didn't separate in-flight.

So the repair was done
correctly.

They conclude a tail
strike did not cause

any part of the MD-11's tail
to detach from the plane.

Maybe the dive was caused
by a failure

in one of the plane's control
surfaces.

Like the horizontal
stabilizer.

The horizontal
stabilizer is the small wing

on the tail that controls
the pitch of the aircraft.

Maybe the jackscrew jammed?

When commanded,
a jackscrew in the tail rotates,

moving the horizontal stabilizer
up or down.

If the jackscrew has jammed
in a nose down position,

now the airplane would suddenly
pitch over

and the flight crew would be
fighting to try

to get the nose up.

- Pitch.
- O-oh-okay. Okay.

But they would
have a lot of forces

on the control column, trying
to fight the aircraft from
pitching down towards the earth.

Was the horizontal
stabilizer jammed

in a nose-down position, causing
the plane to plummet?

Well, the jackscrew
isn't jammed.

So the stabilizer
was working as intended.

And what position
is it in?

10.25 inches.

So it was set to .65 degrees,
nose-up.

The pilots were fighting
against the dive...

Nose up, nose up, nose up.

...trimming
the horizontal stabilizer

nose up while pulling back
on the controls

to try to arrest the descent.

Terrain, terrain.

Chemical analysis report
is in from the wreckage.

No evidence of explosives.

I'll start typing this up
for the press.

We need to reassure the public
it's safe to fly in China.

Sounds good.

The Civil Aviation
Administration of China

along with its U-S and Korean
counterparts release a bulletin

almost two weeks after
the incident.

The Chinese
investigation want to make two
things clear.

One, it's not a bomb.

Two, it's not a fault
from the Chinese ATC controller.

With terrorism,
air traffic control and poor
maintenance discounted,

investigators now focus
their attention to the pilots.

Let's start with the Captain.

In all
accidents, one of the tasks

is investigating the background
of the pilots

to ensure that there's
no issues.

V-1. Rotate.

Rotate.

Training can make a very
big difference.

And also, things going
on in their personal life.

We want to make sure that
the person wasn't under

any particular stressors
that could cause distractions

and inhibit their performance
in any way.

Captain Hong
was quite seasoned.

Almost 13,000 flight hours, with
nearly 5,000 on the MD-11 alone.

No psychological burdens and
a perfect safety record.

Yeah. First Officer Park,
over 1,800 hours, majority
on the MD-11.

No psychological burdens and
also a perfect safety record.

- Two model pilots.
- Yeah.

Yes. Is it intact?

They found the Cockpit Voice
Recorder.

After the accident,
there was very heavy rain
in the Shanghai area.

So they pumped out some water
from some of the ponds

that were left
and they found the CVR.

Memory is
safe. Full data recovery.

Excellent work. And thank you.

They're going to get
the transcripts ready for us.

At this point
in the investigation, we're
wondering what caused

a mechanically sound airplane
piloted by two well-trained,

experienced pilots, to suddenly
dive into the ground.

And that becomes the mystery.

Okay. Let's start with
an aerodynamic stall

from 1,371 metres.

Using a Boeing
simulator in California...

We'll see what rate
of descent we get.

...investigators
combine radar data with evidence

from the wreckage of Korean Air
Flight 6316 to determine

why the plane plummeted
to the ground.

In the simulator,
the investigators accomplished

over a hundred different
scenarios. Trial and error.

How do we match the data points?

Pull up.

Rate of descent was 3,314 feet
per minute,

not even close to 17,000.
It couldn't have been a stall.

And so, they take
all this information

and in the simulator try
to determine what's the best fit
for the data.

And you start eliminating
things.

Let's try Out of Control
Elevators.

The accident plane impacted
nose down

at an estimated
20 to 40 degrees.

The pitch is way too sharp.

Let's try to pull up anyway
for accuracy.

Through all the simulator
runs they did...

Pull up.

86 degrees.

Okay, it was not Out of Control
Elevators either.

...they found
that you could not match

the rate of descent and
the profile you needed to match

the data with an aerodynamic
stall or a mechanical failure.

Try intentionally pushing
the plane into a dive...

Push your nose down.

Let vertical speed increase.

Then trim the horizontal
stabilizer up,

then try to pull out of it.

Start the dive in three,
two, one, go.

Stabilizer in motion. Pull up.

Only one simulation
precisely replicates the data
from Flight 6316.

Dive time, 18 seconds.

25 degrees nose down.

Maxed out rate of descent.

That's the closest
we've been yet.

Investigators
conclude that the plane

must have been put into a nose
dive intentionally.

The data showed
that the upset was caused
by a pilot input.

And so now the focus becomes on,
why would the pilot do this?

Knowing that the
crash of Flight 6316

could have resulted only
from deliberate pilot input,

investigators listen to the CVR
to determine why the pilots

commanded the airplane
into a steep dive.

Okay. Let's have a listen.

Captain,
can you release the parking
brake?

Okay, brake released.

Wow. Something's not right.

Why is that brake temperature
light on?

Is the high brake
temperature somehow connected
to the nosedive?

Yeah,
when we landed, that brake temp
showed up.

But soon after...

It's dropping down now.

So the brake was a non-factor.

Agreed. Let's keep going.

Flight 6316,
copy ATC clearance.

Go ahead, Korean Air 6316.

Korean Air 6316,
after departure turn left

direct to November
Hotel Whiskey.

Initially climb and
maintain 900 metres.

Read back please.

Okay, sir, initially maintain
900 metres, then after takeoff,

left turn direct to November
Hotel Whiskey. Is that correct?

That's affirmative.

- Did he say 900 metres?
- Yeah, 900 feet.

Did you catch that?

After the controller read
the altitude clearance.

Investigators hear
that there's some confusion

about altitude measurements.

Yeah, why are they using
metric at all?

Imperial is airspace standard.

Not in China.

Most of this world, including
South Korea, measure altitude
in feet.

The Chinese aviation industry
is based on the old Soviet Union
aviation industry.

The USSR used the Metric system,
so today China still uses
the Metric system.

Okay. But I imagine
the Captain will sort that out

in the takeoff briefing.

Let's find out.

Korean Air
6316...

...clear for takeoff.

Clear for take off 6316.

Confirming, we're clear
for takeoff.

Wait...

Did the Captain skip his takeoff
briefing?

I'm not seeing one in here.

A takeoff
briefing is a way to create

what we call "a shared mental
model," where both pilots

are on the same page.

Otherwise you're simply
not prepared for the flight.

The briefing would
have also noted that Shanghai
uses metric altitudes.

So did skipping the briefing

somehow play a role
in the nose dive?

Investigators
revisit the CVR

searching for evidence that
the omission

of a critical briefing
contributed to the crash
of Flight 6316.

Let's start with the initial
climb.

Turn left direct
to November Hotel Whiskey,

then climb and maintain
1,500 metres.

The team hears
the controller giving the pilots

their climb out instructions...

I don't see NHW.

Where is it?

...but the Captain
can't find the navigation beacon
on his display.

It sounds like an issue
with the Captain's NAV display.

Uh... here. Keep turning left.

The recording
suggests the First Officer's

navigation display
was functioning properly.

- Keep turning
- Keep turning?

Yes, keep turning more.

Damn.
Why isn't NHW showing?

The CVR portrays
a captain who appears confused.

I bet he zoomed in too far
on the NAV display.

That's why he can't see
the beacon.

Had the pilot
reached up and changed
the range on his display,

he would have had that available
to him.

That would explain why it took
them so long to turn left.

Had they done the takeoff
briefing, they could have caught
the issue.

Had they discussed completely
in the preflight briefing,

here's where we're going, and
cross-checked their displays

that would have been caught.
And it wasn't.

It still doesn't explain
the dive, though.

Korean Air 6316...

climb and maintain 1,500 metres.

Are they asking us to--

Yes, they're telling us
to climb.

It seems like they're
so preoccupied getting the plane

to turn left they forgot
to climb.

Especially since
the controller told them twice.

Then investigators
hear a warning telling
the pilots

that they're approaching
their target altitude...

Altitude.

Uh, pitch, sir.

...the First Officer
points out that they're climbing
too quickly.

Why is he climbing so quickly?

His mistakes are adding up.

He's trying to overcompensate
to get to his altitude.

He's pitching up too fast.

He's doing things too quickly.

Was the nosedive just another
mistake?

How far are
they telling us to climb?

He still doesn't know
his altitude clearance.

It doesn't look like the First
Officer knows either.

Fif...1,500 feet, sir.

Fif...

They're talking in terms
of feet,

even though the controller's
instructions were in metres.

Investigators now
realize the controller

and the pilots are using
different altitude measurements.

Weren't they trained to use
metric?

Should be, but let's check.

Certainly the
more training you have

that would have helped greatly
in terms of sorting out

the metres versus feet.

I see.
Thank you for your time.

They look deeper
into the training procedures
for Korean Air pilots.

Korean Air says the Seoul
to Shanghai route

is the only one where
their pilots need to use metric.

What kind of training did
they have?

They require their pilots
to watch a single training video

to learn metric conversion.

According to the pilot
records,

the Captain had only flown
into Shanghai once prior.

The First Officer had never
flown there before.

Which means the First Officer
would have watched

the training video for the first
time only that morning.

Investigators
conclude that the pilots

of Flight 6316 confused metric
and imperial...

Fif... teen.

...because
they were inadequately prepared
for the flight.

For the pilots
to operate in a metric
environment,

this is something that you need
to get into a simulator,

and you need practise it.

Watching a video is just
not going to be enough, period.

So was the metric confusion
the reason why they pushed

the plane into a nosedive?

How... How far did
they tell us to climb?

As the flight
reaches its assigned altitude

of 4,500 feet,
or 1,500 metres...

Fif...1,500 feet, sir.

Fif...

...the First
Officer leads the Captain

to believe they should be much
lower, at 1,500 feet.

The Captain,
thinking that they have blown
through their clearance,

would be extremely alarmed,
because now,

there is a very strong potential
for a traffic conflict.

Fifteen...
I'm too high.

Descend... descend... descend.

The quickest response is to
push forward on the controls.

- Wait. Wait, wait, wait...
- Just a moment.

The Captain pushes
the plane into a steep dive

to descend to a much lower
altitude.

You can hear the Captain trim
the plane down.

He put them in the dive.

He pitches
the aircraft nose down,

and simultaneously is trimming
the horizontal stabilizer,

which relieves the control
column pressure.

But the combination of these
things put the aircraft

into a dive from which
it's almost impossible
to recover.

During descent,
the First Officer suddenly

recognises the seriousness
of their situation.

Wait, wait. Pitch

O-oh-okay. Okay.

But by the time
the pilots realize the danger...

Nose up,
nose up, nose up.

Pull up.

...it's too late.

Investigators
conclude that the crash

was caused by the Captain's
confusion over his altitude
measurement.

Even if the Captain thought
he was too high,

why not descend more gradually?

Wait, wait, wait, wait.

First, he climbed too quickly,

then he descended way
too quickly.

Investigators try
to determine why the Captain

of Korean Air Flight 6316
reacted so drastically

to his belief that the aircraft
was too high?

Maybe he was trying to cover
up his mistakes?

On one hand,
the Captain knows

it is dangerous when they're
overshooting the altitude.

How far did they tell us
to climb?

On the other hand,
the Captain doesn't want

the controller to know that
he made a mistake.

So he tried to get down quickly
to save face.

What I don't understand is,

why didn't the First Officer try
to stop him?

Especially since he was
guiding him earlier.

There's a lot going on,
and the First Officer

is not only trying to read back
the clearances

but also trying to ensure
that the Captain is turning

in the direction that needs
to be turned.

Keep turning.

- Keep turning?
- Yes. Keep turning more.

I've got the CVR all set
for the moment before the dive.

Did the First
Officer ever recognize
the error?

How far
did they tell us to climb?

Fif... 1,500 feet, sir.

Uh... oh.

Wait. Wait, wait, wait.

Investigators hear
the First Officer hesitate

after providing the Captain
with the wrong altitude.

Maybe at that point the First
Officer recognized his mistake

was feet and metres,
we don't know.

Just-just a moment.

- Wait, pitch.
- O-oh-okay. Okay.

So the dive starts and
he says: "Wait, wait, wait".

Then after five full seconds
of free fall, he says:
"Wait, pitch".

Clearly, there should have
been some input,

some effort from the First
Officer to try to slow
things down.

In my opinion,
the First Officer was speaking

but he wasn't speaking up.

Wait. Wait, wait, wait.

Just-just a moment.

He gave little
hints that things were going
wrong to the Captain,

but it was apparent that
the pilots were not
on the same page.

At the end of the day,
the Captain caused the dive.

He overreacted.

The rate of descent was
so high,

that now it became very
difficult to recover

once you got down to the lower
altitudes.

And probably, they didn't
realize the trouble they were in

until they could see breaks
in the clouds and see
the ground.

Terrain,
terrain.

Nose up, nose up, nose up.

Pull up...
Pull up.

In their final
report, investigators conclude
that confusion

over the metric system led
the First Officer

to relay the wrong altitude.

How far did they tell us
to climb?

Fif... 1,500 hundred feet, sir.

That mistake caused
the Captain to overcompensate...

Wait. Wait, wait.

Just-just one moment.

...and push
the aircraft into a fatal dive.

We can look at this
as a training accident,

as much as anything else.

The way the pilots were trained
at that time resulted

in a series of decisions and
actions that put the airplane

in an unrecoverable situation.

In Chinese aviation
industry, we have a motto:

Every line in the checklist
is written in blood.

Because behind every line
in the checklist is a disaster,

but it's an opportunity
to improve.

One of the recommendations was
that Korean Air reinforce

its cockpit resource management
training.

It's part of the fabric that
holds a safe flight together.

And that includes things like
a pre-takeoff briefing.

So these are some of the items
that, in my mind, were most
important.

Today, Korean Air
is recognized

as one of the safest airlines
in the world.

The amount of standardization
through all the airlines,

the amount of training now
is a much higher level than it
was before.

The digital airplanes,
there's a button you can turn,

and all your display shows
metres instead of feet.

But it does bring up the need
for vigilance.

This crew made so many errors.

Losing control of a big airplane
is very unusual.

And hopefully,
we won't see it again.

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