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Safety Recommendation Details

Safety Recommendation A-00-019
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 PART 129 AND WAS ON AN INSTRUMENT FLIGHT RULES FLIGHT PLAN.
Recommendation: THE NTSB RECOMMEND THAT THE GOVERNOR OF THE TERRITORY OF GUAM: FORM, WITHIN 90 DAYS, A TASK FORCE COMPRISING REPRESENTIVES FROM ALL EMERGENCY RESPONSE AGENCIES ON THE ISLAND, INCLUDING THE APPROPRIATE DEPARTMENTS WITHIN THE GOVERNMENT OF GUAM, FEDERAL AVIATION ADMINISTRATION, GUAM INTERNATIONAL AIRPORT AUTHORITY, U.S. NAVY, U.S. AIR FORCE, U.S. COAST GUARD, FEDERAL EMERGENCY MANAGEMENT AGENCY, AND ALL OTHER AFFECTED AGENCIES, TO DEFINE AND COORDINATE EMERGENCY NOTIFICATION AND RESPONSE PROCEDURES TO ENSURE THAT TIMELY EMERGENCY NOTIFICATIONS ARE MADE TO ALL LOCAL AND FEDERAL AGENCIES ACCORDING TO NEED, LOCATION, AND RESPONSE TIME CAPABILITY.
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: 5/17/2002
Addressee(s) and Addressee Status: Territory of Guam (Closed - Acceptable Action)
Keyword(s): Emergency Response

Safety Recommendation History
From: NTSB
To: Territory of Guam
Date: 5/17/2002
Response: Thank you for this additional information. As JP 101 serves the same purpose as the MOU previously suggested by the Board, Safety Recommendation A-00-19 is classified "Closed--Acceptable Action."

From: Territory of Guam
To: NTSB
Date: 1/3/2002
Response: Letter Mail Controlled 02/20/2002 6:54:55 PM MC# 2020172 Although both recommendations were issued on January 27, 2000, Guam has made considerable progress since November 1999 in addressing A-00-19. Secondly, the OCD November 29, 1999 letter never stated that it had 'fully addressed" the recommendation. It did however stated that "'based on what we have reviewed thus far and coupled with the sincere commitment exhibited by everyone, the Government of Guam believes that when all is said and done, ii will define, coordinate, and improve its notification and response procedures not only in the event of another air crash incident but more importantly in any and all types of emergencies." I can understand your statement regarding the Aviation Incident/Accident Annex and your deduction regarding MO& notification, and coordination among all emergency response agencies on Guam. To answer your questions, I have enclosed Annex 7 which was partially provided in my April 16, 2001 letter. Because a cop-v had been provided to NTSB after its completion last year, I did not think it necessary to provide one at the time. However, to alleviate any doubts you may have on Guam's enhanced capabilities to handle an aircraft accident, a full and complete copy is enclosed. Furthermore, because the OCD manages, coordinates, and facilitates all Government of Guam response agencies' manpower and resources during an emergency, it does not need an MOU between its agencies. The FBI, FEMA (through the OCD), and the American Red Cross' involvement are evident by the input in their respective appendices in the GERP. FAA's involvement is outlined in the GIAA Appendix and their GIAA emergency response plan. DOD'S involvement is outlined in Joint Plan - 101. JP-101 is an operational plan jointly developed by the US Navy, US Air Force, and the US Coast Guard under the umbrella of the COMNAVMAR. DOD'S commitment is addressed in Annex E - "military support to civil authorities". This Annex identifies the Military's involvement in Gov Guam emergencies requiring their support and vice versa. We consider Joint Plan 101 to be a supplemental operational procedure to the existing National Search and Rescue Plan, the Search and Rescue Agreement between the Guam Fire Department (GFD) and the US Coast Guard, and the MOU between the GFD and the US Air Force. Therefore, we do not think it necessary to write another redundant MOU. Although there was no after action input from the FAA, the exercise could not have taken place without their involvement. The Control Tower involved with the off-airport exercise is an FAA contracted tower. They are required to perform aircraft accident notifications in accordance with FAA directives. Therefore, FAA's involvement was evident from the initial report of the accident. Additionally, based on time logs that have been attached to my April 16, 2001 letter, FAA was in the midst of the exercise and appropriate notifications were made to other FAA offices and the US Coast Guard Search and Rescue Coordination Center. Aside from the GZAA's FAA required tri-annual aircraft exercise, the OCD is required by Annex 7 to conduct an exercise on a bi-annual basis. In fact, the OCD has budgeted $30,000 in fiscal year 2002 for the purpose of conducting a full-scale off-airport exercise to be held in the third quarter of FY2002. A proposed scenario will involve an off-airport/Government of Guam property air carrier aircraft accident. I sincerely hope that this response addresses all your concerns. I believe that the Government of Guam has come a long way since the unfortunate crash of KAL 801. My Office's proactive support and involvement in improving our emergency management capabilities has resulted in a more coordinated and team-oriented approach to many emergencies and incidents in the past two years. Guam's geographical location and climate makes the island vulnerable to the devastating effects of both natural and man made disasters. We certainly do not lack the practice in the mitigation, preparation, response, rescue and recovery from these incidents, and for the most part we have done an excellent job in all phases of emergency management. As a part of our effort to enhance our emergency management capabilities and to effectively address all potential threats, the Office of Civil Defense (OCD) embarked on an aggressive campaign to update and revise Guam's emergency response plan - the Territorial Emergency Plan (TEP). The TEP was a generalized and broad approach to dealing with an emergency or disaster and was last revised and updated in 1991. Because of lessons learned and new technologies involved with emergency management, the OCD developed the Guam Emergency Response Plan (GERP) in September 1999. Although the GERP will replace the TEP, the plan's basic format remains the same. However, the concept of operations now embraces the Incident Command System (ICS). Other significant changes include further development of Hazard Specific Annexes and Functional Annexes. The new plan outlines 11 potential hazards and 14 functional guidelines to address pre and post disaster preparation, response, and recovery efforts (Attachment A - GERP Table of Contents). The GERP's ICS is utilized in all emergencies and a Unified Command is established where an Incident Commander directs a!! response agencies whether it be in a primary or support role. The challenge of updating and revising the TEP was made simpler by the overwhelming support and cooperation provided by all GovGuam response agencies and our military partners under my direction. Because of NTSB's Abstract of Final Report AAR-99/02 (Attachment B) that was released in late October 1999 and the recommendations that were made (Page 6 of 6), it was my decision that the OCD not only head the Air Disaster Task Force, but also work towards completing the GERP's Aviation Incident/Accident Annex first. Through the collaboration and input from all pertinent Gov Guam response agencies, our federal and military partners, and our non-profit liaison organizations, the Aviation Incident/Accident Annex was completed on March 2000. A copy of this Annex was immediately provided to the NTSB to address safety recommendation A-00- 19 as well as actions taken by Guam regarding safety recommendation A-00-20. I was surprised to find out a year later, on your March 30, 2001 that you had not received Guam's progress on the recommendations. Because of my desire to address your concern, I responded to your inquiry in April 16, 200l. Your letter dated July 25, 2001 tells me that further clarification needs to be brought to your attention. To answer your questions, I have formatted Guam's answer in the following manner. Page 1: Paragraph 2 "The Government of Guam states that a November 29, 1999, letter from the Guam Office of Civil Defense (OCD) to Mr., Larry Roman, a former investigator at the Safety Board, addresses both recommendations. Safety Recommendations A-00-19 and -20 were issued on January 27, 2000. If the intent of these recommendations had been fully addressed in the November 29, 1999 letter, which predates the issuance of the recommendations, the Board would not have issued the recommendations." First, my decision to form the task force was based on the abstract of final report forwarded by the NTSB to Guam in late October 1999. Although both recommendations were issued on January 27, 2000, Guam has made considerable progress since November 1999 in addressing A-00-19. Secondly, the OCD November 29, 1999 letter never stated that it had 'fully addressed" the recommendation. It did however stated that "'based on what we have reviewed thus far and coupled with the sincere commitment exhibited by everyone, the Government of Guam believes that when all is said and done, ii will define, coordinate, and improve its notification and response procedures not only in the event of another air crash incident but more importantly in any and all types of emergencies" (Attachment C - Larry Roman letter Page 2 and part of Page 3). The letter stated actions it has taken towards addressing the recommendations. It never stated that the "recommendations had been fully addressed". Page 2: Paragraph 2 and 3 I can understand your statement regarding the Aviation Incident/Accident Annex and your deduction regarding MO& notification, and coordination among all emergency response agencies on Guam. To answer your questions, I have enclosed Annex 7 which was partially provided in my April 16, 2001 letter. Because a cop-v had been provided to NTSB after its completion last year, I did not think it necessary to provide one at the time. However, to alleviate any doubts you may have on Guam's enhanced capabilities to handle an aircraft accident, a full and complete copy is enclosed. Furthermore, because the OCD manages, coordinates, and facilitates all Government of Guam response agencies' manpower and resources during an emergency, it does not need an MOU between its agencies. The FBI, FEMA (through the OCD), and the American Red Cross' involvement are evident by the input in their respective appendices in the GERP. FAA's involvement is outlined in the GIAA Appendix and their GIAA emergency response plan. DOD'S involvement is outlined in Joint Plan - 101. JP-101 is an operational plan jointly developed by the US Navy, US Air Force, and the US Coast Guard under the umbrella of the COMNAVMAR. DOD'S commitment is addressed in Annex E - "military support to civil authorities". This Annex identifies the Military's involvement in Gov Guam emergencies requiring their support and vice versa. We consider Joint Plan 101 to be a supplemental operational procedure to the existing National Search and Rescue Plan, the Search and Rescue Agreement between the Guam Fire Department (GFD) and the US Coast Guard, and the MOU between the GFD and the US Air Force. Therefore, we do not think it necessary to write another redundant MOU. Page 2: Paragraph 3 Although there was no after action input from the FAA, the exercise could not have taken place without their involvement. The Control Tower involved with the off-airport exercise is an FAA contracted tower. They are required to perform aircraft accident notifications in accordance with FAA directives. Therefore, FAA's involvement was evident from the initial report of the accident. Additionally, based on time logs that have been attached to my April 16, 2001 letter, FAA was in the midst of the exercise and appropriate notifications were made to other FAA offices and the US Coast Guard Search and Rescue Coordination Center. Aside from the GIAA's FAA required tri-annual aircraft exercise, the OCD is required by Annex 7 to conduct an exercise on a bi-annual basis. In fact, the OCD has budgeted $30,000 in fiscal year 2002 for the purpose of conducting a full-scale off-airport exercise to be held in the third quarter of FY2002. A proposed scenario will involve an off-airport/Government of Guam property air carrier aircraft accident. I sincerely hope that this response addresses all your concerns. I believe that the Government of Guam has come a long way since the unfortunate crash of KAL 801. My Office's proactive support and involvement in improving our emergency management capabilities has resulted in a more coordinated and team-oriented approach to many emergencies and incidents in the past two years. If you have any questions or require additional information, please let me know.

From: NTSB
To: Territory of Guam
Date: 7/25/2001
Response: The Government of Guam states that a November 29, 1999, letter from the Guam Office of Civil Defense (OCD) to Mr. Larry Roman, a former investigator at the Safety Board, addresses both recommendations. Safety Recommendations A-00-19 and -20 were issued on January 27, 2000. If the intent of these recommendations had been fully addressed in the November 29, 1999, letter, which predates the issuance of the recommendations, the Board would not have issued the recommendations. Regarding Safety Recommendation A-00-19, the Government of Guam reports that the Guam Office of Civil Defense prepared the Guam Emergency Response Plan (GERP), which revises and updates the 1991 Guam Territorial Emergency Plan. Annex 7 of the GERP, "Aviation Incident/Accident Annex," outlines the responsibilities necessary to respond to an aviation incident or accident. Regarding Safety Recommendation A-00-20, the Government of Guam states that on February 23, 2000, the Guam International Airport Authority conducted a successful off-airport disaster exercise as part of its Federal Aviation Administration (FAA)-required triannual aircraft disaster exercise. To assess the actions that the Government of Guam has taken to address these recommendations, the Board reviewed two items enclosed in the April 16, 2001, letter: (1) Annex 7 of the GERP, dated March 23, 2000, and (2) the After Action Report of the off-airport disaster exercise. Although the revision to Annex 7 of the GERP is a positive step, it does not directly address the intent of Safety Recommendation A-00-19. The recommendation letter indicates that some sort of a formal agreement is anticipated, such as a Memorandum of Understanding (MOU) between the organizations listed in the recommendation. The GERP only outlines the responsibilities of a single organization (the OCD) and does not fully address the issues of notification and coordination among the emergency response agencies on Guam, as recommended. Further, although the GERP outlines the OCD's responsibilities for notification, it does not contain procedures to identify the closest emergency response resources available to respond to an aviation accident on Guam and to ensure that all appropriate resources are mobilized as quickly as possible. The Board also notes that Annex 7 of the GERP does not reference coordination with the FAA, which is one of the organizations specifically mentioned in Safety Recommendation A-00-19. The Safety Board recognizes that the revisions to Annex 7 of the GERP should improve the emergency response to future aviation accidents on Guam. However, the Board continues to believe that the Government of Guam needs to define and coordinate emergency notification and response procedures and implement formal agreements, such as an MOU, among all emergency response agencies on Guam to ensure that timely emergency notifications are made to all local and Federal agencies according to need, location, and response time capability. Pending the development and implementation of these procedures and agreements, Safety Recommendation A-00-19 is classified "Open--Unacceptable Response." The Safety Board's review of the After Action Report of the off-airport disaster exercise conducted on February 23, 2000, by the Guam International Airport Authority in response to Safety Recommendation A-00-20 showed that it was a useful and successful exercise. However, the report did not indicate that the FAA had been involved in the exercise, and the Board believes the FAA should be a part of any aviation disaster response on Guam. Further, the Board notes that the recommendation asks for periodic and regularly scheduled exercises. The Board would appreciate receiving information about when the next regularly scheduled exercise will take place and what type of aviation disaster (that is, what type of airplane and the location of the crash) will be the subject of this exercise. The Board would also appreciate being informed of long-range plans for regularly scheduled interagency disaster response exercises. Pending receipt of information on the date of the next regularly scheduled aviation disaster exercise, the scenario of that exercise, and future plans for regularly scheduled exercises, Safety Recommendation A-00-20 is classified "Open--Acceptable Response."

From: Territory of Guam
To: NTSB
Date: 4/16/2001
Response: Letter Mail Controlled 04/25/2001 9:56:51 AM MC# 2010348 Our letter dated November 29, 1999 from the Guam Office of Civil Defense to Mr. Larry Roman, Senior Accident Investigator of Aviation Safety, National Transportation Board, addresses both recommendations A-00-19 and A-00-20. Further, concerning A-00-20, on February 23, 2000 the Guam Int'l Airport Authority conducted a successful off-airport disaster exercise, as part of their FAA required tri-annual aircraft disaster exercise (documents attached). Additionally the Guam Office of Civil Defense has promulgated the Guam Emergency Response Plan, which is a revision and update of the 1991 Guam Territorial Emergency Plan. Annex 7 of the Guam Emergency Response Plan entitled "Aviation Incident/Accident Annex" outlines the responsibilities necessary to respond to an aviation incident (copy attached).

From: NTSB
To: Territory of Guam
Date: 3/9/2001
Response: Safety Board records indicate that the Territory has not responded to either of these recommendations. The Board would appreciate learning of any current, completed, or planned activities that the Territory has taken in response to the recommendations. A copy of the recommendation letter is enclosed for your reference. Please cite the recommendation numbers in your response.