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BOEING 747 CRASH CVR COCKPIT VOICE RECORDING CFIT BLACK BOX RECORDING MALAYSIA CRASH

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Published on Sep 8, 2011

On February 19, 1989, a Boeing 747-249F operating as Flying Tiger Flight 66 was flying an international cargo flight from Singapore to Kuala Lumpur, Malaysia. The aircraft impacted terrain 12 miles from the airport, resulting in 4 fatalities.
The aircraft was assigned an non-directional beacon (NDB) approach to Runway 33 at Sultan Abdul Aziz Shah Airport, Kuala Lumpur, after having flown 30 minutes from Singapore Changi Airport.[1] In descent, the flight was cleared to "Kayell" with a morse code of "KL" of which four separate points on the ground were commonly called by Malaysian ATC albeit with different frequencies. Two separate radio beacons were identically coded "KL" as well as the VOR abbreviation (Kuala Lumpur shortened to "KL") and the airport was also sometimes referred to as "KL" by local ATC (instead of the full "Kuala Lumpur"). The crew was unsure to which point they were cleared, and the cockpit voice recorder revealed that the crew argued about which radios should be set to which frequencies and which approach was actually going to be conducted. (Even in the last few moments of the flight, the captain referenced the ILS approach for runway 33 which was notamed as inop on the flight release and the ATIS, additionally the crew was told by ATC that the ILS approach was not available.)
ATC radioed to the flight, "Tiger 66, descend two four zero zero [2,400 ft]. Cleared for NDB approach runway three three." The captain of Tiger 66, who heard "descend to four zero zero" replied with, "Okay, four zero zero" (meaning 400 ft above sea level, which was 2,000 ft too low). The proper radio call from ATC, instead of "descend two four zero zero", should have been "descend and maintain two thousand four hundred feet". The captain read back "okay, four zero zero" where the proper read back should have been "Roger, descend and maintain four-hundred feet". The Cockpit voice recorder[2] also revealed several communication errors made by the flight crew prior to this miscommunication and a revealed general casual nature of the Captain, who was the pilot-not-flying on this particular leg of the trip.
Numerous clear warnings were given by the on-board Ground Proximity Warning System all were ignored entirely by the crew, and the aircraft impacted a hillside 437 ft above sea level, killing all four people on board; two pilots, a flight engineer and an aircraft mechanic. The subsequent fire burned for two days[3].
The First Officer had complained that he did not have an approach plate in front of him and hadn't seen the approach. Additionally, the FO, who was the pilot flying at the time, expressed concern about conducting the NDB approach and indicated a preference for the ILS for runway 15. However, the FO was not assertive and no further action was taken. The Captain dismissed his concern saying he was familiar with the airport and the approaches. The second officer was 70 years old and used a magnifying glass to see.[citation needed] A contributing factor to this accident was the non-ICAO International Civil Aviation Organization phraseology used by Kuala Lumpur air traffic control and the Captain of the aircraft. This breakdown of communication contributed to the crew misinterpreting the instructions given. However, this notorious controlled-flight-into-terrain accident ultimately resulted from a crew failure to adhere to the instrument approach procedure, poor crew resource management and poor situational awareness.[1]
This accident caused the creation of the GPWS escape maneuver which all airlines now use[citation needed]. It further stressed the need for increased awareness and training of crew resource management techniques and standard operating procedures. This accident is used as an example of 'what not to do' by flight training organizations such as FlightSafety International. The FAA video production[4] using the original CVR is still used to study the events and how to improve current techinques. Much of this information is derived from that video.

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