National Transportation Safety Board

“ The NASA study concluded that, to reduce pressures on pilots, operators "must be willing to stand behind their pilots who take a safe course of action rather than a riskier one, even if there is a cost associated." The study noted that integrated flight displays that present up-to-date information on dynamic variables, such as weather and traffic, could reduce the ambiguity of events flight crews might encounter and that training to help flight crews develop "strategies for choosing a course of action" would be beneficial. ”

“ Nonprecision approaches generally are much more complex than precision approaches. For many pilots, they are less familiar. They are more error-prone. They require [a] more comprehensive briefing. They need particularly careful and accurate monitoring, and it is possible for complex step-down procedures for steps to be missed or to be taken out of step. In other words, to get one step ahead of the airplane could be fatal. ”

“ The Korean Air Boeing 747 Guidebook states that the "descent checklist" is to be performed while the airplane is descending through 20,000 feet to approximately 18,000 feet (or 1,000 feet above transition level in North America) . The guidebook also states that the "approach checklist" is to be performed after a speed reduction to 250 knots and while the airplane is descending through 10,000 feet with its inboard landing lights on and that the "landing checklist" is to be performed when the airplane has been configured for landing. ”

“ High TSA crews made significantly more procedural errors and tactical decision errors than low TSA crews. These results suggested that the degraded performance by high TSA crews tended to involve ineffective decision-making (such as failing to perform a missed approach) and procedural slips (such as not making altitude awareness callouts) rather than a deterioration of aircraft handling skill. Also, the number and types of errors made by the flight crews varied according to the TSA length before the accident. ”

“ On October 19, 1998, the Safety Board stated that the primary intent of this recommendation was to ensure that VFR tower controllers who have a visual representation from a distant host radar receive an aural alert when aircraft under their control and with whom they are in radio communication descend below the minimum safe altitude. If the tower controller was engaged in visually scanning for other aircraft, the aural alert would allow the controller to determine the aircraft call sign and transmit the appropriate warning to the pilot. ”

“ The challenges associated with operations to Guam International Airport support its immediate consideration as a special airport requiring special pilot qualifications. Although the captain apparently became confused about the glideslope's status, the flight crew had sufficient information to be aware that the glideslope was unusable for vertical guidance and should have ignored any glideslope indications while executing the nonprecision localizer-only approach. Navigation receivers, including glideslope receivers, may be susceptible to spurious radio signals. ”

“ Thus, the presence of the off flags over the glideslope needles at some times and the absence of FMA glideslope capture indicators on the captain's and first officer's instrument panels should have been sufficient to convince the flight 801 flight crew to disregard the glideslope indications. Even if the flight crewmembers did see a continuous glideslope needle activation and flag retraction, it would not have been prudent or reasonable for them to rely on a glideslope signal of any sort when the glideslope had been reported to be unusable. ”

“ Company policy should specify well-defined go-around gates for approach and landing operations. Parameters should include visibility minima required before proceeding past the final approach fix or the outer marker, assessment at the final approach fix or the outer marker of crew and aircraft readiness for the approach, and minimum altitude at which the aircraft must be stabilized. Companies should declare and support no-fault go-around and missed approach policies. ”

“ Controlled flight into terrain accident awareness and avoidance training is an important accident reduction strategy and should be mandatory for all pilots operating under 14 Code of Federal Regulations Part 121. By providing vertical guidance along a constant descent gradient to the runway, the use of on-board flight management system- and/or global positioning system-based equipment can provide most of the safety advantages of a precision approach during a nonprecision approach. ”

“ The Board was unable to obtain information on the recent sleeping patterns of the first officer and flight engineer.
The accident occurred after midnight (about 0042) in the flight crew's home time zone (which is 1 hour behind Guam local time) . Research has found that this time of day is often associated with degraded alertness and performance and a higher probability of errors and accidents. [15] The arrival time was also several hours after the captain's normal bedtime (2200 to 2300 Seoul local time) and a time at which his body would have been primed for sleep. ”

“ Operators should provide education and training that enhance flight crew decision-making and risk (error) management. Operators should develop SOPs regarding the use of automation in approach and landing operations and train flight crews accordingly. There should be a clear policy in all operators' manuals regarding the role of the pilot-in-command (PIC) in complex and demanding flight situations. Training should address the practice of transferring pilot-flying duties during operationally complex situations. ”

“ When the airplane was descending, the flying pilot would normally have reset the altitude selector to the next (lower) altitude target and moved the VERT SPEED (vertical speed) wheel to position the airplane in about a 1,000-feet-per-minute rate of descent to reach the next crossing altitude. The FD pitch command bars would move up and down to provide guidance to maintain the desired rate of descent. (In a precision approach, the command bars would provide guidance to maintain the glideslope; in nonprecision approaches, they provide guidance to maintain the desired vertical speed.) ”

“ The captain and first officer--the sole occupants aboard the flight--were killed when the airplane struck trees and impacted the ground, and the airplane was destroyed by impact forces and fire. The airplane was not equipped with a GPWS and was not required by the FARs to be so equipped. Although the Safety Board determined that the probable cause of this accident was flight crew error, the Board also found that the lack of an FAA requirement for a GPWS on the airplane was a factor in the accident. ”

“ The implementation of certified constant angle, stabilized approach procedures for nonprecision approaches should be expedited globally. Flight crews should be trained on the proper use of constant angle, stabilized approach procedures. Flight crews should also be educated on approach design criteria and obstacle clearance requirements. Flight crews should "take time to make time" when the cockpit situation becomes confusing or ambiguous, which means climbing, holding, requesting vectors for delaying purposes, or performing a missed approach early. ”

“ A country's civil aviation authority found not to meet ICAO standards for aviation oversight. Unacceptable ratings apply if the civil aviation authority has not developed or implemented laws or regulations in accordance with ICAO standards; if it lacks the technical expertise or resources to license or oversee civil aviation; if it lacks the flight operations capability to certify, oversee and enforce air carrier operations requirements; if it lacks the aircraft maintenance capability to certify, oversee and enforce air carrier maintenance requirements ”

“ The Agana tower is responsible for operations within the surrounding Class D airspace, which is defined as the airspace within a 5-statute mile radius from the center of the Guam International Airport up to, but not including, 2,500 feet agl. The tower facility is located on the south-southwest side of the airport and is operational 24 hours a day. The controller positions are arranged in a semicircular pattern that face generally from the southwest to the northeast. The four operational positions are the controller-in-charge, local control, ground control, and flight data. ”

“ Thus, ALPA concluded that the risk associated with this "inherently less safe type of approach" is compounded by the infrequency of flight crew exposure and practice. ALPA stated that most nonprecision approaches are presented in a series of step-down altitudes and that, although step-down altitudes may be satisfactory for light, slow, maneuverable aircraft, they are unacceptable for transport-category aircraft. ”

“ The 250-nm-radius outer ring, which encompasses all of the airspace from above the surface, is classified as oceanic airspace. A 100-nm-radius inner ring, which extends over the Saipan radio beacon and from the surface to 28,000 feet, is classified as domestic airspace. [43] The CERAP airspace is adjoined on all sides by the Oakland Air Route Traffic Control Center oceanic sectors. The airspace over Saipan and Guam is classified as approach control airspace, and its boundaries extend from the surface to 17,000 feet. The CERAP was classified as a Level II facility at the time of the accident. ”

“ On August 5, 1998, Korean Air flight 8702, a Boeing 747-400, HL7496, skidded off the runway and crashed during a landing roll in heavy rain at Kimpo Airport in Seoul. None of the 16 crewmembers were injured, and 65 of the 379 passengers received minor injuries. The accident caused substantial damage to the airplane. The KCAB's investigation determined that the accident was caused by the captain's misuse of the thrust reverser during the landing roll and his confusion over crosswind conditions. ”

“ During a June 17, 1999, briefing to Safety Board staff, the FAA indicated that, although the IASA program is intended to determine whether a foreign country's CAA is providing adequate oversight, the program does not directly assess whether foreign carriers are receiving such oversight or are complying with the provisions of Annex 6 to the Convention on International Civil Aviation. The FAA assessment team does not conduct surveillance of foreign air carriers; rather, it collects information and evaluates a foreign CAA's compliance with Annex 6 standards in seven areas: aviation law ”

“ Several factors that frequently appeared in CFIT accident reports included night and limited visibility conditions, terrain not observed until just before impact, loss of horizontal or vertical situational awareness, unfamiliarity with terrain and obstructions, flight crew uncertainty about altitudes and distance from the airport, navigational equipment improperly set or misinterpreted by the flight crew, and an unstabilized approach. ”

“ Establishing and adhering to adequate standard operating procedures and CRM processes will improve approach and landing safety. Improving communication and mutual understanding between ATC services and flight crews of each other's operational environment will improve approach and landing safety. Unstabilized and rushed approaches contribute to ALAs. Failure to recognize the need for and to execute a missed approach, when appropriate, is a major cause of ALAs. ”

“ A successful missed approach was accomplished, and the aircraft landed safely. On the basis of the results of its investigation, the Safety Board issued Safety Recommendation A-71-53, asking the FAA to
Develop a ground proximity warning system for use in the approach and landing phases of operation, which will warn flight crews of excessive rates of descent, unwanted/inadvertent descent below minimum descent altitudes, or descent through decision heights. It would be desirable if the equipment now installed could meet this need. ”

“ The safety of executing a nonprecision approach using the constant angle of descent, or stabilized descent technique, would be enhanced by adding to approach charts the cross-referenced altitudes versus distance from the airport. Terrain depiction on the profile view of approach charts could result in increased flight crew awareness of significant terrain on the approach path. ”