GENERAL INFORMATION

NARRATIVE

[O] 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 6L 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 of International Civil Aviation and the provisions of 14 Code of Federal Regulations (CFR) Part 129 and was on an instrument flight rules flight plan. [Recommendations] A-00-15. Include, in nonprecision approach procedures, tabular information that allows pilots to fly a constant angle of descent by cross-referencing the distance from the airport and the barometric altitude. [Responses] FAA LTR DTD: 4/4/00 This concept was considered by Jeppesen and has been under consideration for publication on United States Government plates. Jeppesen has decided not to do this on regular subscription charts, but will do so as requested on tailored charts. As stated in response to Safety Recommendation A-00-14, the FAA has published the descent angle on nonprecision approaches. The Notices to Airmen publication instructs pilots to adjust aircraft configuration and airspeed to comply with the published angle. The Government publishes a descent-rate table in each approach book that converts the published angle and ground speed to a target rate of descent. The Inter-Agency Cartographic Committee makes the final decision regarding the publication on Government charts. Consequently, the FAA will present this safety recommendation to the committee at the next government/industry charting forum for evaluation. I will keep the Board informed of the FAA's progress on this safety recommendation. NTSB LTR DTD: 6/27/00 The FAA reports that the concept recommended was considered by Jeppesen and has been under consideration for publication on U.S. Government plates. Jeppesen decided not to do this on regular subscription charts, but will do so, as requested, on tailored charts. The FAA reports that it has published the descent angle on nonprecision approaches in Notices to Airmen, which instructs pilots to adjust aircraft configuration and airspeed to comply with the published angle. The FAA further reports that the Government publishes a descent-rate table in each approach book that converts the published angle and ground speed to a target rate of descent. Because the Inter-Agency Cartographic Committee makes the final decision regarding the publication on Government charts, the FAA reports that it will present this safety recommendation to the committee at the next government/industry charting forum for evaluation. The Safety Board is concerned that the FAA may not fully understand the intent of this recommendation. Descent rate tables do not allow pilots to monitor or cross-check the approach descent progress throughout an approach. The Safety Board believes that it is safer to have periodic progress checks throughout an approach descent and to have tabular information presented on approach plates for ready reference to cross-check the distance from the facility against altitude. This allows pilots to constantly evaluate whether they need to increase or decrease the rate of descent. In areas where terrain or other obstructions are a consideration on the approach path, as in Guam, it is more important that pilots be able to accurately assess their approach profile. Pending inclusion in non-precision approach procedures of tabular information that allows pilots to fly a constant angle of descent by cross-referencing the distance from the airport and the barometric altitude, Safety Recommendation A-00-15 is classified "Open Unacceptable Response." FAA LTR DTD: 8/21/01 The FAA fully understands the intent of this safety recommendation. The Board states that the FAA should include tabular information in nonprecision approach procedures that allows pilots to fly a constant angle of descent by cross-referencing the distance from the airport and the barometric altitude. The publication entitled Notices to Airmen instructs pilots to adjust aircraft configuration and airspeed to comply with the published angle and the Government publishes a descent rate table in each approach book that converts the published angle and ground speed to a target rate of descent. These procedures, while not providing the specific portrayal requested by the Board (i.e., distance from the airport against the barometric altitude), do allow the pilot to accurately plan and monitor the descent rate during a nonprecision approach. The FAA presented this safety recommendation to the Aeronautical Charting Forum in April 2001 for evaluation. Much of the discussion centered on clutter and the loss of "real estate" in the planview of procedures where the tabular data would be charted. The planview area available for the charting of essential flight information is already approaching the critically limited stage. Consensus of the Aeronautical Charting Forum was that this issue should be redelegated to the Inter-Agency Cartographic Committee (IACC) for resolution. Results of the IACC evaluation may be available at the next meeting of the Aeronautical Charting Forum in October 2001. I will keep the Board informed of the outcome of this effort in response to this safety recommendation. NTSB LTR DTD: 1/23/02 The FAA notes that Notices to Airmen instructs pilots to adjust aircraft configuration and airspeed to comply with the published angle and that the government publishes a descent rate table in each approach book that converts the published angle and ground speed to a target rate of descent. The FAA states that these procedures, while not providing the specific portrayal in Safety Recommendation A-00-15 (the distance from the airport against the barometric altitude), allow the pilot to accurately plan and monitor the descent rate during a nonprecision approach. The FAA reports that it presented these safety recommendations to the Aeronautical Charting Forum (ACF) in April 2001 for evaluation. The FAA states that much of the resulting discussion on Safety Recommendation A-00-15 centered on clutter and the loss of "real estate" in the planview of procedures where the tabular data would be included. The FAA reports that in considering Safety Recommendation A-00-16, the ACF expressed concern about the additional clutter that would result by including the additional information. The FAA states that the ACF believes that the current practice of depicting terrain in the planview is sufficient for pilot orientation and awareness of the flying environment in which the approach procedure is conducted. The FAA states that the issues in Safety Recommendations A-00-15 and -16 were redelegated to the Inter-Agency Cartographic Committee (IACC) for resolution. Although it appreciates the concerns expressed by the ACF concerning clutter and available space for the information requested, the Safety Board believes that the circumstances of the Korean Air flight 801 accident support the need for these recommendations. Pending the results of the IACC's evaluation and implementation of the recommended actions, Safety Recommendations A-00-15 and -16 are classified "Open Acceptable Response." NTSB LTR DTD: 5/18/04 At the December 12, 2003, meeting, the FAA indicated that it opposes the recommended action because of concerns that the added information would make charts, already crowded with information, more difficult to read, particularly in the high workload environment of a nonprecision approach. The FAA also asked the Interagency Coordinating Committee (IACC) to consider the recommended action. The IACC also expressed opposition to the recommendation based on similar concerns about information crowding the charts. The Safety Board believes the FAA's concerns are well founded. Therefore, Safety Recommendation A-00-15 is classified "Closed-Reconsidered." 4

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