National Transportation Safety Board

“ The en route and approach radar positions at Guam are typically performed by one controller using two independcnt radar systems. Both systems are equipped with a minimum safe altitude warning (MSAW) system that is designed to alert the controller both aurally and visually when an aircraft, in a predetermined geographic area, is below or predicted to be below a specified safe altitude. The investigation revealed that the MSAW system at Guam was not operating as designed or intended at the time of the accident. ”

“ The following organizations were given party status and provided technical assistance to the Safety Board: the Federal Aviation Administration, Korean Air Company, Inc., Boeing Airplane Company, Pratt & Whitney Engines, the National Air Traffic Controllers Association, the United States Navy, and emergency response personnel from Guam. ”

“ In addition, the emergency response vehicles were delayed in arriving on-scene because access to the accident site was initially stopped by a fenced gate that encircled the property where the accident occurred; response was further hampered by a narrow paved road that was blocked by a broken pipeline that had been struck by the airplane and disable parked vehicles that congested the access road and prevented fire trucks from maneuvering close to the wreckage. ”

“ The published approach procedure for the ILS to runway 6 Left with the glideslope inoperative depicts a series of "step down" altitudes that the pilot is required to maintain during the execution of the approach. The step down altitudes ensure sufficient obstruction/terrain clearance. The lowest altitude for the first segment is 2,000 feet until 1.6 nautical miles from the VOR ”