Page:KAL801Finalreport.pdf/188

 If the ARTS IIA minimum safe altitude warning system had been operating as initially intended, a visual and aural warning would have activated about 64 seconds before flight 801 impacted terrain, and this warning would have likely alerted the Combined Center/Radar Approach Control controller that the airplane was descending below the minimum safe altitude for that portion of the approach. Sixty-four seconds would have been sufficient time for the Combined Center/Radar Approach Control controller to notify the Agana tower controller of the low-altitude alert, the tower controller to convey the alert to the crew of flight 801, and the crew to take appropriate action to avoid the accident. The Federal Aviation Administration's quality assurance for the minimum safe altitude warning system was inadequate, and the agency's intentional inhibition of that system contributed to the flight 801 accident. A substantial portion of the delayed emergency response was caused by preventable factors. The delayed emergency response hampered the timely evacuation of injured persons, and at least one passenger who survived the initial impact and fire might not have died if emergency medical responders had reached the accident site sooner. 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. 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. Controlled flight into terrain accident awareness and avoidance training is an important accident reduction strategy and should be mandatory for all pilots operating under 14 Code of Federal Regulations Part 121.</li> <li>By providing vertical guidance along a constant descent gradient to the runway, the use of on-board flight management system- and/or global positioning system-based equipment can provide most of the safety advantages of a precision approach during a nonprecision approach.</li> <li>The safety of executing a nonprecision approach using the constant angle of descent, or stabilized descent technique, would be enhanced by adding to approach charts the cross-referenced altitudes versus distance from the airport.</li> <li>Terrain depiction on the profile view of approach charts could result in increased flight crew awareness of significant terrain on the approach path.</li> </ol>