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Safety Recommendation Details

Safety Recommendation A-00-015
Synopsis: On 8/6/97, about 0142:26 Guam local time, Korean Air flight 801, a Boeing 747-3b5b (747-300), Korean registration HL7468, operated by Korean Air Company, Ltd., crashed at Nimitz Hill, Guam. Flight 801 departed from Kimpo International 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 6l at A.B. Won Guam International Airport, Agana, Guam, and crashed into high terrain about 3 miles southwest of the airport. Of the 254 persons on board, 228 were killed, and 23 passengers and 3 flight attendants survived the accident with serious injuries. The airplane was destroyed by impact forces and a postcrash fire. Flight 801 was operating in U.S. airspace as a regularly scheduled international passenger service flight under the convention on international civil aviation and the provisions of 14 code of federal regulations (CFR) part 129 and was on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Include, in nonprecision approach procedures, tabular information that allows pilots to fly a constant angle of descent by cross-referencing the distance from the airport and the barometric altitude.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
Mode: Aviation
Location: NIMITZ HILL, GU, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA97MA058
Accident Reports: Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468
Report #: AAR-00-01
Accident Date: 8/6/1997
Issue Date: 1/27/2000
Date Closed: 5/18/2004
Addressee(s) and Addressee Status: FAA (Closed - Reconsidered)
Keyword(s): Approach: Non-Precision, Procedures

Safety Recommendation History
From: NTSB
Date: 5/18/2004
Response: NMC# 102454: At the December 12, 2003, meeting, the FAA indicated that it opposes the recommended action because of concerns that the added information would make charts, already crowded with information, more difficult to read, particularly in the high workload environment of a nonprecision approach. The FAA also asked the Interagency Coordinating Committee (IACC) to consider the recommended action. The IACC also expressed opposition to the recommendation based on similar concerns about information crowding the charts. The Safety Board believes the FAA's concerns are well founded. Therefore, Safety Recommendation A-00-15 is classified CLOSED -- RECONSIDERED.

From: FAA
Date: 4/22/2003
Response: We nonconcur with RD 538, Distance/Altitude Table on Non-Precision Approaches. RD 538 forwards NTSB Safety Recommendation A-00-15 requesting the publication of final approach course distances cross-referenced with advisory altitudes in a tabular form. Implementation would have an unacceptable workload burden on AVN-100 and an unacceptable impact on the planview area of an IAP chart. Additionally, the Volpe NTSC study attached to the RD makes some assumptions that could lead to questions as to the validity of the study's recommendations. AVN-100 has no requirement in FAA Order 8260.19 to list the requested data on the Form 8260. Also, computing and adding the distances and altitudes to the Form would place a burdensome workload requirement on the National Flight Procedures Office. Implementation of this RD has a strong probability of delaying instrument procedure development due to workload constraints. The LAP Branch of AVN-500 has stated that the RD will definitely reduce space for depicting planview information. This results in any one, combination of, or all of the following: chart congestion and clutter'; chart scale changes (zooming out); and, previously charted terrain, obstructions, and feature information being 'hidden' by the ribbon table. Additionally, since the planview is 'notched' and the Airport Sketch will not accommodate a ribbon table stretching across the whole page, the ribbon table will be significantly shorter. This in turn results in an unacceptable compression of the table data due to a probable inability to easily discern the numbers. Chart planview real estate has already been reduced with the conversion to the new format (Volpe), and this recommendation would result in an even further reduction. This recommendation would increase chart clutter and increase the potential for pilot error. Finally, the study appears to use as examples only VORs that have DME availability. In fact, not all VOR,s have DMEs. This sets up the study conclusion that VOR approach procedures do not suffer as high a workload effort by the aircrews as did NDB approach procedures. On the contrary, having to read a ribbon table on the planview to determine expected and planned distance and altitude at a specific location in space contributes to an already intensive cockpit workload. Implementation of this RD would result in an unacceptable prioritization of charted information, constraining what could be charted on an already diminished planview to accommodate nice-to-know, but not need-to-know information"

From: NTSB
Date: 1/23/2002
Response: Although it appreciates the concerns expressed by the ACF concerning clutter and available space for the information requested, the Safety Board believes that the circumstances of the Korean Air flight 801 accident support the need for these recommendations. Pending the results of the IACC's evaluation and implementation of the recommended actions, Safety Recommendations A-00-15 and -16 are classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
Date: 8/21/2001
Response: Letter Mail Controlled 08/29/2001 4:02:04 PM MC# 2010694: - From Jane F. Garvey, Administrator: The FAA fully understands the intent of this safety recommendation. The Board states that the FAA should include tabular information in nonprecision approach procedures that allows pilots to fly a constant angle of descent by cross- referencing the distance from the airport and the barometric altitude. The publication entitled Notices to Airmen instructs pilots to adjust aircraft configuration and airspeed to comply with the published angle and the Government publishes a descent rate table in each approach book that converts the published angle and ground speed to a target rate of descent. These procedures, while not providing the specific portrayal requested by the Board (i.e., distance from the airport against the barometric altitude), do allow the pilot to accurately plan and monitor the descent rate during a nonprecision approach. The FAA presented this safety recommendation to the Aeronautical Charting Forum in April 2001 for evaluation. Much of the discussion centered on clutter and the loss of "real estate" in the planview of procedures where the tabular data would be charted. The planview area available for the charting of essential flight information is already approaching the critically limited stage. Consensus of the Aeronautical Charting Forum was that this issue should be redelegated to the Inter-Agency Cartographic Committee (IACC) for resolution. Results of the IACC evaluation may be available at the next meeting of the Aeronautical Charting Forum in October 2001. I will keep the Board informed of the outcome of this effort in response to this safety recommendation.

From: NTSB
Date: 6/27/2000
Response: The Safety Board is concerned that the FAA may not fully understand the intent of this recommendation. Descent rate tables do not allow pilots to monitor or cross-check the approach descent progress throughout an approach. The Safety Board believes that it is safer to have periodic progress checks throughout an approach descent and to have tabular information presented on approach plates for ready reference to cross-check the distance from the facility against altitude. This allows pilots to constantly evaluate whether they need to increase or decrease the rate of descent. In areas where terrain or other obstructions are a consideration on the approach path, as in Guam, it is more important that pilots be able to accurately assess their approach profile. Pending inclusion in non-precision approach procedures of tabular information that allows pilots to fly a constant angle of descent by cross-referencing the distance from the airport and the barometric altitude, A-00-15 is classified OPEN – UNACCEPTABLE RESPONSE.

From: FAA
Date: 4/4/2000
Response: Letter Mail Controlled 04/07/2000 2:43:03 PM MC# 2000502 - From Jane F.Garvey, Administrator: This concept was considered by Jeppesen and has been under consideration for publication on United States government plates. Jeppesen has decided not to do this on regular subscription charts, but will do so as requested on tailored charts. As stated in response to A-00-14, the FAA has published the descent angle on non-precision approaches. The Notices to Airmen publication instructs pilots to adjust aircraft configuration and airspeed to comply with the published angle. The government publishes a descent-rate table in each approach book that converts the published angle and ground speed to a target rate of descent. The Inter-Agency Cartographic Committee makes the final decision regarding the publication on government charts. Consequently, the FAA will present this recommendation to the committee at the next government/industry charting forum for evaluation. I will keep the Board informed of the FAA's progress on this safety recommendation.