Page:KAL801Finalreport.pdf/173

 had been formed to develop an MOU; an off-airport aircraft accident drill was planned for September 1998; and new radios had been purchased to allow interagency communication and coordination during emergency responses. However, Guam Civil Defense officials told the Safety Board in June 1999 that no MOU had been signed and that a draft of standard operating procedures for joint emergency response was being circulated to agencies for review. Further, Guam Civil Defense officials stated that the planned September 1998 off-airport aircraft accident drill did not take place and that such an exercise was still in the planning stage.

Although it is pleased with the purchase of new emergency radios, the Safety Board concludes that improved formal coordination among Guam's emergency response agencies has not been implemented, and off-airport drills to identify and correct deficiencies in disaster response planning before an accident occurs have still not been conducted in the more than 2 years since the flight 801 accident. Thus, the Safety Board also concludes that actions taken by Guam's emergency response agencies after the accident have been inadequate because they failed to ensure that emergency notifications and responses would be timely and coordinated. Therefore, the Safety Board believes that the Governor of the Territory of Guam should form, within 90 days, a task force comprising representatives from all emergency response agencies on the island, including the appropriate departments within the government of Guam, FAA, Guam International Airport Authority, U.S. Navy, U.S. Air Force, U.S. Coast Guard, Federal Emergency Management Agency, and all other affected agencies, to define and coordinate emergency notification and response procedures to ensure that timely emergency notifications are made to all local and Federal agencies according to need, location, and response time capability. Further, the Safety Board believes that the Governor of the Territory of Guam should require periodic and regularly scheduled interagency disaster response exercises, including an off-airport aircraft accident scenario, in addition to those response drills already required at Guam International Airport in accordance with 14 CFR Section 139.325.

According to Flight Safety Foundation (FSF) accident data, CFIT accidents have killed more passengers and crewmembers than any other type of air carrier accident, and approach and landing accidents accounted for 70 percent of CFIT accidents, with most accident airplanes "in line with the runway" at impact. CFIT accident data also indicated that nonprecision approaches presented a greater risk than precision approaches and that many CFIT accidents involved failed step-down approaches, with flight profiles similar to that of flight 801's approach to Guam. As noted in section 2.5, nonprecision approaches are practiced infrequently by air carrier pilots and generally require more extensive briefings and careful monitoring than a typical instrument approach.

The FSF CFIT task force also identified several common factors found in CFIT accidents, including night conditions, limited visibility, terrain not seen until just before impact, a stabilized descent path approximating a 3° slope, loss of horizontal and/or