Page:KAL801Finalreport.pdf/180

 The Safety Board acknowledges that, since the Guam accident, Korean Air has taken significant management, operational, and flight crew training actions. However, in light of the specific deficiencies that were discovered during the investigation of this accident and Korean Air's accident and incident history, the Safety Board concludes that, at the time of the flight 801 accident, there were underlying systemic problems within Korean Air's operations and pilot training programs that indicated the need for a broad safety assessment of these programs.

The KCAB is charged with oversight of the Korean civil airlines. At the time of the accident, two KCAB operations inspectors were assigned to provide oversight of Korean Air's flight operations. Korean Air pilots who were designated by the KCAB as check airmen and examiners conducted flight instruction, check rides, and proficiency checks and issued type ratings. The KCAB inspectors provided an annual evaluation of the flight skills of the check airmen and examiners but did not observe proficiency checks or check rides on Korean Air's wide-body fleet.

According to its director, the KCAB routinely conducts one annual safety inspection, four quarterly inspections, and an average of 40 random inspections of the airline each year. The director added that the two safety inspectors assigned to Korean Air at the time of the accident also had oversight duties at another Korean carrier. Regardless of the number of inspections of Korean Air performed by the KCAB, its failure to identify and monitor trends within the airline that might be indicative of safety problems raises questions about the adequacy of KCAB's oversight of Korean Air. Further, KCAB officials acknowledged that the agency, because of personnel workload constraints, frequently relied on Korean Air to self-report corrective actions taken in response to KCAB inspections and did not confirm directly that identified problems had been addressed by the airline.

As previously noted, the syllabus for Korean Air's KCAB-approved simulator training program described the scenarios used in training, type ratings, and proficiency checks, and these scenarios were followed repetitively, without deviation, during training