DCA97MA058

NTSB accident investigation · Boeing 747-300 · Nimitz Hill · August 6, 1997

Accident · FatalClass 1 · MajorFinal report
Date
August 6, 1997, 01:42 local (09:42 UTC)
Place
Nimitz Hill
Injuries
228 fatal, 26 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
H7468Boeing 747-300
Weather
Instrument (IMC) · Night/dark
Status
Completed · report October 5, 2006
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
Case key
11027

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

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.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

UndershootApproach - faf/outer marker to threshold (ifr)
Light condition - night
Ifr procedure - not followedPilot in commandCause
FatiguePilot in commandFactor
Minimum descent altitude - not maintainedPilot in commandCause
Inadequate trainingCompany/operator managementFactor
Radar,msaw - inoperativeFactor
Monitoring - inadequateCopilot/second pilotCause
Monitoring - inadequateFlight engineerCause
In flight collision with objectApproach - faf/outer marker to threshold (ifr)
Object - tree(s)
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - high terrain

Analysis

The Board's full report is available at http://www/ntsb.gov/publictn/publictn.htm, AAR-00/01, PB00-910401.

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 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 1239 and was on an instrument flight rules flight plan.

Factual narrative

The Board's full report is available at http://www/ntsb.gov/publictn/publictn.htm, AAR-00/01, PB00-910401.

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 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 1239 and was on an instrument flight rules flight plan.

Aircraft

Registration
H7468
Reported as
Boeing 747-300
Category
Airplane
Serial number
22487
Airframe hours
50,105
Engine
P&W JT9D-7R4G2, 54,750 lbs thrust, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Part 129
Registered owner
Korean Airlines Ltd
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · December 16, 1996
Departed
SEL · Seoul
Destination
KGUM · Agana
Flight plan
IFR
Airport
KGUM · Agana International Airpo, runway 6

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Unknown, Unknown
Seat
Left
Toxicology
Performed

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
90° at 6 knots
Visibility
4 statute miles
Lowest ceiling
2,500 ft broken
Temperature
81 °F, dew point 77 °F
Altimeter
29.00 inHg
Observed at
GUM

Docket · 206

The files NTSB released with the investigation on March 23, 1998, on NTSB’s docket system: statements, records, photos and specialists’ reports. 114 MB in all.

Exhibit 1A - Order of HearingItem 1 · .PDF · 24 KBExhibit 1B - Designation of Hearing OfficerItem 2 · .PDF · 34 KBExhibit 1C - Notice of HearingItem 3 · .PDF · 33 KBExhibit 1D - Designation of Parties to the HearingItem 4 · .PDF · 30 KBExhibit 1E - Notice of Designation of Chairman of Board of InquiryItem 5 · .PDF · 25 KBOperations/Human Performance 2 - Exhibit No. 2A - Group Chairman Factual ReportItem 6 · .PDF · 1.5 MBOperations/Human Performance 2 - Exhibit No. 2B - Flight PapersItem 7 · .PDF · 977 KBOperations/Human Performance 2 - Exhibit No. 2C - Interview Summaries (Guam-Seoul, Korea, August 1997Item 8 · .PDF · 1.3 MBOperations/Human Performance 2 - Exhibit No. 2D - English Text of Guam Audio Visual PresentationItem 9 · .PDF · 219 KBOperations/Human Performance 2 - Exhibit No. 2E - Korean Text of Guam Audio Visual PresentationItem 10 · .PDF · 229 KBOperations/Human Performance 2 - Exhibit No. 2F - Letter of Level 3 Pilot English TestItem 11 · .PDF · 63 KBOperations/Human Performance 2 - Exhibit No. 2G - Forensic Toxicology ReportItem 12 · .PDF · 189 KBOperations/Human Performance 2 - Exhibit No. 2H - Outline of B-747 Initial and Transition TrainingItem 13 · .PDF · 205 KBOperations/Human Performance 2 - Exhibit No. 2I - Copy of B-747-200 Simulator Training GuideItem 14 · .PDF · 486 KBOperations/Human Performance 2 - Exhibit No. 2J - Copy of ChecklistsItem 15 · .PDF · 220 KBOperations/Human Performance 2 - Exhibit No. 2K - Copy of Landing Briefing CardItem 16 · .PDF · 20 KBOperations/Human Performance 2 - Exhibit No. 2L - Airport DiagramItem 17 · .PDF · 49 KBOperations/Human Performance 2 - Exhibit No. 2M - Copies of Approach Plates from Accident AirplaneItem 18 · .PDF · 242 KBOperations/Human Performance 2 - Exhibit No. 2N - Copy of August 2, 1996 ILS 6L Approach PlateItem 19 · .PDF · 67 KBOperations/Human Performance 2 - Exhibit No. 2O - Accident Crewmember's Flight Schedule (June, July, August - 1997)Item 20 · .PDF · 308 KBOperations/Human Performance 2 - Exhibit No. 2P - United States D.O.D. Capability Survey of Korean AirItem 21 · .PDF · 67 KBOperations/Human Performance 2 - Exhibit No. 2Q - Captain's Flight Activity Record (Aug. 3-4, 1997)Item 22 · .PDF · 78 KBOperations/Human Performance 2 - Exhibit No. 2R - Interview Summaries (Guam, January 13, 1998)Item 23 · .PDF · 187 KBOperations/Human Performance 2 - Exhibit No. 2S - Flight Safety Bi-Monthly Magazine Excerpts Presented By: Korean AirItem 24 · .PDF · 1.5 MBOperations/Human Performance 2 - Exhibit No. 2T - Approach Procedure ChartingItem 25 · .PDF · 609 KBOperations/Human Performance 2 - Exhibit No. 2U - Captain Paul Woodburn Witness PresentationItem 26 · .PDF · 747 KBOperations/Human Performance 2 - Exhibit No. 2V - Alpa Presentation on Terps Criteria for Instrument ApproachesItem 27 · .PDF · 556 KBOperations/Human Performance 2 - Exhibit No. 2W - Instrument Approach Chart ComparisonItem 28 · .PDF · 140 KBOperations/Human Performance 2 - Exhibit No. 2X - KAL Letter to Robert Francis - Dated March 26, 1998Item 29 · .PDF · 24 KBATC 3 - Exhibit 3A - Group Chairman Factual ReportItem 30 · .PDF · 1.2 MBATC 3 - Exhibit 3B - Transcripts from the CERAPItem 31 · .PDF · 750 KBATC 3 - Exhibit 3C - Air Traffic Control Transcript - TowerItem 32 · .PDF · 410 KBATC 3 - Exhibit No. 3D - CERAP LayoutItem 33 · .PDF · 44 KBATC 3 - Exhibit No. 3E - Tower LayoutItem 34 · .PDF · 53 KBATC 3 - Exhibit No. 3F - Weather ObservationsItem 35 · .PDF · 200 KBATC 3 - Exhibit No. 3G - Accident Notification Record - CERAPItem 36 · .PDF · 70 KBATC 3 - Exhibit 3H - Accident Notification Record - TowerItem 37 · .PDF · 56 KBATC 3 - Exhibit 3I - Excerpts from FAA Order 7110.65 Air Traffic ControlItem 38 · .PDF · 1.5 MBATC 3 - Exhibit 3J - Excerpts from FAA Order 7210.3 Facility Operation and AdministrationItem 39 · .PDF · 1.1 MBATC 3 - Exhibit No. 3K - Excerpts from Agana FCT Standard Operating Procedures (June 1, 1996)Item 40 · .PDF · 163 KBATC 3 - Exhibit No. 3L - FAA'S Response to Questions Regarding MSAW at Guam CERAP & TowerItem 41 · .PDF · 323 KBATC 3 - Exhibit 3M - Executive Summary and Fact Finding Review of National MSAW Program (September 1997)Item 42 · .PDF · 159 KBATC 3 - Exhibit No. 3N - NTSB Staff Review & Conclusions FAA's MSAW Program Evaluation Program of 10 Air Traffic Control FacilitiesItem 43 · .PDF · 214 KBATC 3 - Exhibit No. 3O - FAA'S Review & Corrective Actions Concerning National MSAW ProgramItem 44 · .PDF · 406 KBATC 3 - Exhibit No. 3P - FAA'S Facility Evaluations of The GUAM CERAP - 1995 & 1997Item 45 · .PDF · 904 KBATC 3 - Exhibit No. 3Q - Briefing Memorandum dated January 26, 1998 MSAW Altitude Settings for Houston Intercontinental AirportItem 46 · .PDF · 67 KBATC 3 - Exhibit 3R - Safety Recommendation Letter to the FAA Dated June 8, 1994 and ResponsesItem 47 · .PDF · 778 KBATC 3 - Exhibit 3S - Safety Board Recommendation Letter to the FAA Dated November 30, 1995 and ResponsesItem 48 · .PDF · 514 KBATC 3 - Exhibit 3T - Safety Board Recommendation Letter to the FAA Dated April 13, 1997 and ResponsesItem 49 · .PDF · 703 KBATC 3 - Exhibit No. 3U - GUAM ARTS-IIA MSAW Chronology dated October 17, 1997Item 50 · .PDF · 126 KBATC 3 - Exhibit No. 3V - Post-Accident Report on MSAW at the GUAM CERAPItem 51 · .PDF · 90 KBATC 3 - Exhibit No. 3W - FAA Standards & Guidelines to Define & Adapt Values for MSAW & Conflict Alert Site Variables (A2.08)Item 52 · .PDF · 1.4 MBATC 3 - Exhibit 3X - FAA Form 6030.1 Facility Maintenance Logs Outer Marker, VOR, Localizer, Glideslope VASI & MALSItem 53 · .PDF · 3.0 MBATC 3 - Exhibit 3Y - FAA Memorandum Dated June 9, 1997 Concerning Controller Refresher Training on MSAW ProceduresItem 54 · .PDF · 52 KBATC 3 - Exhibit 3Z - FAA Order 7010.1 Air Traffic Evaluations and ChecklistsItem 55 · .PDF · 4.0 MBATC 3 - Exhibit 3AA - Guam CERAP Order 7220.10C Dated July 29, 1997Item 56 · .PDF · 343 KBATC 3 - Exhibit No. 3BB - FAA Memorandum dated August 14, 1997 Subject: Responses to NTSB QuestionsItem 57 · .PDF · 137 KBATC 3 - Exhibit 3CC - Personnel StatementsItem 58 · .PDF · 148 KBATC 3 - Exhibit No. 3DD - Microprocessor En Route Automated Radar Tracking System (Mico-EARTS0 dated October 1996Item 59 · .PDF · 1.0 MBATC 3 - Exhibit No. 3EE - Micro-Earts MSAW Alerts on KAL801 - August 6, 1997Item 60 · .PDF · 185 KB
All 206 files on NTSB’s docket