Investigation Summary
The accident occurred during a winter morning departure. As the Fokker F28 rotated and began its climb, it experienced a sudden roll to the left. The South Korean Ministry of Transportation and Boeing reached differing conclusions regarding the primary sequence of events. The Ministry focused on the captain's flight technique, noting a climb angle of 15 degrees, which exceeded the standard 10 degrees, and argued that the pilot's sharp corrective inputs to the right exacerbated the loss of control. Conversely, Boeing's 1993 analysis emphasized wing icing as the catalyst, suggesting that ice ingestion caused the number 1 engine to fail and disrupted airflow over the wings. Boeing's interest in the case stemmed from the Fokker F28's known vulnerability to aerodynamic degradation from even small amounts of ice, a factor that was also central to the investigations of Air Ontario Flight 1363 and USAir Flight 405. The evacuation was hampered when an emergency exit door failed to open, forcing passengers to break it open manually to escape the burning wreckage.
Final Conclusions
The South Korean Ministry of Transportation concluded the primary cause was pilot error, specifically an excessive pitch angle during takeoff and improper handling of the subsequent emergency. Following the investigation, the captain's pilot license was permanently revoked and he was arrested. However, a 1993 Boeing report identified wing icing as the primary cause, noting that the Fokker F28 was particularly susceptible to aerodynamic degradation from ice, a factor also seen in the Air Ontario 1363 and US Air 405 accidents.
Video Analysis
No video analysis linked for this case file yet.
Systems & Failure Modes
Wing De-icing System
The investigation found the aircraft had not been properly de-iced prior to takeoff, leading to ice ingestion in the number 1 engine and aerodynamic stall.
Emergency Exits
One emergency exit door failed to open during the fire, forcing passengers to manually break the door to escape.
Interesting Facts
- 01The aircraft was a Fokker F28 Fellowship 4000 manufactured in 1985.
- 02The Ministry of Transportation cited a 15-degree climb angle as a major contributing factor.
- 03Boeing's 1993 report argued that wing icing was the primary cause of the engine failure and roll.
- 04The aircraft was completely destroyed by the impact and subsequent fire.
- 05The captain's pilot qualification was permanently revoked following the Ministry's findings.
- 06While official reports and the Plane Crash Wiki record 1 fatality (a passenger who died 12 days later), some databases like Wikipedia list 0 fatalities as the death occurred post-accident.
Safety Actions & Advisories
De-icing Procedure Revision
Enhanced aircraft de-icing procedures were implemented for winter operations in South Korea.
Pilot Training Enhancement
Improved pilot training for emergency response during the critical takeoff phase was mandated.
Emergency Exit Standards
Revised standards for emergency exit accessibility and maintenance were introduced following the door failure.
Known Controversies & Unanswered Questions
Conflicting Investigative Findings
Reference ↗The South Korean Ministry of Transportation blamed pilot error (excessive pitch and poor response), while Boeing's 1993 report attributed the crash to wing icing and engine failure, a known vulnerability of the F28.