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Safety Recommendation Details

Safety Recommendation A-00-016
Details
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: Evaluate the benefits of depicting terrain and other obstacles along a specific approach path on the profile view of approach charts and require such depiction if the evaluation demonstrates the benefits.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: NIMITZ HILL, GU, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: 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 - Acceptable Action)
Keyword(s): Approach Charts

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/18/2004
Response: At the December 12, 2003, meeting, the FAA indicated that it had forwarded this recommendation to the Aeronautical Charting Forum (ACF) and the IACC. The ACF and the IACC opposed revising the approach charts as recommended due to concerns about human factors issues. Specific concerns revolved around chart clutter and difficulty in adequately depicting this information as obstacles. Since the Korean Airlines flight 801 accident, a requirement to depict colored-terrain information in the planview on approach charts has been implemented. The ACF and the IACC viewed this change as adequately providing for situational awareness of the surrounding terrain without mixing more data into an already busy profile view of the approach chart. The Safety Board agrees that the FAA has evaluated the benefits of depicting terrain and other obstacles along a specific approach path on the profile view of approach charts, as recommended. The Board thanks the FAA for sharing the results of its evaluation. Safety Recommendation A-00-16 is classified "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 3/25/2004
Response: The FAA evaluated the benefits of depicting terrain and other obstacles along a specific approach path on the profile view of approach charts, as recommended, and determined that a plan view provides better information. If the FAA can supply a summary of the evaluation, A-00-16 will be classified "Closed--Acceptable Action." No real evaluation was conducted. It was more of an assessment by the ACF (made up of reps from the aviation industry and FAA) that the charts would be too busy if the info recommended by the NTSB were added. Attached are minutes from various meetings on this issue. Following is a synopsis of The Board proposal was presented by AFS to the ACF, which did not recommend this proposal for consideration by the IACC. Even without the ACF recommendation, AFS brought the issue before the IACC, but the IACC rejected the change of charting standards based on human factor issues. Specific concerns revolved around chart clutter and difficulty adequately depicting this information as obstacles. Since the accident involving Korean Airlines 801, the FAA has proposed, and the IACC has approved, the requirement to depict colored-terrain information in the planview on approach charts. This significant enhancement was viewed by the participants of the ACF, including AOPA, ALPA, NBAA, DoD, and IACC representatives as adequate for providing situational awareness of the surrounding terrain without mixing more data into an already busy profile view of an approach chart.

From: NTSB
To: FAA
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
To: NTSB
Date: 8/21/2001
Response: Letter Mail Controlled 08/29/2001 4:02:04 PM MC# 2010694: The FAA discussed this safety recommendation at the April 2001 Aeronautical Charting Forum. The group xpressed concern about the additional clutter that would result by adding this additional information. The group believes that the current (new) practice of depicting terrain in the planview was sufficient for pilot orientation and awareness of the flying environment in which the approach procedure is conducted. Consensus of the Aeronautical Charting Forum was that this issue should be redelegated to the 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 the IACC study.

From: NTSB
To: FAA
Date: 6/27/2000
Response: ACCORDINGLY, BASED ON THE FAA'S RESPONSE, A-00-16 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 4/4/2000
Response: Letter Mail Controlled 04/07/2000 2:43:03 PM MC# 2000502 DISCUSSION BETWEEN THE FAA AND DEPT. OF DEFENSE (DOD) REPRESENTATIVES ON THE INTER-AGENCY CARTOGRAPHIC COMMITTEE REGARDING DEPICTING TERRAIN IN THE PROFILE VIEW IS ONGOING. INITIAL PILOT REACTION IS THAT THE ADDITIONAL CLUTTER MAY OUTWEIGH ANY BENEFIT FROM DEPICTING THE PROFILE VIEW. THE FAA, DOD, AND JEPPESEN PREVIOUSLY DISCUSSED THIS ISSUE OVER A YEAR AGO AND DECIDED TO PURSUE COLOR PLANVIEW DEPICTION ONLY. HOWEVER, THE FAA WILL PRESENT THIS RECOMMENDATION TO THE GOVERNMENT/INDUSTRY CHARTING FORUM FOR EVALUATION. I WILL KEEP THE BOARD INFORMED OF THE FAA'S PROGRESS ON THIS SAFETY RECOMMENDATION.