Page:KAL801Finalreport.pdf/13

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On August 6, 1997, about 0142:26 Guam local time, Korean Air flight 801, a Boeing 747-3B5B (747-300), Korean registration HL7468, operated by Korean Air Company, Ltd., crashed at Nimitz Hill, Guam. Flight 801 departed from Kimpo International Airport, Seoul, Korea, with 2 pilots, 1 flight engineer, 14 flight attendants, and 237 passengers on board. The airplane had been cleared to land on runway 6 Left at A.B. Won Guam International Airport, Agana, Guam, and crashed into high terrain about 3 miles southwest of the airport. Of the 254 persons on board, 228 were killed, and 23 passengers and 3 flight attendants survived the accident with serious injuries. The airplane was destroyed by impact forces and a postcrash fire. Flight 801 was operating in U.S. airspace as a regularly scheduled international passenger service flight under the Convention on International Civil Aviation and the provisions of 14 Code of Federal Regulations Part 129 and was on an instrument flight rules flight plan.

The National Transportation Safety Board determines that the probable cause of the Korean Air flight 801 accident was the captain's failure to adequately brief and execute the nonprecision approach and the first officer's and flight engineer's failure to effectively monitor and cross-check the captain's execution of the approach. Contributing to these failures were the captain's fatigue and Korean Air's inadequate flight crew training. Contributing to the accident was the Federal Aviation Administration's (FAA) intentional inhibition of the minimum safe altitude warning system (MSAW) at Guam and the agency's failure to adequately manage the system.

The safety issues in this report focus on flight crew performance, approach procedures, and pilot training; air traffic control, including controller performance and the intentional inhibition of the MSAW system at Guam; emergency response; the adequacy of Korean Civil Aviation Bureau (KCAB) and FAA oversight; and flight data recorder documentation. Safety recommendations concerning these issues are addressed to the FAA, the Governor of the Territory of Guam, and the KCAB.