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RTATIONSAFETYBOARDWASHINGTON, D.C. 20594AIRCRAFT ACCIDENT REPORTCONTROLLED FLIGHT INTO TERRAINKOREAN AIR FLIGHT 801BOEING 747-300, HL7468NIMITZ HILL, GUAMAUGUST 6, 19976952B‘I
National Transportation Safety Board. 2000. Controlled Flight Into Terrain, Korean Air Flight 801, Boeing747-300, HL7468, Nimitz Hill, Guam, August 6, 1997. Aircraft Accident Report NTSB/AAR-00/01.Washington, DC.Abstract: This report explains the accident involving Korean Air flight 801, a Boeing 747-300, whichcrashed into high terrain at Nimitz Hill, Guam, on August 6, 1997. Safety issues in the report focus onflight crew performance, approach procedures, and pilot training; air traffic control, including controllerperformance and the inhibition of the minimum safe altitude warning system at Guam; emergencyresponse; the adequacy of Korean Civil Aviation Bureau and Federal Aviation Administration oversight;and flight data recorder documentation. Safety recommendations concerning these issues are addressed tothe Federal Aviation Administration, the Governor of the Territory of Guam, and the Korean CivilAviation Bureau.The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, raiload,highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congressthrough the Independent Safety Board Act of 1974 to investigate transportation accidents, study transportation safetyissues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Boardmakes public its actions and decisions through accident reports, safety studies, special investigation reports, safetyrecommendations, and statistical reviews.Recent publications are available in their entirety at http://www.ntsb.gov . Other information about availablepublications may also be obtained from the Web site or by contacting:National Transportation Safety BoardPublic Inquiries Section, RE-51490 L’Enfant Plaza, East, S.W.Washington, D.C. 20594(800) 877-6799 or (202) 314-6551Safety Board publications may be purchased, by individual copy or by subscription, from the National TechnicalInformation Service. To purchase this publication, order report number PB00-910401 from:National Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(800) 553-6847 or (703) 605-6000
Aircraft Accident ReportControlled Flight Into TerrainKorean Air Flight 801Boeing 747-300, HL7468Nimitz Hill, GuamAugust 6, 1997NTSB/AAR-00/01PB00-910401Notation 6952BAdopted January 13, 2000National Transportation Safety Board490 L’Enfant Plaza, S.W.Washington, D.C. 20594
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iiiAircraft Accident ReportContentsAbbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viiiExecutive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Injuries to Persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.5 Personnel Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.5.2 The First Officer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.5.3 The Flight Engineer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.5.4 The Flight Attendants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.5.5 The Air Traffic Controllers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.5.5.1 Combined Center/Radar Approach Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.5.5.2 Air Traffic Control Tower . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.6.1 Maintenance Discrepancies Before the Accident Flight . . . . . . . . . . . . . . . . . . . . . 141.6.2 Cockpit Instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.6.2.1 Autopilot System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.6.2.2 Ground Proximity Warning System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.6.2.3 Instrument Landing System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.6.3 Weight and Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201.7.1 Weather Conditions at Guam International Airport. . . . . . . . . . . . . . . . . . . . . . . . . 201.7.2 Air Traffic Control Weather Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211.7.3 Additional Weather Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251.10 Airport Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251.10.1 Air Traffic Control Services for Guam International Airport . . . . . . . . . . . . . . . . . 251.10.1.1 Combined Center/Radar Approach Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251.10.1.2 Minimum Safe Altitude Warning System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281.10.1.3 Air Traffic Control Tower . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301.10.2 Instrument Landing System Ground-Based Equipment. . . . . . . . . . . . . . . . . . . . . . 311.10.3 Instrument Approach Procedures at Guam International Airport . . . . . . . . . . . . . . 321.10.3.1 The Nonprecision Runway 6L Instrument Landing SystemLocalizer-only (Glideslope Out) Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331.10.3.2 Instrument Approach Charts for Guam International Airport . . . . . . . . . . . . . . . 331.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341.11.1 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341.11.2 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
ContentsivAircraft Accident Report1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371.12.1 General Wreckage Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371.12.2 Fuselage and Empennage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391.12.3 Wings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411.12.4 Engines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431.15.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431.15.2 Survivor Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451.15.3 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451.15.3.1 Emergency Response Planning and Exercises. . . . . . . . . . . . . . . . . . . . . . . . . . . 481.15.4 Guam Governor’s Accident Response Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491.16.1 Enhanced Ground Proximity Warning System Simulation . . . . . . . . . . . . . . . . . . . 491.16.2 Minimum Safe Altitude Warning System Simulation . . . . . . . . . . . . . . . . . . . . . . . 501.16.3 Korean Air Spurious Radio Signal Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501.16.3.1 Guam Instrument Landing System and Potential InterferenceFrom Spurious Radio Signals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 521.17.1 Korean Air Postaccident Safety Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531.17.2 Korean Air Flight Crew Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561.17.2.1 Basic and Advanced Instrument Flight Course . . . . . . . . . . . . . . . . . . . . . . . . . . 561.17.2.2 Boeing 747 Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571.17.2.3 Crew Resource Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 581.17.2.4 Postaccident Changes to Flight Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 591.17.3 Korean Air Preflight Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 601.17.3.1 Supervisor of Flying Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611.17.3.2 Airport Familiarization Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611.17.4 Korean Air Descent and Approach Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621.17.4.1 Briefing and Checklist Usage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 621.17.4.2 Flight Crew Actions and Callouts During Nonprecision Approaches. . . . . . . . . 641.17.4.3 Terrain Avoidance Recovery Maneuvers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681.17.5 Korean Air Accident and Incident History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681.17.5.1 1983 to 1997 Accident History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 701.17.5.2 1998 and 1999 Accident and Incident History . . . . . . . . . . . . . . . . . . . . . . . . . . 711.17.6 Oversight of Korean Air. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721.17.6.1 Korean Civil Aviation Bureau . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721.17.6.1.1 Accident and Incident Investigation Authority . . . . . . . . . . . . . . . . . . . . . . . 731.17.6.2 Federal Aviation Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 741.17.6.2.1 International Aviation Safety Assessment Program . . . . . . . . . . . . . . . . . . . 751.17.6.3 Department of Transportation Audit Report on Aviation SafetyUnder International Code Share Agreements . . . . . . . . . . . . . . . . . . . . . . . . . . . 781.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811.18.1 Minimum Safe Altitude Warning System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 811.18.1.1 Postaccident Actions Taken by the Federal Aviation Administration. . . . . . . . . 811.18.1.2 Previous Safety Board Recommendations on theMinimum Safe Altitude Warning System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 831.18.2 Traditional and Enhanced Ground Proximity Warning Systems . . . . . . . . . . . . . . . 931.18.2.1 Traditional Ground Proximity Warning System . . . . . . . . . . . . . . . . . . . . . . . . . 93
ContentsvAircraft Accident Report1.18.2.2 Enhanced Ground Proximity Warning System . . . . . . . . . . . . . . . . . . . . . . . . . . 941.18.2.2.1 Notice of Proposed Rulemaking for Enhanced GroundProximity Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 941.18.2.3 Department of Transportation Studies on Traditional andEnhanced Ground Proximity Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . 951.18.2.4 Previous Safety Board Recommendations on Traditional andEnhanced Ground Proximity Warning Systems . . . . . . . . . . . . . . . . . . . . . . . . . 961.18.3 Controlled Flight Into Terrain Accident Information . . . . . . . . . . . . . . . . . . . . . . 1031.18.3.1 Flight Safety Foundation Study ofControlled Flight Into Terrain Accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1031.18.3.2 Factors Involved in Recent Controlled FlightInto Terrain Accidents and Incidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1051.18.3.3 Controlled Flight Into Terrain Training Aids . . . . . . . . . . . . . . . . . . . . . . . . . . 1071.18.3.4 Previous Safety Board Recommendations Related toControlled Flight Into Terrain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1081.18.3.5 Previous Controlled Flight Into Terrain Accidents Related toNonprecision Instrument Approach Procedures . . . . . . . . . . . . . . . . . . . . . . . . 1131.18.4 Industry Actions to Improve the Safety of NonprecisionInstrument Approaches Conducted by Air Carriers. . . . . . . . . . . . . . . . . . . . . . . . 1141.18.4.1 Nonprecision Approach Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1141.18.4.2 Approach Chart Terrain Depiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1151.18.4.3 Federal Aviation Administration Form 8260. . . . . . . . . . . . . . . . . . . . . . . . . . . 1161.18.4.4 Previous Safety Board Recommendations Related toApproach Procedure Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161.18.5 Flight Crew Decision-making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1201.18.5.1 Safety Board Study of Flight Crew Involvement in Major Accidents. . . . . . . . 1201.18.5.2 Previous Safety Recommendations on Flight Crew Decision-making . . . . . . . 1221.18.5.3 National Aeronautics and Space Administration’sFlight Crew Decision-making Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1241.18.6 Previous Fatigue-Related Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1261.18.6.1 Previous Safety Recommendations Regarding Fatigue . . . . . . . . . . . . . . . . . . . 1281.18.7 Flight Data Recorder Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291.18.7.1 Previous Safety Board Recommendations on Flight Data RecorderParameter Verification and Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291.18.7.1.1 Digital Flight Data Recorder Advisory Circular . . . . . . . . . . . . . . . . . . . . . 1321.18.7.2 International Guidance Regarding the Documentation ofFlight Data Recorder Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1321.18.8 Special Airport Criteria and Designation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1332. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1352.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1352.2 Weather Factors on the Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1352.3 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1362.3.1 Description of the Approach and Required Flight Crew Procedures. . . . . . . . . . . 1362.3.2 Flight 801’s Premature Descent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1372.4 Flight Crew Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1382.4.1 The Captain’s Performance of the Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1382.4.1.1 Approach Briefing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
ContentsviAircraft Accident Report2.4.1.2Expectation of a Visual Approach and Role of the GuamAirport Familiarization Video . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1402.4.1.3 Possible Explanations for the Approach Conducted . . . . . . . . . . . . . . . . . . . . . 1422.4.1.3.1 Confusion About Status of Glideslope . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1422.4.1.3.2 Confusion About Location of DME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1442.4.1.4 Summary of Captain’s Performance on the Approach . . . . . . . . . . . . . . . . . . . 1452.4.2 Flight Crew Monitoring of the Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1452.4.3 Flight Crew Fatigue Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1482.5 Pilot Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1502.6 Air Traffic Control Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1522.6.1 Controller Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1522.6.2 Intentional Inhibition of the Minimum Safe AltitudeWarning System at Guam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1542.7 Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1572.8 Controlled Flight Into Terrain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1592.8.1 Constant Angle of Descent Nonprecision Approaches . . . . . . . . . . . . . . . . . . . . . 1612.8.2 Safety Aspects of Enhanced Ground Proximity Warning Systems . . . . . . . . . . . . 1622.8.3 Terrain Depiction on Approach Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1632.8.4 User Review of Instrument Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1642.9 Oversight Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1652.9.1 Korean Air . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1652.9.2 Korean Civil Aviation Bureau Oversight of Korean Air . . . . . . . . . . . . . . . . . . . . 1662.9.3 Federal Aviation Administration Oversight of Korean Airand Assessment of Korean Civil Aviation Bureau. . . . . . . . . . . . . . . . . . . . . . . . . 1672.9.3.1 Independent Accident Investigation Authority . . . . . . . . . . . . . . . . . . . . . . . . . 1692.10 Flight Data Recorder Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1703. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1723.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1723.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1754. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1765. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179A: Investigation and Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179B: Cockpit Voice Recorder Transcript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180C: Flight Safety Foundation Study Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
ContentsviiAircraft Accident ReportFigures1. Instrument approach chart for the Guam International Airportrunway 6L ILS procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62. Side view of FAA radar data with selected ATCand CVR communication excerpts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73. Overhead view of FAA radar data with selected ATCand CVR communication excerpts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84. Captain’s instrumentation panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165. First officer’s instrumentation panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176. WSR-88D four-panel base reflectivity product for Guam. . . . . . . . . . . . . . . . . . . . . . . . . . . 227. The January 19, 1996, 11-1 ILS runway 6L instrument approach chart. . . . . . . . . . . . . . . . 358a. Wreckage from Korean Air flight 801 in relation toGuam International Airport runway 6L, the NIMITZ VOR, and Apra Harbor. . . . . . . . . . . 388b. Closer view of the wreckage from Korean Air flight 801 and the NIMITZ VOR. . . . . . . . 399. Korean Air flight 801 cabin configuration and survivor seat locations. . . . . . . . . . . . . . . . . 4410. Vertical profile information from the 40 CFIT accidentsand incidents between 1986 and 1990. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Tables1. Injury chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92. Information differences between the January 19 and August 2, 1996,Guam ILS runway 6L approach charts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363. Loss totals and rates for the 10-year period ending December 31, 1998,by losses per 1 million departures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694. Distribution of errors identified in the 37 accidents reviewedin the Safety Board’s 1994 safety study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
viiiAircraft Accident SASRATCATCTATISATPadvisory circularautomatic direction finderattitude director indicatorAir Force Baseabove ground levelAccident Investigation Groupapproach and landing accidentAir Line Pilots Associationaircraft rescue and firefightingAutomated Radar Terminal SystemAirport Surveillance Radarair traffic controlair traffic control towerautomatic terminal information serviceairline transport pilotCAACAMICDICERAPCFITCFRCRMCVRcivil aviation authorityCivil Aeromedical Institutecourse deviation indicatorCombined Center/Radar Approach Controlcontrolled flight into terrainCode of Federal Regulationscrew resource managementcockpit voice recorderD-BRITEDFDRDHDMEDODDOTDOT/IGdigital bright radar indicator tower equipmentdigital flight data recorderdecision heightdistance measuring equipmentDepartment of DefenseDepartment of TransportationDepartment of Transportation Office of Inspector GeneralEARTSEMTEUEn route Automated Radar Tracking Systememergency management technicianEuropean UnionFAAFAFFARFDFDAUFDRF/EFMAFederal Aviation Administrationfinal approach fixFederal Aviation Regulationflight directorflight data acquisition unitflight data recorderflight engineerflight mode annunciator
AbbreviationsixFMSFSFflight management systemFlight Safety FoundationGCDGFDGPSGPWSGSGuam Civil DefenseGuam Fire Departmentglobal positioning systemground proximity warning systemglideslopeHATHgHSIHzheight above touchdownMercuryhorizontal situation indicatorHertzIAFIASAICAOIFRILSIMCIOEinitial approach fixInternational Aviation Safety AssessmentInternational Civil Aviation Organizationinstrument flight rulesinstrument landing systeminstrument meteorological conditionsinitial operational experienceKCABkgKorean Civil Aviation BureaukilogramLOCLOFTlocalizerline-oriented flight trainingMAPMDAMHzMOCTMOUMSAWmslmissed approach pointminimum descent altitudemegahertzMinistry of Construction and Transportmemorandum of understandingminimum safe altitude warningmean sea levelNASANDBnmNOTAMNPRMNWSNational Aeronautics and Space Administrationnondirectional beaconnautical mileNotice to Airmennotice of proposed rulemakingNational Weather ServiceOSCOSTon-scene commanderOffice of the Secretary of TransportationPAPIPFPICPNFPOIprecision approach path indicatorpilot flyingpilot-in-commandpilot not flyingprincipal operations inspectorAircraft Accident Report
AbbreviationsxAircraft Accident ReportSIGMETSOFSOPSTARSTARSSignificant Meteorological Informationsupervisor of flyingstandard operating procedurestandard terminal arrivalsStandard Terminal Automation Replacement tical air control and navigationTransportes Aereos Ejecutivos, S.A.terminal aerodrome forecastterrain awareness and warning systemtraffic alert and collision avoidance systemTerminal Instrument Procedurestop of descentterminal radar approach controltime since awakeningtechnical standard orderUTCcoordinated universal timeVASIVFRVHFVMCVNAVVORvisual approach slope indicatorvisual flight rulesvery high frequencyvisual meteorological conditionsvertical navigationvery high frequency omnidirectional radio rangeWSR-88DWeather Surveillance Radar-1988, Doppler
xiAircraft Accident ReportExecutive SummaryOn August 6, 1997, about 0142:26 Guam local time, Korean Air flight 801, aBoeing 747-3B5B (747-300), Korean registration HL7468, operated by Korean AirCompany, Ltd., crashed at Nimitz Hill, Guam. Flight 801 departed from KimpoInternational Airport, Seoul, Korea, with 2 pilots, 1 flight engineer, 14 flight attendants,and 237 passengers on board. The airplane had been cleared to land on runway 6 Left atA.B. Won Guam International Airport, Agana, Guam, and crashed into high terrain about3 miles southwest of the airport. Of the 254 persons on board, 228 were killed, and23 passengers and 3 flight attendants survived the accident with serious injuries. Theairplane was destroyed by impact forces and a postcrash fire. Flight 801 was operating inU.S. airspace as a regularly scheduled international passenger service flight under theConvention on International Civil Aviation and the provisions of 14 Code of FederalRegulations Part 129 and was on an instrument flight rules flight plan.The National Transportation Safety Board determines that the probable cause ofthe Korean Air flight 801 accident was the captain’s failure to adequately brief andexecute the nonprecision approach and the first officer’s and flight engineer’s failure toeffectively monitor and cross-check the captain’s execution of the approach. Contributingto these failures were the captain’s fatigue and Korean Air’s inadequate flight crewtraining. Contributing to the accident was the Federal Aviation Administration’s (FAA)intentional inhibition of the minimum safe altitude warning system (MSAW) at Guam andthe agency’s failure to adequately manage the system.The safety issues in this report focus on flight crew performance, approachprocedures, and pilot training; air traffic control, including controller performance and theintentional inhibition of the MSAW system at Guam; emergency response; the adequacyof Korean Civil Aviation Bureau (KCAB) and FAA oversight; and flight data recorderdocumentation. Safety recommendations concerning these issues are addressed to theFAA, the Governor of the Territory of Guam, and the KCAB.
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1Aircraft Accident Report1. Factual Information1.1 History of FlightOn August 6, 1997, about 0142:26 Guam local time,1 Korean Air flight 801, aBoeing 747-3B5B (747-300), Korean registration HL7468, operated by Korean AirCompany, Ltd., crashed at Nimitz Hill, Guam.2 Flight 801 departed from KimpoInternational Airport, Seoul, Korea, with 2 pilots, 1 flight engineer, 14 flight attendants,and 237 passengers3 on board. The airplane had been cleared to land on runway 6 Left atA.B. Won Guam Internation
National Transportation Safety Board. 2000. Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468, Nimitz Hill, Guam, August 6, 1997. Aircraft Accident Report NTSB/AAR-00/01. Washington, DC. Abstract: This report explains the accident involving Korean Air flight 801, a Boeing 747-300, which
