Ramon Lopez/WASHINGTON DC
The US National Transportation Safety Board (NTSB) has blamed the flight crew for the crash of a Korean Air Boeing 747-300 in Guam, in which 229 of the 254 people on board were killed. But the board says actions by Korean Air, the Korean Civil Aviation Bureau (KCAB) and the US Federal Aviation Administration (FAA) contributed to the accident.
On 6 August 1997, Korean Air Flight 801 hit the 200m (658ft)-high Nimitz Hill on a night approach to Guam International in bad weather. It was what Robert Francis, vice chairman of the US Safety Board, called a "classic controlled flight into terrain (CFIT) accident." The approach to runway 06L was flown using the instrument landing system (ILS) localiser only, because the ILS glide-slope system (GSS) was withdrawn for upgrading.
In the absence of the GSS, the Nimitz VOR beacon with its distance-measuring equipment (DME) was to be used to provide the crew -who died in the crash- with position data to monitor their descent progress. A pilot information notice also said the airport's surveillance radar was not operating.
Approach procedures to the runway without GSS called for an aircraft to be at 1,440ft (440m) over the Nimitz VOR/DME, which is 6km (3.3nm) short of the threshold. It was then to descend to a minimum safe altitude of 560ft by the "middle marker", just 1km short of the runway, which is 256ft above sea level. The investigation determined that controllers had turned off the Minimum Safe Altitude Warning (MSAW) system's aural alarm because of nuisance alerts.
The report places most of the blame for the accident on a series of cockpit miscues, but also highlights broader training issues, air traffic control equipment problems and the captain's fatigue as contributing factors. The investigators concluded that the pilots were confused by the GSS's status, and did not know precisely where the aircraft was at the moment of impact, having failed to cross-check the aircraft position and altitude with approach charts. Crew resource management was also found to be lacking.
There were "underlying systemic problems" with Korean Air's pilot training, and the KCAB was "ineffective" in its oversight of the airline. The report also says the FAA failed to keep the MSAW system operational, concluding it might have saved the aircraft. Since the crash, the airline has launched a safety-improvement programme, and the FAA has fixed the warning device problems.
The NTSB concluded that the FAA has failed to adequately oversee the safety of foreign airlines serving the USA, but stopped short of recommending adoption of tougher rules. The NTSB says the issue needs more study.
Source: Flight International
