Korean Air 801

WHAT HAPPENED?

The day of August 6, 1997 was a time that changed the Korean Airlines Flight 801. Korean Airlines was operating a Boeing 737-300 when it crashed into a high terrain towards the Won Guam International Airport in Agana, Guam which was about three miles southwest.

Operating under Instrument Flight Rules (IFR), Flight 801 was in route from the Seoul, Korea Kimpo International Airport. On board there were two pilots, one flight engineer, 14 flight attendants and 237 passengers when they impacted Nimitz Hill while on an approach to runway 6L. The results of this terrible crash were fatalities for 228 people of the 254 on board.

WHY DID THE ACCIDENT HAPPEN?

The accident was in a category of a Controlled Flight Into Terrain (CFIT) while concentrating on the aspects of the accident. The National Transportation Safety Board (NTSB), the Federal Aviation Administration (FAA), Korean Airlines, Government of Guam and Boeing are among the group of people conducting the investigation. The flight crew, air traffic control (ATC), the instrumentation design for the Runway, training of Korean Airlines and weather all played a significant part on the accident. The NTSB determined that the cause of the accident was the failure of the captain to brief and conduct a non-precision approach while the first officer and flight engineer's failure to monitor the situation (NTSB, 2000).

The flight crew didn't plan on using an instrument approach even though they were completely aware of the inoperative glide slope of Runway 6L. The early sight of the airport was a contributing factor of the crew. Although the crew was expecting the visual approach, preparation should have been put in place so that would in essence prepare them for any weather conditions and any approach for that matter. In Aircraft Accident Analysis: Final Reports, it states that there was not enough crew preparation for the difficult instrument approach (Walters & Sumwalt, 2000).

Weather always plays a big part in the investigation of trying to determine what was happening at the time and what truly occurred at the time of the impact. The Korean Airlines Flight 801 was flying while there was rain however it didn't affect the crew's visibility toward the airport. Since the rain wasn't really the issue the focus was on the broken layer of clouds that could have blocked the view of the pilot toward final approach. In the path of Runway 6L, there was storm cells that most likely were over the visual of the approach. Even after the squall, they still were unable to see the airport due to another rain shower located on the approach course to the northeast of Nimitz Hill (Walters & Sumwalt, 2000).

There was much confusion with the glide slope concerning the instrumentation approach towards the Runway 6L. Training was never provided by Korean Airlines that involved these very unusual approaches. The training definitely was a contributing factor to the accident. The ironic thing is that the Guam airport Automatic Terminal Information Service (ATIS) information and air traffic control (ATC)controllers alerted the crew to the fact that the glide slope was unusable; however this accident is proof that they didn't listen (Walters & Sumwalt, 2000). The Guam approach is very different because you count down first then it starts to count back up which makes it very difficult if you have never been trained or used one before.

The Board also found out that based on the cockpit voice recorder (CVR) and the flight data recorder (FDR) the captain "failed to take timely and appropriate action to prevent the airplane from impacting terrain even when confronted with repeated ground proximity warning system (GPWS) and then failed to initiate an aggressive missed approach when he announced his intention to go around" (Walters & Sumwalt, 2000, p. 201). So the stubbornness of the captain whom didn't respond to the alerts as well as making the proper decisions also contributed to why the accident occurred.

RECOMMENDATIONS

There is a great deal of recommendations that needed to focus upon. There are recommendations for the various groups that were assisting in the investigation of this accident.

The recommendations that were directed to the Korean Civil Aviation Bureau was that they would require them to revise video training for Guam to emphasize that instrument approaches should be expected. They also wanted them to go into detail with these approaches and any terrain that should be of question. They wanted to make sure that the Aviation Bureau would conduct thorough training for the approaches that had terrain close to the airport.

The Federal Aviation Administration definitely had their work cut out for them because there is a great deal of recommendations specifically intended towards them. Possibly create an advisory or report that would put Guam International Airport in a different category and only those that had certain upgrades or training would be permitted to fly there. The air traffic control controllers needed to trained and reminded of following the ATC protocol. Consider work on the glide slope and the approach procedures that could be alerted in training sessions or circular advisories. If a new approach was going to be implemented then it would be necessary that they would be aware of the changes. The United States air carrier POIs to ensure that the air carrier pilots would conduct briefings for instrument approach that backs up the visual approaches conducted at night or when weather conditions might be expected. Also research the benefits of the "monitored" approach, and mandate its use if appropriate. When evaluating the adequacy of that airline's oversight, consider the accident and incident history of a foreign air carrier. Also require within two years of the accident that all turbine-powered airplanes with six or more passenger seats not currently equipped with GPWS have an operating enhanced GPWS or terrain awareness and also include a warning system.

Don't think for a minute that there weren't more recommendations and mostly so that these groups would work together to get these changes complete in order to prevent the next accident. The Governor of Guam should form an elite group that would assist the agencies with emergencies that occur in Guam. They would aid where their help is needed and even do periodic checks on these agencies to ensure they are following the tragedy drills in preparation for such accidents.

AVIATION SAFETY ISSUES

CFIT accidents have not occurred so often due to the installation of the GPWS and