DOCKET NO.: SA-517 EXHIBIT NO. 2A NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. OPERATIONS / HUMAN PERFORMANCE GROUP CHAIRMAN’S FACTUAL REPORT By: Paul R. Misencik (35 pages) NATIONAL TRANSPORTATION SAFETY BOARD Office of Aviation Safety Washington, D.C. 20594 DCA97MA058 Operations / Human Performance Group Chairman’s Factual Report PAUL R. MISENCIK AVIATION SAFETY INVESTIGATOR OPERATIONS MALCOLM BRENNER, PH.D HUMAN PERFORMANCE INVESTIGATOR FEBRUARY 24, 1998 Factual Page 1 TABLE OF CONTENTS A. Accident B. Operations Group C. Summary D. Details of the Investigation E. History of Flight F. Personnel Information 1. The Captain 2. The First Officer 3. The Flight Engineer G. Toxicology H. Flight Crew Histories 1. Medical factors 2. Interviews of Flight Crew Family Members 3. Accident Crewmember’s Flight Schedules I. Korean Air Procedures 1. Self Briefing 2. Supervisor of Flying Briefing 3. Full Crew Briefing 4. Audio Visual Airport Familiarization 5. Briefing of Unfamiliar Airport J. Local Conditions - Guam Area 1. General 2. Witness Observations (a.) Continental Air Micronesia (b.) Ryan International K. Training 1. Pilot Recruitment 2. Ground School and Flight Training Facilities 3. Crew Resource Management (CRM) Factual Page 2 4. English Language Competency 5. Basic and Advanced Course in Instrument Flying 6. Flight Crew Training Curriculum (a.) Ground School (b.) Cockpit Procedures Training (CPT) (c.) Simulator Flight Training L. Korean Air Approach Procedures 1. Checklist Usage 2. Landing Briefing 3. Descent and Approach Procedures M. Airport Information 1. Location 2. Airport Overview 3. Guam Weather Overview 4. Airport Operations 5. Airport Communications 6. Navigational Aids to Airport 7. Runway 6L/24R 8. NOTAM Information - Guam International Airport 9. Airport rescue and Fire Fighting (ARFF) N. Airplane Information 1. Weight and Balance O. Company History P. Additional Information Attachments
Interview Summaries (Guam - Seoul Korea, August 1997)
English Text of Guam Audio Visual Presentation
Korean Text of Guam Audio Visual Presentation
Factual Page 3
Outline of B-747 Initial and Transition Training
Copy of B-747-200 Simulator Training Guide
Copies of Approach Plates from Accident Airplane
Copies of August 2, 1996 ILS 6L Approach Plate
Accident Crewmember’s Flight Schedule (June, July, August-1997) 6 Pages
Summary of United States D.O.D. Capability Survey of Korean Air.
Captains Flight Activity Record - (Aug. 3-4, 1997)
Interview Summaries (Guam, January 13, 1998)
Factual Page 4 A. ACCIDENT
0142 Guam Local Time1 - (1542 UTC2 August 5, 1997)
Boeing 747-300 (3B5B), Registration HL-7468, S/N 22489
B. OPERATIONS GROUP
Captain Paul R. MisencikOperations Group ChairmanNational Transportation Safety Board (AS-30)490 L’Enfant Plaza East, S.W,Washington, DC 20594
Dr. Malcolm Brenner, Ph.D. Human Performance InvestigatorNational Transportation Safety Board (AS-50)490 L’Enfant Plaza East, S.W,Washington, DC 20594
Mr. Ron JohnsonAviation Safety Inspector - Air Carrier OperationsFederal Aviation AdministrationFlight Standards District Office135 Nakolo PlaceHonolulu, HI 96819
Captain Lee, Kwang-SukFlight CheckerMinistry of Construction & TransportationSeoul Regional Aviation Office (Kimpo)Seoul, Korea
Captain Park, Pyung-WooVice President & Chief Captain - Flight Crew Operations DepartmentKorean Air Co. Ltd. 351, Konghang-DongKangseo-KuSeoul, Korea
1 All times are Guam Local Time (LCL) based on a 24-hour clock unless otherwise noted.
2 Coordinated Universal Time (UTC) - Formerly Greenwich Mean Time (GMT) or (Z). Factual Page 5 C. SUMMARY
On August 6, 1997 at approximately 0142, a Boeing 747-300 (3B5B), operated by Korean
Air Co. Ltd. as Korean Air flight 801 from Seoul, Korea (RKSS) to Agana, Guam, crashed onapproach to runway 6 Left at the Guam International Airport (PGUM).
At the time of the accident the glide slope associated with the instrument landing system
(ILS) to runway 6L was out of service, and the crew was conducting a localizer approach tothe runway when the airplane contacted high terrain approximately 3 nautical miles southwestof the airport.
The 0132 reported weather at PGUM indicated that the wind was from 090º at 6 knots; visibil-ity was 7 statute miles with showers and there was a scattered layer of clouds at 1,600 feet, abroken layer at 2,500 feet and an overcast cloud layer at 5,000 feet.
While in U.S. airspace the flight was operated as a scheduled passenger flight under 14
Code of Federal Regulations (CFR) Part 129. There were two pilots, one flight engineer, onepurser, nineteen flight attendants (including six deadheading flight attendants) and 231 pas-sengers aboard the airplane at the time of the accident. The airplane was destroyed by im-pact forces and a post-accident fire. Of the 254 occupants on board, 225 were fatally injured,and 25 passengers and four flight attendants survived the accident with minor to serious inju-ries. During the 30 days following the accident, two passengers and one deadheading flightattendant who initially survived the accident succumbed to their injuries. D. DETAILS OF THE INVESTIGATION
Phase I of the operations group investigation began on August 7, 1997 when the opera-
tions group convened at the Parc Hotel in Tumon, Guam. The Korean Ministry of Constructionand Transportation (M.O.C.T.) assigned Mr. Kim, Jae-Young as their representative for thisphase of the investigation. While in Guam, members of the operations group examined theaccident site and interviewed crewmembers of other airline companies who were operating inthe vicinity of Guam International prior to and after the accident of Korean Air 801. DuringPhase I, materials, manuals and data were requested from Korean Air and the FAA.
Phase II of the investigation began on August 11, 1997 when the operations group con-
vened in Seoul, Korea. Captain Lee, Kwang-Suk represented the Korean M.O.C.T. for thisphase of the investigation. The operations group toured the Korean Air headquarters facilitiesin Seoul and the training facilities at Inchon. Interviews were conducted with Korean Air pilots,instructors, supervisory pilots, check-airmen and management personnel. Members of the Ko-rean M.O.C.T. were also interviewed. Additional materials and data were requested from theKorean M.O.C.T. and Korean Air. Factual Page 6 E. HISTORY OF FLIGHT
According to Korean Air records the accident crew arrived at the Dispatch Center in the Ko-rean Air Headquarters building at least two hours prior to the scheduled departure time ofKorean Air 801.3 Proposed departure time from Kimpo Airport was 2105. The flight plan for Korean Air 801 listed a different captain’s name. The accident captainhad originally been scheduled to fly to Dubai, United Arab Emirates, but when it becameapparent that he would not have had adequate crew rest, he was assigned the shorter tripto Guam and replaced the original captain. The original captain’s name was crossed outand the accident captain’s name was added. The accident captain’s previous trip hadbeen a flight from Seoul to Hong Kong on August 3, 1997, with a return to Seoul on August4, 1997.4 Korean Air personnel stated that the accident flight crew met in the Dispatch Center areaand collected the necessary trip paperwork. They conducted a self-briefing and then pro-ceeded to their assigned supervisor of flying for the supervisor briefing.5 The supervisor offlying who briefed the accident crew was a retired Korean Air B-747 captain with approxi-mately 23,330 hours total flying time. He had been a supervisor of flying since December26, 1996. The supervisor of flying said he reviewed the flight data and asked about the weather en-route and at Guam. He said there was some discussion about Typhoon Tina and the pos-sibility of enroute turbulence. The supervisor of flying said he recommended maximum useof the weather radar to the flight crew. He said he checked their ratings, licenses, passports and company identification. He saidthat he did not check whether the crewmembers carried the proper manuals or whethertheir manual revisions were up to date. He said that he frequently checks those items. The supervisor of flying said he discussed company notices with the accident crew. Hestated that they did not discuss the NOTAMS6 at Guam nor did they discuss the out-of-service glideslope associated with the 6L ILS at Guam because the crew did not mentionthem. He said his main concern was to confirm that crews had closely studied their trippaperwork. The supervisor of flying said he had never flown with the accident captain and did not knowhim personally. However, he said the accident captain seemed absolutely normal and notat all fatigued. He said he had flown with the accident flight engineer and had known himfrom the military when they had served together during the Viet Nam War.
3 The Korean Air Operations Manual requires B-747 crewmembers to show up at the Dispatch Center (or otherdesignated place) no later than 1 hour 20 minutes prior to the scheduled departure time for a domestic flight andno later than 1 hour 30 minutes prior to the scheduled departure time for an international flight.
4 Captain’s Flight Activity Record included in attachments.
5 Supervisor briefing explained in Korean Air Procedures section. Factual Page 7
According to Korean Air records and witness interviews, the accident crew followed com-pany pre-departure check-in, trip planning and dispatching requirements. The weight andbalance manifest for the flight was approved by the captain at 2108. Korean Air flight 801blocked out from the gate at 2127 and took-off at 2153. According to ATC transcripts7 Korean Air 801 contacted Guam Center and Radar Ap-proach Control (CERAP) at approximately 0103 Korean Air 801 was at FL4108 and overMIXSS intersection which is approximately 240 nautical miles northwest of the Nimitz VOR. ATC transcripts indicate that Guam CERAP told Korean Air 801 to expect runway 6L whichthey acknowledged. At approximately 1522 UTC, Guam CERAP informed Korean Air 801that ATIS9 information “Uniform” was current and the altimeter setting was 29.86” hg. Ko-rean Air 801 answered that they were “checking Uniform” but they did not acknowledge thealtimeter setting. Two minutes later Korean Air 801 began deviating around weather. At approximately 0131 Korean Air 801 stated they were clear of “Charlie Bravo”10 and re-quested radar vectoring for runway 6L. Korean Air 801 was given radar vector headings byGuam CERAP and at approximately 0139 was cleared to intercept the localizer11 whichwas acknowledged by Korean Air 801. At approximately 0140, Guam CERAP cleared Korean Air 801 “for ILS 6L approach,glideslope unusable.” Korean Air 801 acknowledged they were cleared for the ILS ap-proach. The flight did not acknowledge that the glideslope was unusable. At approximately 15:41 UTC, Korean Air 801 was told to contact Agana Tower, which theyacknowledged. Korean Air 801 crashed near the summit of Nimitz Hill at approximately 0142. At the approximate time of the crash a Ryan International B-727 was approximately 125nautical miles to the southeast of Guam. The Ryan first officer said he noticed a red glowilluminate the clouds surrounding Guam which flared up and quickly died out. By the timehe could bring it to the attention of the other crewmembers the flare up was no longer dis-cernible. When ATC was unable to reestablish contact with Korean Air 801, they requested that theRyan crew assist them in locating the missing flight. They were given radar vectors overNimitz Hill where they spotted what they described as “a big fire on the hill.”
F. PERSONNEL INFORMATION
7 Excerpts from ATC transcripts included in ATC Group Factual
8 Flight Level 410 (FL410) - 41,000 feet above sea level based on an altimeter setting of 29.92” hg, (QNE).
9 Automated Terminal Information Service (ATIS).
10 “Charlie Bravo” (CB) - cumulonimbus clouds
11 the component of an instrument landing system (ILS) which provides lateral guidance. Factual Page 8
All three crewmembers were certified in compliance with existing Korean Air and M.O.C.T. 1. THE CAPTAIN Captain Park, Yong-Chul According to Korean Air records, the following information
The captain was born on September 20, 1954 and was hired by Korean Air on November
2, 1987. Prior to his employment with Korean Air, the captain was a pilot in the Korean AirForce.
He flew as first officer on the Boeing 727 and on the B-747. He received a type rating on
the B-727 on November 15, 1988, and a type rating on the B-747 on November 17, 1990. Company records indicate the captain had approximately 8,932 hours total flying time, includ-ing 2,884 hours as a military pilot and 6,048 hours as a civilian pilot.
A synopsis of his flight experience with Korean Air follows:Qualified as B-727 first officer:
Total flight time as B-747 first officer:
The captain’s recency of flight experience follows:Previous 7 days flight time (including accident flight):
Previous 30 days flight time (including accident flight):
Previous 60 days flight time (including accident flight):
Previous 90 days flight time (including accident flight):
The captain’s experience and training pertaining to Guam operations were as follows:Guam airport familiarization audio-visual presentation:
The captain’s latest pertinent training:Route Check (SEL-NRT-SEL)
Factual Page 9
The captain’s last route check prior to the accident was a route check from Seoul to Narita
and return on July 19, 1997. The total elapsed time was 4:42 hours. Weather at Narita andSeoul was well above minimums and the winds were less than 10 knots. Both approacheswere full ILS. The Captain was given an “above standard” evaluation on that check.
The captain’s last proficiency check prior to the accident was a simulator proficiency check
on June 11, 1997. The total elapsed time was 2:00 hours. During the check ride the captainexecuted a VOR / DME approach to runway 32L at Kimpo. The weather for the approach was900 feet overcast, wind 290/11 kts. The captain was given an “excellent” evaluation for thatcheck.
A Korean Air spokesperson stated that the captain had taken and passed the Level 3 Pilot
English Test12 and had attended Crew Resource Management (CRM) training. However, thedates of attendance could not be determined from available records. 2. THE FIRST OFFICER First Officer Song, Kyung-Ho According to Korean Air records, The following informa-
tion pertains to First Officer Song, Kyung-Ho:
The first officer was born on December 15, 1956, and was hired by Korean Air January
10, 1994. He was a graduate of the Korean Air Force Academy and prior to his employmentwith Korean Air, the first officer was a pilot in the Korean Air Force.
He received a type rating on the B-747 March 11, 1995. Company records indicate the
first officer had approximately 4,066 hours total flying time, including 2,276 hours as a militarypilot and 1,790 hours as a civilian pilot.
A synopsis of his flight experience with Korean Air follows:Qualified as B-747 first officer:
The first officer’s recency of flight experience follows:Previous 7 days flight time (including accident flight):
Previous 30 days flight time (including accident flight):
Previous 60 days flight time (including accident flight):
Previous 90 days flight time (including accident flight):
The first officer’s experience and training pertaining to Guam operations are as follows:Guam airport familiarization audio-visual presentation:
The first officer’s latest pertinent training:Proficiency Check (Simulator)
Factual Page 10
The first officer’s last proficiency check prior to the accident was a simulator proficiency
check on March 28, 1997. The total elapsed time was 2:00 hours. During the check ride thefirst officer executed a VOR / DME approach to runway 32L at Kimpo. The weather for theapproach was 900 feet broken, wind 260/11 kts. The first officer was given an “above stan-dard” with instructor comments which stated, “control skills and knowledge are above stan-dard” as a total evaluation for the checkride. He was given an evaluation of “standard” fornon-precision VOR approaches but the instructor’s comment for the non-precision VOR ap-proach stated: “altitude management on non precision approach somewhat less than desir-able. Another instructor commented relative to an evaluation criteria titled, Adherence to Law& Regulation, “Somewhat slow to carry out directions.”
According to Korean Air records, the first officer was not observed during a route check
A Korean Air spokesperson stated that the first officer had taken and passed the Level 3Pilot English Test13 and had attended Crew Resource Management (CRM) training. How-ever, the dates of attendance could not be determined from available records. 3. THE FLIGHT ENGINEER Flight Engineer Nam, Suk-Hoon According to Korean Air records, The following infor-
mation pertains to Flight Engineer Nam, Suk-Hoon:
The flight engineer was born on December 20, 1939, and was hired by Korean Air May 7,
1979. He was a graduate of the Korean Air Force Academy and prior to his employment withKorean Air, the flight Engineer was a navigator in the Korean Air Force.
With Korean Air, he flew as a flight engineer on Boeing B-727, Airbus A-300, and Boeing
B-747 airplanes. Company records indicate the flight engineer had approximately 13,065hours total flying time, including 1,977 hours with the military and 11,088 hours as a civilianflight engineer.
Korean Air records indicate the flight engineer received a medical certificate on June 17,
A synopsis of his flight experience with Korean Air follows:Qualified as Boeing B-727 flight engineer:
Total flight time, B-727 flight engineer:
Qualified as Airbus A-300 flight engineer:
Total flight time, A-300 flight engineer:
Qualified as Boeing B-747 flight engineer:
Total flight time, B-747 flight engineer:
Factual Page 11
The flight engineer’s recency of flight experience follows:Previous 7 days flight time (including accident flight):
Previous 30 days flight time (including accident flight):
Previous 60 days flight time (including accident flight):
Previous 90 days flight time (including accident flight):
The flight engineer’s latest pertinent training:
The flight engineer’s last proficiency check prior to the accident was a simulator profi-
ciency check on March 7, 1997. The total elapsed time was 2:00 hours. The flight engineerwas given a “above standard” total evaluation and the instructor comments for the totalevaluation were, “control skills and knowledge are above standard.” Crew coordination wasrated “above standard.”
The flight engineer was observed on two route checks in April 1997. On April 18, 1997 his
overall evaluation was “above standard” and the instructor’s overall comment stated, “controlskills and knowledge are above standard.”
On the April 18, 1997, route check he was given an overall evaluation of “excellent” and
the instructor’s overall comment stated, ‘control skills and knowledge are excellent.”
The flight engineer’s CRM skills for the two route checks were rated “above standard” and
A Korean Air spokesperson stated that the flight engineer had taken and passed the Level
3 Pilot English Test14 and had attended Crew Resource Management (CRM) training. How-ever, the dates of attendance could not be determined from available records. G. TOXICOLOGY
The forensic toxicology report is included in the attachments. H. FLIGHT CREW HISTORIES Factual Page 12 1. MEDICAL FACTORS
According to his brother, the captain was very healthy and there had been no changes
in his health in the past 12 months. The brother stated that the captain drank alcohol, butnever more than 2 or 3 drinks, did not smoke, and did not take prescription medicine. Thecaptain held a valid First Class Korean airman’s medical certificate dated March 13, 1997. Healso held a valid FAA First Class Airman’s Medical Certificate dated March 13, 1997, with norestrictions. His height was 69 inches and weight as 168 pounds. His distant vision was 20/20without correction, and near vision as 20/30 in the right eye and 20/20 in the left eye withoutcorrection.
According to his brother, the first officer’s health was very good and had not changed in
the past 12 months. The brother stated that the first officer did not drink alcohol because ofreligious beliefs, did not smoke, and did not take prescription medicine although he usedherbal medicines. The first officer held a valid First Class Korean airman’s medical certificatedated June 13, 1997. He also held a valid FAA First Class Airman’s Medical Certificate datedJune 13, 1997, with no restrictions. The examination noted prior history of tuberculosis,treated from January to June, 1980. No change was noted in history since the last examina-tion. His height was 64.3 inches and weight as 137 pounds. His distant and near vision wereboth 20/20 without correction.
According to his family, the health of the flight engineer was very good and had not
changed in the past 12 months. He used glasses for close work. He drank alcohol sparinglyand smoked tobacco. He did not use prescription medicine, but took herbal medicine. Theflight engineer held a valid First Class Korean airman’s medical certificate dated June 5, 1997
The crewmember’s bodies were not refrigerated for the first 2 days following the acci-
dent, and were in states of moderate to severe postmortem decomposition. Fluid and tissuespecimens were obtained from the bodies of all three crewmembers at autopsy and were usedfor toxicological testing at the FAA Civil Aeromedical Institute Toxicology Laboratory. The toxi-cological test results are attached to this report. For the captain, blood and urine samplestested positive for alcohol and acetaldehyde, and a vitreous fluid sample tested negative foralcohol. The laboratory noted that the alcohol “found in this case is most likely from postmor-tem ethanol production.” For the first officer, blood, muscle, and brain samples tested positivefor alcohol and acetaldehyde, and blood tested positive for n-butanol. For the flight engineer, ,blood, muscle, and brain samples tested positive for alcohol and acetaldehyde, and bloodtested positive for n-propanol and n-butanol. The laboratory noted that the alcohol “found inthis case may be the result of postmortem production.” Urine samples from all three crew-members tested negative on a screen for abused drugs.
In autopsy examination, identifiable fragments of food material were found in the stom-
ach contents of all three crewmembers.
Among personal effects found in the wreckage, in a crew bag, investigators found a
plastic pill container labeled “Cartilex, shark cartilage” containing 25 capsules of varied shapesand colors. Toxicology testing detected melatonin in one tablet, and no drugs in the remainingtablets. Factual Page 13
The medical examiner found a packet of tablets, with the name of a Korean physician
at an internal medicine center in Seoul, among the personal effects of the captain. The physi-cian was contacted by investigators, and he confirmed that the captain was a patient of his. The physician’s records provided the following information: the physician examined the cap-tain on July 27, 1997, and diagnosed bronchitis. He prescribed three medications: Copan(clenbuterol), a medication which opens up the upper airways; Sentil (clobazam), an anti-anxiety medication in the benzodiazepine class of drugs occasionally used as a sleep aid; andVibramycin (doxycycline), an antibiotic. The physician prescribed the Sentil at half its usualdosage because of the captain’s occupation as an airline pilot. (Note: a portion of the toxicol-ogy evaluation at the FAA Civil Aeromedical Institute Toxicology Laboratory was a screen forbenzodiazepines, including clobazam, in the captain’s blood: no indications were found of itspresence.)
Company records indicate that on July 28, 1997, at 0535 (UTC), the captain departed
on a 10 hour 36 minutes trip from Seoul to San Francisco. He returned from San Franciscothe following day, arriving in Seoul at 0748 (UTC) on July 30. The captain did not advise thecompany prior to this trip that he had been diagnosed with bronchitis and treated with pre-scription medications, and did not receive medical approval from the company to conduct thistrip
The Korean Air Operations Manual (5/21/97, Chapter 4-12-4) requires that a crewmember
who “must be on duty under influence of medication, shall follow the direction of an Aeromedi-cal Specialist.” The Korean Ministry of Transportation Aviation Regulations (12/14/91, Provi-sion 47) indicates that a pilot shall not be on flight duty under the influence of alcoholic bever-ages, anesthetics or any other drugs that will jeopardize the safe operation of an aircraft. TheICAO Standards Annex 1 (11/16/89, Section 1.2.6.) specifies that license holders shall not ex-ercise the privileges of their licenses and related ratings at any time when they are aware ofany decrease in their medical fitness which might render them unable to safely exercise theseprivileges. 2. INTERVIEWS OF FLIGHT CREW FAMILY MEMBERS
The Human Performance investigator conducted interviews of family members for each
of the three flight crewmembers. Interview summaries are attached. Mr. Park, Yung-Kil Brother of the Captain
On August 8, 1997, the Human Performance investigator interviewed Mr. Park at the PacificStar Hotel, Guam. Questions were asked in English and answered in Korean, with Mr. HanChar Ki, of the Korean Senior Youth Association, Guam, serving as the interpreter. Mr. Parkprovided the following information:
Mr. Park’s last contact with his brother, Captain Park, was in a telephone conversation
around 1300-1400 on Tuesday, August 5. They discussed the captain’s plans the next day to
Factual Page 14
bring his wife and two children on a visit to his relatives living in the countryside (including hismother and Mr. Park). The captain lived in Seoul. On the evening of August 6, following hisreturn from the trip to Guam, the captain, his wife, and their children planned to take a com-mercial flight to Sachon Airport, Kyeongnam, Korea. They would arrive around 2000, and heasked Mr. Park to pick them up at the airport. The captain sounded bright and excited. Hewas in a very good mood.
The captain and his wife had been married for 20 years. Within the past 12 months,
there had been no major changes in his personal or financial conditions. He owned twohouses (renting out one), earned a good income and lived comfortably. He had very good re-lations with his whole family. Mr. Park usually received telephone calls from the captain 3 or 4times per month. He had great respect for the captain, and described him as very industriousand pleasant. He said the captain was a simple man.
Mr. Park did not know the captain’s specific activities in the days before the accident.
The captain usually spent his days off duty with his family, and enjoyed activities such as pic-nics. The captain ate his meals with his family in the days before the accident, and nobody inthe family reported being sick from the food.
The captain wanted to be a pilot when he was young. He was one of 9 children, and
the only one to enter aviation (although a sister married a pilot). He was admitted to the Ko-rean Air Force school, was an excellent student, and flew jets in the Korean military prior to hisemployment with Korean Air. He did not have any previous aviation accidents. He was sup-posed to become a flight instructor with the company. Several times, he received safety rec-ognition. The captain often flew at night, including long trips to Europe. He never complainedabout anything involved in flying. He kept aviation study materials at home.
The captain was very healthy and there had been no changes in his health in the past
12 months. He hiked in the mountains and always took care of himself. He did not wear cor-rective lenses. He drank alcohol, but never more than 2 or 3 drinks. He did not smoke to-bacco, and did not take prescription medicine. Mr. Park, Yung-Kil Brother of the Captain
On August 9, 1997, the Human Performance investigator had a second interview with Mr. Parkat the Pacific Star Hotel, Guam. Questions were asked in English and answered in Korean,with Mr. Han Char Ki, of the Korean Senior Youth Association, Guam, serving as the inter-preter. To assist the NTSB, Mr. Park had telephoned the wife of the captain to obtain furtherinformation concerning the captain’s activities before the accident. Based on his conversationwith Mrs. Park, he provided the following information:
When he was off duty, the captain normally went to bed between 2200-2300, and
awoke between 0600-0630. On Friday, August 1, the captain was off duty. He went to bedbetween 2200-2300. On Saturday, August 2, he awoke between 0600-0630 . He flew a trip toCheju Island and returned home about 1700. He went to bed between 2200-2300. On Sun-day, August 3, he awoke between 0600-0630. He flew a trip to Hong Kong and overnightedthere. On Monday, August 4, he returned home around noon. He followed routine activities
Factual Page 15
around the house, including reading the newspaper and watching television, and went to bedat his normal time. On Tuesday, August 5, he awoke at 0600. He went to the gym for 1 hour,then returned home and ate breakfast. He studied the flight schedule for his upcoming trip toGuam. He took a nap from 1100 to 1340, then arose and ate lunch. It consisted of vegeta-bles, his usual lunch. He departed for the airport, a 20 minute drive, at 1500. The flight wasscheduled at 2000, but he left home early, his usual practice, to allow time to prepare for theflight. Mr. Song, Seung-Ho Brother of the First Officer
On August 8, 1997, the Human Performance investigator interviewed Mr. Song at the
Pacific Star Hotel, Guam. Questions were asked in English and answered in Korean, with Mr. Han Char Ki, of the Korean Senior Youth Association, Guam, serving as the interpreter. Mr. Song provided the following information:
Mr. Song’s last spoke with his brother, First Officer Song, in a telephone conversation
on Tuesday, July 29. The first officer was the oldest of 5 brothers and, as the eldest son, wasresponsible to take care of the parents. He missed visiting them at the last holiday because ofhis work, and he asked Mr. Song to take good care of the parents in his absence.
The first officer spoke by telephone with his mother about 1700 on Tuesday, August 5.
It was a brief call. He had not expected to fly to Guam, but, since he would receive time offduty after the trip, indicated that he would visit the mother and brother in the countryside. Thefirst officer lived in Seoul. It was a normal call, and everything seemed routine.
Many people travel between Korean and Guam now which is a common vacation time,
so there was a change of schedule to send a larger airplane on the flight to Guam. The firstofficer learned of this change about 2 days before the trip, or at least was advised then thatthis trip was possible. The first officer had flown to Guam many times before.
The first officer lived alone and Mr. Song did not know the specifics of his activities be-
fore the accident. The first officer married in 1981, and was the father of two teenage sons. Since March, 1997, the wife and sons lived in New Zealand to further the education of theboys. The first officer visited them in New Zealand and did not mind living alone. He enjoyedoutdoor sports and attended church on Sunday.
The first officer was the only member of the family to enter aviation. He dreamed of
flying when he was a boy, and he passed a competitive test to enter the Air Force flyingschool. He really enjoyed flying. As an Air Force pilot, in 1984, he received a PresidentialAward for escorting a defecting pilot from North Korea to a landing. The first officer was doinga training flight when the pilot entered South Korean airspace in a MIG airplane and an-nounced his intentions to defect. Within Korean Air, the first officer sometimes taught pilotclasses and was recognized. The first officer did not have previous aviation accidents oremergencies. Factual Page 16
The first officer’s financial situation was very good, and there had been no major
changes in it in the past 12 months. There had been no major changes in his personal lifeduring this period other than his wife and children moving to New Zealand. He always hadenergy to fly demanding flight schedules and always was ready for any trip. Mrs. Nam, Pae-Malhee Wife of the Flight Engineer Mr. Nam, Gun-Woo Son of the Flight Engineer Mr. Ko, Sung-Yong Friend of the Flight Engineer
On August 8, 1997, the Human Performance investigator interviewed Mrs. Nam at the
Pacific Star Hotel, Guam. Mr. Nam and Mr. Ko were present and also contributed informa-tion. Questions were asked in English and answered in Korean, with Mr. Han Char Ki, of theKorean Senior Youth Association, Guam, serving as the interpreter. Mrs. Nam provided thefollowing information:
Mrs. Nam’s last contact with her husband was on Tuesday morning, August 5, around
0900-0930, when he departed the house for his upcoming trip. He said he would be homeabout 0900 the next day, and Mrs. Nam thought he might be returning from Guam as a pas-senger. Nothing was unusual; his mood was normal.
On Sunday, August 3, the flight engineer returned in the morning from a trip to New
York and Alaska. He stayed at home doing routine activities. He was off duty on Monday anddid routine activities at home. She thinks that he had flown to Guam before, but was not sure. He had been flying the A-300 for 10 years, so he probably flew into Guam many times. [Nofurther information could be obtained regarding the activities or sleeping history of the flightengineer before the accident.]
Mr. Nam is in the military and does not live at home. He last talked with his father by
telephone on Wednesday evening, July 30, and the father advised him to take care of himselfin the Army. The father was doing well.
Mr. Ko, who is a flightcrew member with Korean Air, last saw the flight engineer at the
company two days before the accident around 0900. The flight engineer was happy andsmiling. He had just returned from Moscow, and was going to Cheongju Island.
The flight engineer married in 1970 and was the father of 3 children. According to Mr.
Ko, he graduated from the pilot academy in 1963 and received military training as a pilot butdid not succeed in the program. He became an air traffic controller and then, in 1965, re-ceived navigator training from the United States Air Force. He flew combat missions in theVietnam war as a navigator for the Korean military. Following this, he began employment withKorean Air. He was not a pilot. He had not experienced any previous aviation accidents oremergencies. About 3 years ago, he received recognition from the company. Mr. Ko thought
Factual Page 17
that the accident trip was the first time he flew with Captain Park and First Officer Song. Hetrained as a B-747 flight engineer two years ago, but only begin flying this position in the pastseveral months.
According to Mrs. Nam, the financial situation of the flight engineer was stable. His finan-
cial and personal situations had not changed in the past 12 months. His health was very goodand had not changed in the past 12 months. He was slim and light but strong, very healthy. He was very industrious, a golf player, and took good care of himself. He liked things to bedone perfectly, and never had any small mistakes. 3. ACCIDENT CREWMEMBER’S FLIGHT SCHEDULES
The accident crewmembers flight schedules for June, July, and August 1997, are included
I. KOREAN AIR PROCEDURES 1. SELF BRIEFING
The Korean Air Operations Manual (page 4-36) states that crewmembers are required to
show up at the Dispatch Center or any other place designated, 1 hour 30 minutes prior toscheduled departure time for international flights. However, a company spokesperson saidthat pilots are required to arrive 2 hours prior to their trip.
Company procedures at the time of the accident directed flight crewmembers to receive
their trip paperwork at the Dispatch Center then gather as a group at one of the tables in theself briefing area to study the paperwork. This was referred to as the self-brief phase of pre-flight operations.
Approximately 15 minutes was allocated for this phase since the supervisor-brief was
scheduled to begin 1 hour 45 minutes before departure time. 2. SUPERVISOR OF FLYING BRIEFING
The supervisor of flying system is a program which had been in place at Korean Air ap-
proximately one year prior to the accident. Korean Air officials described the supervisors offlying as retired captains and instructors who had been among the most experienced pilotsand who had no previous record of disciplinary action. After crewmembers review their flightpaperwork during the self-brief phase of preflight preparations they report as a group to theassigned supervisor of flying 1 hour and 45 minutes prior to scheduled departure time.
A company spokesperson said that the function of supervisors of flying is to insure that
pilots have reviewed all materials for the trip including the NOTAMS. Supervisors of flying also
Factual Page 18
periodically spot check Jeppesen and other required manuals including the revision dates. They also spot check licenses, ratings, passports and identification badges.
15 minutes was allocated for the supervisor-brief but, it averaged about 10 minutes. The
company spokesperson also stated that crews did not like the supervisor-brief at first becausethey considered it a cumbersome procedure, but by the time of the accident they had ac-cepted it. 3. FULL CREW BRIEFING
Following the supervisor-brief, the pilots went to the flight attendant area to meet with the
cabin crew. The captain provided a briefing to the entire crew which lasted approximately 5minutes. After the full crew briefing the entire crew boarded company buses for the ride to theairplane. 4. AUDIO VISUAL AIRPORT FAMILIARIZATION
Since June 1, 1997, Korean Air had incorporated an audio-visual presentation for airport
familiarization. The program was purchased from Japan Airlines and was used to satisfy pilotrequirements for operations into designated special airports.
Guam International was not classified as a designated special airport and viewing the
Guam video was not required. However, a Korean Air spokesperson said it was recom-mended to pilots that they view the video if they had not been into Guam within the preceding3 months.
The audio visual system was available for pilots to view on their own, 6 days a week. It
was not available for viewing on Sunday. After viewing the audio-visual presentation, pilotsrecorded their name and other pertinent data on a sign-in sheet in the audio-visual room.
Company records indicate that Captain Park, Y.C. viewed the Guam audio-visual presen-
tation on July 4, 1997. First Officer Song, K.H. viewed the Guam audio visual presentation onJuly 8, 1997.
The script narration for the Guam audio-visual airport familiarization is included in the at-
The accident captain had last flown into PGUM on July 4, 1997, which was the same trip
sequence as the accident flight. The first officer from the July 4, 1997, flight stated the acci-dent captain telephoned him the day before and asked him to report to the Dispatch Centerearlier than normal in order to get a familiarization briefing for PGUM. The first officer said hemet the captain approximately 1 hour prior to the normal check-in time and watched thePGUM audio-visual presentation and received a unfamiliar airport briefing.
The first officer who flew with the accident captain on July 4, 1997, said the accident cap-
tain reminded him that the Nimitz VOR was located in a mountainous area which called for
Factual Page 19
care. He said the accident captain used the term “black hole” which was a term the first officerwas not familiar with. 5. BRIEFING OF UNFAMILIAR AIRPORT
The Korean Air Operations Manual stated unfamiliar airport briefings should be imple-
mented for unscheduled or charter operations to unfamiliar airports. The Operations Manualindicated that that unfamiliar airports refers to an airport to which Korean Air had no experi-ence of flight operations within one year.
The Operations Manual recommended that a MOCT-commissioned Checker Captain be
included on the crew being dispatched to an unfamiliar airport. If the MOCT-commissionedChecker Captain was not available then the pilot-in-command should have at least one of thefollowing:
• 1500 flight hours as PIC on the aircraft type.
• 1000 flight hours as PIC on the aircraft type and certified as a flight instructor on the air-
• 1000 flight hours including 500 or more as PIC on the aircraft type and experience of
one round trip to concerned airport within last 6 months and obtained approval of Teammanager of Flight Crew Evaluation and Analysis Team.
In addition, the Operations Manual recommends that if a captain has not flown the type of
airplane to the unfamiliar airport within the preceding year, the crew shall be briefed by theTeam manager of the Flight Operations Standards Team. LOCAL CONDITIONS - GUAM AREA 1. GENERAL
Members of the operations group interviewed the crew of a B-747 which preceded Korean
Air 801 to Guam. Members of the operations group also interviewed the crew of a B-727which landed at Guam International just after the accident. Other pilots based on the island ofGuam were also interviewed15.
The airline pilots interviewed agreed that runway 6L is the preferred runway. None could
recall ever landing in the opposite direction on runway 24. In visual conditions the B-747 andB-727 pilots stated that it was standard procedure to turn base leg inside Nimitz Hill whenlanding on runway 6L.
The pilots agreed that most approaches into Guam were made in visual conditions and a
check airman stated that there is a tendency for crewmembers to press on, hoping to regain
15 Interview summaries included in attachments. Factual Page 20
visual contact once it is lost. A training check-airman stated his biggest worry about crewsflying into Guam was complacency.
The pilots all stated that rain showers throughout the area are very common. Generally
they are small, very localized and usually isolated. It is not unusual for pilots to fly in and outof clouds while maneuvering and losing ground or airport contact for only short periods of time. The Continental Air Micronesia chief pilot stated that a person unfamiliar with the airport mak-ing the descent may have a sense of complacency if he had the field in sight.
A check-airman stated that there are usually build-ups in the vicinity of Guam as is typical
in the South Pacific. He said the trade winds tend to move the weather toward Nimitz Hill. The Continental Air Micronesia Chief Pilot/Guam Operations said in his experience he has runinto a lot of “heavy weather” over the VOR16. He also stated that an approach to runway 6Lwithout a glide slope had to be well briefed and the pilots had to pay close attention to the ap-proach to make it successful
A Continental Air Micronesia check-airman said he briefs crews that it is possible to get a
GPWS17 warning on approach over Nimitz Hill if the airplane is not in the landing configuration. He also stated that in his experience the DME18 associated with Nimitz VOR is never intermit-tent or unreliable. It has always worked normally or has not worked at all. 2. WITNESS OBSERVATIONS (a.) CONTINENTAL AIR MICRONESIA
A Continental Air Micronesia B-747 arrived at Guam from over PAYEE intersection, 240
nautical miles north of the Nimitz VOR. They were approximately 30 minutes ahead of KoreanAir 801. A synopsis of their observations regarding their arrival at Guam are as follow19:
• Visibility was excellent from Payee intersection. There were scattered thunderstorms be-
tween Payee and the Nimitz VOR. There was “weather” over the Tumon area but no con-vective activity and no lightning.
• Their weather radar indicated “weather” over the Nimitz VOR.
• They saw there was rain over the Nimitz VOR but not from the VOR to the airport. How-
ever, after landing and taxiing to the gate it began raining and by the time the crew wasgetting on the crew bus there was “moderate rain” at the field.
• At 2,600’ (Qnh)20 visibility was not so good because of clouds and rain showers. Below
2,600’ the visibility improved and at 2,000’ they could see all the way to the airport.
17 Ground Proximity Warning System (GPWS)
19 Witness interview summaries included in attachments. Factual Page 21
• The ride was smooth with no turbulence.
• The ATIS mentioned the glide slope was not functioning although they could not remember
• They did not recall ATC commenting that the glide slope was inoperative during their com-
• They stated that the glide slope was “flagged off” on their instruments.
• They made a visual approach and turned final inside the VOR. RYAN INTERNATIONAL
A Ryan International B-727 arrived at Guam from Truk Island. Their flight path was from
the southeast and they arrived in the vicinity of Nimitz VOR approximately 15 minutes after theaccident. A synopsis of their observations regarding their arrival at Guam are as follows21:
• Visibility was good enough from the southeast to see the lights of Guam from approxi-
• The radar indicated some clouds northeast and southeast of Guam.
• Approximately 100 - 125 miles out the first officer saw a red glow illuminate the clouds sur-
• The DME was operating at the time the crew saw the red flash illuminate the clouds ap-
proximately 100-125 miles from the VOR. The last time they noticed the DME operatingwas when they were approximately 25 miles from the VOR.
• The ATIS mentioned the glideslope was inoperable.
• They recall ATC advised another crew the glideslope was inoperable but, were not certain
• ATC did not advise the Ryan crew that the glideslope was inoperable until they were vec-
• They did not ever recall ATC advising flight crews of high terrain on the approach path.
21 Witness interview summaries included in attachments. Factual Page 22
• During past flights they recalled occasionally getting GPWS22 alerts while making visual
• 100 miles from Guam it became more difficult to see the island because of clouds at a
• The radar indicated some clouds over the shoreline and some lightning flashes 50-80 miles
• Southwest of the airport, while being vectored at 2,600 feet, they were in and out of the
clouds and It was difficult to keep the runway in sight without descending below 2,600 feet. They were in the rain but, they never encountered heavy rain.
• During the vectors they encountered light rain but could sometimes see the airport through
• In the vicinity of the VOR they were mostly in the clouds. However, over the crash site they
were not in the clouds and had ground contact.
• They stated that the Nimitz Hill area is a “black hole” and sometimes at night it is difficult to
distinguish the hill from clouds if any clouds are in the area. They said that if it is raining orclouds are in the area it would be almost impossible to spot the hill or tell the hill from theclouds.
VASI23 would keep the flight path clear of the hill if the VASI was visible.
• The captain said in the past he noticed the runway 6L glideslope and localizer had a slight
• The captain said that he recalled the Guam 6L glideslope had previously been out of serv-
K. TRAINING 1. PILOT RECRUITMENT
According to company management personnel pilot recruitment historically was from the
Korean military. However, as the airline grew the supply of available Korean military pilotscould not keep up with the demand for a rapidly expanding pilot force. In 1989 an ab-initio24program was begun at Korean Air to train pilot candidates from “zero time”. At the time of the
22 Ground Proximity Warning System (GPWS).
23 Visual Approach Slope Indicator (VASI).
24 ab-initio - Literally: From the Beginning. A company program to select candidates who may have no prior flightexperience and to train them from zero flight time. Factual Page 23
accident 389 pilots had been trained under the ab-initio program. According to a companyspokesman, the ab-initio pilots were first assigned to the smaller airplanes flying domesticroutes. As they gained experience they were upgraded to the larger equipment flying interna-tional routes. Korean Air estimated that the first of the ab-initio pilots who began training in1989 would be evaluated for possible upgrade to captain during 1998.
Korean Air also recruited non-Korean national pilots to supplement the pilot force. At the
time of the accident there were 167 foreign pilots employed by Korean Air. There were a mul-titude of nationalities represented, but the majority of the foreign pilots working for Korean Airwere from the United States and Canada. Foreign pilots were hired through several crewleasing companies and their employment was subject to the terms of a renewable contract. 2. GROUND SCHOOL AND FLIGHT TRAINING FACILITIES
Korean Air conducted ab-initio training at the Sierra Academy of Aeronautics, Livermore
Ground instruction was conducted at the Korean Air Flight Crew Training Center in Seoul,
Korean while the simulator flight training was conducted at the Korean Air flight training facilityin Inchon, Korea.
Boeing 747 airplanes were divided into two classifications. The Boeing B-747-100, B-747-
200 and the B-747-300 were classified as “Classics.” The Boeing B-747-400 was a separatecategory. Boeing B-747 pilots were classified as either “Classic” or “B-747-400” pilots. A“Classic” pilot flew all three “Classic” B-747s. Although there was no company policy of dualqualification, a company spokesman indicated that occasionally pilots were dual qualified onthe Falcon Jet only. At the time of the accident Korean Air did not dual qualify B-747 pilots.
The simulator utilized by the B-747 “Classic” pilots was a B-747-200 simulator located at
the flight training facility at Inchon, Korea. It utilized instrumentation and software for JT9Dengines and the flight directors had “Command Bar” type presentations. The B-747-200simulator is Level “C” with a Vital-IV 4W/3CH visual system. 3. CREW RESOURCE MANAGEMENT (CRM)
CRM training was instituted at Korean Air in December, 1986 as a result of the Korean Air
flight 007 shootdown. The CRM program was purchased from United Air Lines and used as amodel.
The four day CRM program is given only to pilots. CRM training was held in a campus-
like setting approximately 1 hour by automobile from Seoul. The size of the class was limitedto 18-24 pilots at a time.
Prior to attending the CRM program, pilots would be given manuals to study and when
they arrived at the CRM location they were given additional materials. Factual Page 24
According to the Korean Air Director of Academic Training, the purpose of the CRM pro-
gram is to help pilots identify and improve their own behavior and attitude. The course em-phasizes conflict and dilemma resolution. During the course, pilots are given problems andconflicts to resolve.
The Director stated the CRM course also emphasizes “advocacy.” Advocacy teaches the
first officers and flight engineers to intervene when necessary. At first there were some “cul-tural” difficulties with the curriculum and there were also difficulties teaching the first officerand flight engineer to intervene. The Director stated that those difficulties were not as preva-lent as when the program first began. He said that advocacy is no longer a problem at KoreanAir.
The Director also stated that captains are taught to encourage advocacy. He said most
captain and first officer briefings contain a mention of advocacy and that the other crewmem-bers should feel free to intervene when necessary.
The Director said that there were no annual CRM recurrent classroom sessions. How-
ever, pilots were evaluated on CRM during route checks and during proficiency check rides. Apilot is given a CRM LOFT25 simulator training period once a year. The CRM LOFT periodlasts approximately 1 ½ hours and CRM principles are evaluated as crewmembers cope withvarious abnormalities during a simulated flight.
The initial four day CRM program was not graded, so there were no grading or pilot
evaluation records from that program. 4. ENGLISH LANGUAGE COMPETENCY
The Director of Academic Training stated that Korean Air has English language training.
English language training emphasizes English as used in aviation. The course is 120 hours ofclassroom study conducted by a teacher whose native language is English, usually an Ameri-can. Pilots receive an additional 25-30 hours of ATC English.
In a letter signed by the General manager of the Korean Air Foreign Language Testing
Team26, pilots were required to pass a Level 3 Pilot English Test. The test evaluated written,listening and speaking competency in English. A minimum passing score of 80% was requiredand failure in any portion of the test resulted in the pilot being retrained and re-tested.
The above mentioned letter also stated that the accident captain, first officer, and flight
engineer all passed the Level 3 Pilot English Test.
26 Copy of letter included in attachments. Factual Page 25 5. BASIC AND ADVANCED COURSE IN INSTRUMENT FLYING
The Basic and Advanced Course in Instrument Flying is given to pilots prior to their Initial
training on the airplane type concerned. The captain was initially trained on the Boeing B-727and the first officer was initially trained on the B-747. As a result, they received the Basic andAdvanced Course in Instrument Flying on those respective airplanes.
The Basic Course consisted of eight simulator periods two hours long while the Advanced
Course consisted of ten simulator periods of two hours each.
The Basic Course modules included basic instrument procedures including airwork, in-
strument departures, instrument arrivals, and instrument approaches.
The Advanced Course modules expanded on the procedures of the Basic Course and
added additional procedures including: avionics operation, SIDs27, noise abatement proce-dures, STARs28, and engine(s) out procedures. 6. FLIGHT CREW TRAINING CURICULLUM
The captain and flight engineer were trained on the B-747 under the Transition Training
curriculum. The first officer was trained under the Initial Training curriculum.
The Initial and Transition flight crew training curriculum29 for the Boeing B-747 consisted
2. Cockpit Procedures Training (CPT)3. Simulator Flight Training4. Airplane Local Training5. Route
(a.) GROUND SCHOOL
The B-747 Initial ground school curriculum included general systems, normal procedures,
abnormal & emergency procedures, weight & balance, performance, limitations, differences,Category II, review, and a test. 177:00 hours was allocated for the B-747 Initial ground schoolcurriculum both for pilots and flight engineers
The B-747 Transition ground school curriculum included general systems, normal proce-
dures, abnormal & emergency procedures, weight & balance, performance, limitations, differ-ences, Category II, review, and a test. 153:00 hours was allocated for the B-747 Transitionground school curriculum both for captains and first officers with type ratings on other air-
29 Outline of B-747 Initial and Transition included in attachments. Factual Page 26
planes. The course curriculum comprised 157:00 for flight engineers who had qualified onother airplanes. (b.) COCKPIT PROCEDURES TRAINING (CPT)
The Initial training syllabus for the CPT was 28:00 hours for pilots and flight engineers.
During Transition training the CPT syllabus was 24:00 for pilots and flight engineers. (c.) SIMULATOR FLIGHT TRAINING
24:00 hours was allocated for the simulator phase of Initial training for both pilots and
flight engineers. During Transition training 20:00 - 24:00 hours was allocated for the simulatorphase.
The simulator profiles listed approach modules used in flight training. The following were
the approach modules listed in the Simulator Training Syllabus of the Korean Air TrainingGuide for captains. The first officer syllabus was similar to the captain’s. The only differencewas the first officer would make ILS approaches instead of 2 engine inoperative approaches. Profile 1 Approach Malfunction Profile 2 Approach Malfunction Profile 3 Approach Malfunction Profile 4 Approach Malfunction Factual Page 27 Profile 5 Approach Malfunction Profile 6 Approach Malfunction Profile 7 Approach Malfunction Profile 8 Approach Malfunction Profile 9 Approach Malfunction Profile 10 Approach Malfunction Profile 11 Approach Malfunction Factual Page 28
The B-747-200 Simulator Training Guide (For Instructor)31 describes procedures for the
various approaches used in the training syllabus. The only non-precision approach describedin the Training Guide is the VOR/DME approach to runway 32R at Kimpo Airport. L. KOREAN AIR APPROACH PROCEDURES 1. CHECKLIST USAGE
The Korean Air checklist philosophy is described in the B-747 Guidebook which stated:
“The normal procedures are the recommended actions necessary to operate the airplane foreach phase of flight. They enable the flight crew to more readily memorize the required items,ensure that all necessary actions have been taken, and minimize the time required.
Normal procedures for each phase of flight are performed by recall, and the normal
checklist is used to ascertain that all the safety items have been accomplished. Each re-sponse to the checklist challenge should be preceded by the verification of the present con-figurations, and the crewmembers should check for conformation. If any disagreements havebeen found between present configuration and checklist response, corrective actions shouldbe taken first before any further checklist challenge.”
The B-747 Guidebook stated that the descent checklist will be performed while descend-
ing through 20,000 ft. ~ 18,000 ft. (1,000 ft. above Transition level in North America.)
The Approach Checklist will be performed following speed reduction to 250 kts. Descend-
ing through 10,000 ft. with inboard landing lights on.
The Landing Checklist will be performed with landing configuration completed, (landing
2. LANDING BRIEFING
The Landing Briefing card stated that the landing briefing should be completed prior to ar-
3. DESCENT AND APPROACH PROCEDURES
The B-747 Guide Book stated the following pertinent procedures (in part) regarding de-
scent and approach procedures:• Preparation for enroute descent:
Factual Page 29
Review terminal charts, check them for proper revision. M. AIRPORT INFORMATION33
The following data was correct regarding Guam International Airport (PGUM) on August 6,
The airport had two parallel runways oriented northeast/southwest. 1. LOCATION: 3 miles NE of Agana, Guam, Mariana Islands
Lat./Long.: N13º 28.9’ E144º 47.6’Elevation: 297 feet MSL34 / 90.5 meters (surveyed)Magnetic Variation: 02E
2. AIRPORT OVERVIEW: Guam International Airport was owned by the United States
Navy and operated under lease by A. B. Won Pat Guam International Airport Authority. Theairport is located on the west central coast of the island of Guam. Obstructions rise to 785feet MSL within 2 nm northeast, 807 feet MSL and 1,035 feet MSL both within 3 nm east, 803feet MSL within 5 nm southwest and 1,532 feet MSL within 11 nm southwest. 3. GUAM WEATHER OVERVIEW: Guam’s climate is influenced by its location near
N13º latitude. Weather patterns are typical of a tropical island and are quite uniform through-out the year. The most significant variation in weather is the amount of precipitation. Guamaverages 247 days a year with measurable amounts of rain. The sky is rarely clear. Mostdays begin with a scattered layer becoming broken to overcast by afternoon. However, VFRconditions prevail approximately 80% of the time year round. The rainy season lasts from Julythrough November when precipitation averages 24 days per month. Typhoons and tropicalstorms are most common during this period, but they can occur at any time during the year. Average monthly rainfall averages 11.7 inches of rain with September being the wettest monthwith an average of 13.3 inches rainfall. IFR conditions occur approximately 13% of the timeduring the afternoon hours from August through October. The prevailing winds during therainy season are from the east averaging 9 knots. 4. AIRPORT OPERATIONS:
Control Tower: Contract - Full timeARTCC35: Honolulu CenterFSS36: Honolulu Flight Service Station (long distance phone call)NOTAMs Facility: PGUM (NOTAM-D service available)Certification: Full FAR Part 139 certification.
33 Airport diagram included in attachments.
35 Air Route Traffic Control Center (ARTCC)
Factual Page 30
Last FAA Inspection: February 6, 1997 (FAA Airports Field Personnel)
5. AIRPORT COMMUNICATIONS: 6. NAVIGATIONAL AIDS TO AIRPORT: 7. RUNWAY 6L/24R: 6L/24R was the longest runway, 10,015 feet long and 150 feet
wide. The surface was grooved asphalt/concrete and was classified in “good condition.” Therunway had high intensity runway edge lights. Runway 6L was the primary landing runwayand the runway with the lowest approach minimums.
Runway 6R was closed to B-747 takeoffs and landings. (See NOTAMS)
Runway 6L had precision instrument markings, but at the time of the accident the mark-
ings condition were classed as “fair”. Runway 6L had a medium intensity approach lightingsystem with runway alignment indicator lights (MALSR). The runway did not have runway endidentifier lights (REILS), centerline lights or touchdown zone lights.
Runway 6L had a 4 box VASI39 located on the left side of the runway. The VASI was cali-
brated for a 3.00º visual glide path angle.
The touchdown elevation of 6L was 256 feet which rose to 297 feet at the far end of the
Instrument approaches that were available to runway 6L were:ILS Category ILOC (GS out)VOR/DMEVOR
37 VHF Omni Range with TACAN, distance measuring equipment. (VORTAC)
39 Visual Approach Slope Indicator (VASI). Factual Page 31 8. NOTAM INFORMATION - GUAM INTERNATIONAL AIRPORT:
The trip paperwork provided to the accident crew by Korean Air Dispatch contained the
WIE-9708080400 2200/0400 MON-FRIRWY06L/24R CLSD,
Series A NOTAM, #112 of 1997 Effective immediately thru 1400(Lcl.) August 8, 1997
Series A NOTAM, #109 of 1997, from 1055, July 7, 1997 until further notice, frequency
Series A NOTAM, #086 of 1997, from 0800, July 7, 1997 until 1900, September 12, 1997,
WIE-UFNUNLIGHTED ANTENNA 5 S PGUM 312FT AGL
Series A NOTAM, #078 of 1997, effective immediately until further notice, there is an un-
lighted antenna 5 miles south of PGUM 312 feet above ground level.
WIE-UFNRWY06R CLSD FOR B747 LANDING AND TKOF ONLYALL OTHRS REMAIN THE SAME
Series A NOTAM, #087 of 1997, effective immediately until further notice, runway 6R
closed for B-747 landing and takeoff only, all others remain the same. 9. AIRPORT RESCUE AND FIRE FIGHTING (ARFF):
Under Title 14 CFR Part 139 Guam International Airport (PGUM) was classified Airport In-
dex D according to the Indices and Aircraft Rescue and Fire Fighting (ARFF) requirements. N. AIRPLANE INFORMATION
Boeing-747 airplanes were used by Korean Air since 1974.
B-747-300 (3B5B), serial number 22487 was purchased new from the Boeing Commercial
Airplane Company. The airplane order was placed on April 10, 1979. The new airplane wasrolled out on November 14, 1984 and had the registration number HL7468. The first flight was
Factual Page 32
made on December 3, 1984 and Korean Air took delivery of B-747 HL7468 on December 12,1984. HL7468 was equipped with JT9D - 7R4G2 engines.
On August 5, 1997 the Korean Air fleet included 20 B-747 “Classic” airplanes. The “Clas-
sic” fleet consisted of the following B-747 types:
Of the 128 captains assigned to the “Classic” 69 were foreign nationals. 1. WEIGHT & BALANCE
The planned weight & balance form signed by the accident captain and the dispatcher in-
Planned passenger weight/incl. cabin baggage:
O. COMPANY HISTORY
Korean Air’s company history began in 1948 when Korean National Airlines (KNA) a gov-
ernment owned company initiated service from Seoul to Pusan. On March 1, 1969 the HanjinGroup took over Korean National Airlines and began privatized operations and was re-chris-tened Korean Airlines.
On August 5, 1997 the Korean Air Fleet consisted of the following airplanes:20
Factual Page 33
The company projected a growth to 175 airplanes by the year 2005. The Deputy Director
of Flight Operations stated that most employees are positive about the company.
At the time of the accident the Republic of Korea was experiencing an economic reces-
sion. The Deputy Director of Flight Operations stated that 1995 was “a good year” but “the lasttwo years were in the red.” He said he did not know the financial condition of the companybut, he was able to convince management to allocate additional funds to implement safetyprograms.
He said it was difficult to obtain qualified pilots. As a result, Korean Air initiated ab-initio
training and also began recruiting foreign pilots.
In addition to their domestic route structure Korean Air routes extended to North America,
Europe, The Middle East, Southeast Asia, China, Australia, and Japan. P. ADDITIONAL INFORMATION
In the cockpit area of the accident wreckage investigators found an approximately 8½ X
11 inch clear plastic sleeve containing Jeppesen approach plates for Guam International Air-port40. The approach plates contained in the plastic sleeve were:
Charts 11-1 and 13-2 were side by side visible through one face of the plastic sleeve and
16-1 and the blank side of an approach plate were visible through the other. Chart 11-1 hadthe following items highlighted with a green fluorescent tint:
Plan View: In the ILS facilities box: 063º (inbound magnetic course), 110.3 (ILS freq.), IGUM (identi-
FLAKE (initial approach fix). In the VOR facilities box: 115.3 (NIMITZ VOR freq.), UNZ (identifier). Profile View: 2500’ (MSL altitude crossing FLAKE). 1900’ (MSL altitude crossing the outer marker). 256’ (TDZE touchdown zone elevation - Rwy 6L)
40 Copies of these approach plates included in attachments.
41 Deleted with August 2, 1996 re-issue. Factual Page 34
Approach plates for Guam International had been re-issued on August 2, 1996 with an
effective date of August 15, 1996. Changes to the (11-1) ILS Rwy 6L approach plate included:Location names, crossing altitudes, and the missed approach procedure. A copy of theAugust 15, 1996 (11-1) ILS Rwy 6L approach plate is included in the attachments.
Paul R. MisencikChairman, Operations Group
Factual Page 35
P D D R . M E D . B A R B A R A W I L H E L M Medical School of the Albert-Ludwig-Universität Guest student at the Ademiska Sjukhuset Uppsala, Sweden University of Mainz, practical year, Krankenhaus der Barmherzigen Brüder in Trier, Specialty Neurology. 1982 Medical Thesis at the Med. Fakultät Freiburg „Tumoren des Zentralnervensystems – retrospektive Studie aus strahlentherapeutisc