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Safety Recommendation Details

Safety Recommendation A-00-021
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 INT'L. 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: THE NTSB RECOMMENDS THAT THE KOREAN CIVIL AVIATION BUREAU: REQUIRE KOREAN AIR TO REVISE ITS VIDEO PRESENTATION FOR GUAM TO EMPHASIZE THAT INSTRUMENT APPROACHES SHOULD ALSO BE EXPECTED AND DESCRIBE THE COMPLEXITY OF SUCH APPROACHES AND THE SIGNIFICANT TERRAIN ALONG THE APPROACH COURSES AND IN THE VICINITY OF THE AIRPORT.
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: 5/2/2008
Addressee(s) and Addressee Status: Foreign, Korea, Civil Aviation Bureau (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Foreign, Korea, Civil Aviation Bureau
Date: 5/2/2008
Response: Recently, Korean Air provided the Safety Board with a copy of a video presentation that it had developed in response to this recommendation. This video, last revised in November 2005, is about 15 minutes long and covers all of the approaches to and navigational aids, obstacles, and terrain present at the airport in Guam. The Board reviewed this presentation and found that it fully meets the intent of the recommendation. Consequently, Safety Recommendation A-00-21 is classified Closed Acceptable Action.

From: NTSB
To: Foreign, Korea, Civil Aviation Bureau
Date: 9/7/2005
Response: The most recent correspondence from the KCAB in response to this recommendation is dated March 27, 2000. On July 13, 2000, the Safety Board noted that the video presentation of the instrument approaches to Guam included with the March 27, 2000, letter contained numerous errors, some of which were serious. The Safety Board classified Safety Recommendation A-00-21 "Open--Unacceptable Response" pending a revision to the video presentation on instrument approaches to Guam to correct the errors. In the 5 years since these letters were exchanged, there has been no further correspondence, nor is the Safety Board aware of any further activity. The Safety Board requests your assistance to determine what activities have been taken or are planned in response to Safety Recommendation A-00-21. For your reference, a copy of the letter containing this recommendation and a report showing the correspondence are enclosed.

From: NTSB
To: Foreign, Korea, Civil Aviation Bureau
Date: 7/13/2000
Response: THE KCAB ENCLOSED ITS REVISED VIDEO PRESENTATION OF THE INSTRUMENT APPROACHES FOR GUAM ON A COMPUTER COMPACT DISK (CD) AND A WRITTEN EXPLANATION OF THE MATERIAL ON THE CD (GUAM AIRPORT AV SYSTEM 2000.2). THE CD APPEARS TO HAVE BEEN CREATED WITH A TRIAL VERSION OF A SOFTWARE PACKAGE THAT HAS EXPIRED, PREVENTING THE VIDEO PRESENTATION FROM STARTING. WITH SOME COMPUTER MANIPULATIONS, BOARD STAFF WAS ABLE TO OPEN AND REVIEW THE CD TRAINING PROGRAM. SAFETY BOARD STAFF FOUND NUMEROUS ERRORS, SOME OF WHICH ARE SERIOUS. THE MOST SIGNIFICANT TECHNICAL ERROR IN THE PRESENTATION WAS A REFERENCE TO OBSOLETE APPROACH PROCEDURES TO RUNWAY 06L. THE APPROACH PROCEDURES WERE CHANGED IN AUGUST 1999 WITH THE ADDITION OF A FREQUENCY-PAIRED, CO-LOCATED LOCALIZER DME. THERE WAS NO MENTION OF THE AMENDED NOTES PERTAINING TO THE RUNWAY 06L ILS APPROACH STATING THAT DME OR RADAR IS REQUIRED FOR THE APPROACH AND THAT THE LOCALIZER DME SHOULD BE USED FOR THE APPROACH. THE SAFETY BOARD REQUESTS THAT THE KCAB REVISE THIS PRESENTATION TO CORRECT THE TECHNICAL ERRORS AND THAT ONCE THIS ACTION HAS BEEN COMPLETED, THE KCAB SUBMIT AN UPDATED VERSION FOR REVIEW. WE ALSO REQUEST THAT THE KCAB USE A SOFTWARE PACKAGE THAT HAS NOT EXPIRED. PENDING SUCH A REVISION, A-00-21 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: Foreign, Korea, Civil Aviation Bureau
To: NTSB
Date: 3/27/2000
Response: Letter Mail Controlled 04/04/2000 11:16:40 AM MC# 2000475 WITH REGARD TO YOUR RECOMMENDATION A-00-21, I COULD PROVIDE THAT KOREAN AIR TO REVISE ITS VIDEO PRESENTATION FOR GUAM TO EMPHASIZE THAT INSTRUMENT APPROACHES SHOULD ALSO BE EXPECTED WITH ATTACHMENTS.