S2/2000 - Boeing 747-2B5F, HL-7451

S2/2000 - Boeing 747-2B5F, HL-7451 AAIB Special Bulletin No: S2/2000 Aircraft Type and Registration: Boeing 747-2B5F, HL-7451 No & Type of Engines: 4 Pratt and Whitney JT9D-7Q turbofan engines Year of Manufacture: 1980 Date & Time (UTC): 22 December 1999 at 1838 hrs Location: Hatfield Forest (N 51· 51.385' E 000· 12.988'); 1.9 nm on a bearing of 204· (M) from the centre point of Runway 23/05 at Stansted Airport Type of Flight: Public Transport (Cargo) Persons on Board: Crew - 4 - Passengers - None Injuries: Crew - 4 Fatal - Passengers - N/A (1 crew member was operator's ground engineer) Nature of Damage: Aircraft destroyed Commander's Licence: Airline Transport Pilot's Licence (Republic of Korea) Commander's Age: 57 years Commander's Flying Experience: 13,490 hours (approximately 8,495 hours were on type) Last 90 days - 208 hours Last 28 days - 56 hours Information Source: AAIB Inspector's Investigation History of flight The aircraft arrived at Stansted Airport at 1505 hrs on 22 December 1999, 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 commander'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. The inbound flight crew then left the aircraft without meeting the outbound crew who were due to operate HL-7451 to Milan (Malpensa) Airport later that day. During the turnround, some cargo was offloaded and other cargo, which had been transported by road from London, was loaded. The total cargo on board for the sector to Milan was 140,452 lb. The loading was almost complete when the outbound crew arrived; this crew comprised the commander who was to be the handling pilot, the first officer and flight engineer. The dispatcher went to the cockpit to meet the outbound crew and gave them the navigation logs and weather information for their flight. Prior to engine start, the commander accompanied the load controller through the aircraft to check the security of the cargo, and then checked the loadsheet before signing it and leaving a copy with the load controller. The load sheet copy indicated that the aircraft weight for take-off was 548,352 lb; this included 68,300 lb of fuel. The ground engineer who had met the aircraft on arrival at Stansted boarded the aircraft for the flight to Milan. At 1727 hrs, the crew called 'Stansted Delivery' on frequency 125.55 MHz for their flight clearance; however, this frequency is only manned when a high number of airport movements are planned. After two unsuccessful attempts to contact ATC on the 'Delivery' frequency, the crew contacted 'Stansted Ground' at 1729 hrs on frequency 121.72 MHz to request start and push back clearance from their position at Stand Alpha 6. They were informed by ATC that they had no details for their flight and were requested to standby. Then, at 1733 hrs the crew were informed that no flight plan had been received and that they should contact their handling agents. The agents submitted the flight plan and the crew of HL-7451, callsign KAL 8509, were advised at 1742 hrs that their clearance was to Malpensa with a Dover 6R departure and a transponder setting of 2230; the crew read back their clearance correctly. There was then some delay providing a tug for the aircraft and the crew requested push back clearance at 1813 hrs. However, during the push back the tug experienced problems and was unable to complete the manoeuvre; the result was that HL-7451 was left in a position from which it required marshalling onto the taxyway centre-line. The marshalling vehicle was in position by 1823 hrs and KAL 8509 was cleared to taxy at 1825 hrs to 'Hotel November' (holding point for Runway 23) via 'Hotel Lima'. Shortly after, the 'Ground' controller transferred KAL 8509 to 'Tower' on frequency 123.8 MHz. The crew contacted the 'Tower' at 1835 hrs and were instructed: "After the next landing aircraft on final line up and wait Runway Two Three". Subsequently, at 1836 hrs KAL 8509 was cleared to take-off with a reported surface wind of 190·/18 kt. The Tower controller considered that the take-off was normal and, as the aircraft indicated altitude passed 1,400 feet at 1838 hrs, transferred KAL 8509 to 'London Control' on frequency 118.82 MHz. The air assistant, alongside the controller, also watched the take-off and described it as normal; he also watched the aircraft climbing into cloud. No radio calls were heard from the aircraft subsequent to the frequency transfer instruction from 'Stansted Tower'. The ATC personnel in the Tower then saw an explosion to the south of the airport and realised that KAL 8509 had crashed; they immediately implemented their emergency actions. The Aerodrome Fire Service recorded receipt of the alerting action from ATC at 1840 hrs and dispatched all available vehicles and crews to the reported accident position. Other witnesses heard and saw the aircraft impact the ground. Some reported feeling the shock waves and others reported seeing the aircraft flying much lower than normal. One eyewitness, close to the impact location, reported two fireballs either just before or just after the aircraft crashed. The second fireball was intense and reported as 'Mushroom' shaped. Essex police recorded the first emergency call at 1843 hrs and initiated their emergency response. Weather Subsequent to the accident, the Meteorological Office at Bracknell provided an aftercast of the weather situation at 1830 hrs on 22 December 1999. The synoptic situation showed a strong, mild and very moist southwesterly airstream over the area. A Warm Front was lying just to the west of Stansted Airport, moving quickly eastwards. A strong wind warning was in force at the time of the accident. The METARs (Meteorological Actual Reports) for Stansted were as follows: 1820 hrs: Surface wind of 190·/16 kt; visibility of 3,100 metres in mist; cloud few at 400 feet agl and scattered at 500 feet agl; temperature 10·C/ dew point 9· C; QNH 1008 hpa. 1850 hrs: Surface wind of 190·/17 kt; visibility of 4,200 metres in mist; cloud scattered 500 feet agl, scattered at 600 feet agl and broken at 900 feet agl; temperature 10· C/ dew point 9· C; QNH 1008 hpa. On the initial call to ATC, the crew of KAL 8509 reported that they had received ATIS information 'Mike' (timed at 1650 hrs). The reported surface wind was 180·/17 kt; visibility 5,000 metres; cloud scattered at 500 feet agl and broken at 700 feet agl; temperature 9·C/ dew point 8·C; QNH 1008 hpa. Other flight crews, who were in the area close to the time of the accident, were contacted to confirm the weather conditions. All stated that the weather was as reported, but some pilots in medium sized aircraft experienced turbulence. Wreckage investigation Shortly after the crash, reports were received that debris had been found on the airfield in the vicinity of the runway. An initial search of the runway that evening, and a more comprehensive search of the surrounding areas at first light, revealed many pieces of lightweight material. Examination of the crash site revealed that the impact had resulted in a large fireball capable of carrying many items aloft; when airborne, these items would have been carried back to the north and onto the airfield by the strong Southerly wind. The Cockpit Voice Recorder (CVR) was found on the evening of the accident just beyond the impact crater. Examination of the initial impact area and wreckage trail indicated that the aircraft had crashed on a track of approximately 105· M, close to but fortunately clear of some local houses. On impact, the aircraft was assessed to be pitched approximately 40· nose down and banked close to 90·

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S2/2000 - Boeing 747-2B5F, HL-7451

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