Korean Air Flight 801 investigation/Opening Statement

by National Transportation Safety Board

NATIONAL TRANSPORTATION SAFETY BOARD
WASHINGTON, D.C. 20594

Public Hearing in Connection with the
Investigation of Aircraft Accident
Korean Air Flight 801, Boeing 747-300
Agana, Guam
August 6, 1997

Public Hearing
Opening Statement
by
Honorable Robert T. Francis
Chairman, Board of Inquiry
March 24, 1998

---

Good morning and welcome.

I am Bob Francis, Vice Chairman of the National Transportation Safety Board, and Chairman of this Board of Inquiry.

Today we are opening a public hearing concerning the accident that occurred on August 6, 1997, in Agana, Guam, involving Korean Air flight 801.

The hearing is being held for the purpose of supplementing the facts, conditions, and circumstances discovered during the on-scene investigation. This process will assist the Safety Board in determining the probable cause of the accident and in making any recommendations to prevent similar accidents in the future.

Public hearings such as this arc exercises in accountability: accountability on the part of the Safety Board that it is conducting a thorough and fair investigation, accountability on the part of the FAA that it is adequately regulating the industry, accountability on the part of the airline that it is operating safely, accountability on the part of manufacturers as to the design and performance of their products, and accountability on the part of the working force -- pilots and machinists -- that they are performing up to the standards of professionalism expected of them. These proceedings tend to become highly technical affairs, but they are essential in seeking to reassure the public that everything is being done to ensure the safety of air travel.

This inquiry is not being held to determine the rights or liability of private parties, and matters dealing with such rights or liability will be excluded from these proceedings.

Over the course of this hearing, we will collect information that will assist the Safety Board in its examination of safety issues arising from this accident. Specifically, we will concentrate on the following issues:

1. Controlled-flight-into-terrain (CFIT) accidents, and aviation community efforts to prevent such accidents;

2. Federal Aviation Administration policies and procedures for operation of navigational aids at the Guam airport;

3. Federal Aviation Administration development, installation, and quality assurance oversight of the Minimum Safe Altitude Warning (MSAW) system, and MSAW operational practices at Guam and nationwide;

4. Post-accident search and rescue activities;

5. FAA oversight of foreign air carriers during operations into the United States.

Let me emphasize that these issues are important, and have serious implications for the safety of air travel. We had the crash of an aircraft that apparently was operating normally, with a great loss of life and severe injuries to the survivors. It may be another example of what is called controlled-flight-into-terrain (CFIT).

Many, perhaps even a majority of the world's fatal commercial aviation accidents can be categorized as CFIT. As a string of accidents over the past year has shown, CFIT is a growing concern for the aviation community worldwide.

The new means to help avoid CFIT accidents, such as Enhanced Ground Proximity Warnings Systems (EGPWS), are available, and the major U.S. air carriers and a few others have begun to move in this direction on a voluntary basis. But, as seems clear, CFIT is an international problem that requires a broad, cooperative, international approach. So while we continue to investigate the specific causes of the KAL 801 tragedy, it is also my intention in this hearing to look at the larger picture and explore more precisely the dimensions of the CFIT problem, the various efforts currently underway to deal with it, and what may be done in the future.

At this point, I would like to introduce the other members of the Board of Inquiry:

Mr. Ronald L. Schleede Deputy Director, International Aviation Safety Affairs, Office of Aviation Safety

Mr. Ben Berman Chief, Operational Factors Division, Office of Aviation Safety

Mr. Monty Montgomery Chief, Information and Technology Division, Office of Research and Engineering

Ms. Pat Cariseo Transportation Safety Specialist, Safety Accomplishments Division, Office of Safety Recommendations and Accomplishments The Board of Inquiry will be assisted by a Technical Panel consisting of:

Mr. Gregory Feith, Investigator-in-Charge

Mr. Paul Misencik, Operational Factors Investigator

Dr. Malcolm Brenner, Human Performance Investigator

Mr. Richard Wentworth, National Resource Specialist, ATC

Mr. Scott Dunham, Air Traffic Control Specialist

Mr. Gregory Phillips, Aircraft Systems Investigator

Mr. Charles Pereira, Aircraft Performance Investigator

Mr. Gary Hammack, Airport Crash/Fire/Rescue Investigator

Mr. Paul Schlamm, Mr. Keith Holloway and Mr. Ted Lopatkiewicz from the Safety Board's Public Affairs Office are here to assist members of the news media.

Ms. Denise Daniels, my Special Counsel; Ms. Maria Sturniolo, Confidential Assistant; Ms. Betty Scott of the Office of Government Affairs; Ms. Elizabeth Cotham and Mr. Matthew Furman of the Office of Family Affairs; and Mr. David Bass, Deputy General Counsel, are also present.

Ms. Carolyn Dargan and Ms. Candi Wiseman also are present to provide administrative support as needed. You may contact any of them for assistance regarding copies of exhibits and on other matters.

Neither I nor any other Safety Board personnel will attempt, during this hearing, to analyze the testimony received nor will any attempt be made at this time to determine the probable cause of the accident. Such analyses and cause determinations will be made by the full Safety Board after consideration of all of the evidence gathered during our investigation. The final report on the accident involving Korean Air flight 801, reflecting the Safety Board's analyses and probable cause determinations, will be considered for adoption by the full Board at a public meeting at the Safety Board's headquarters in Washington, DC at a later date.

The Safety Board's rules provide for the designation of parties to a public hearing. In accordance with these rules, those persons, governmental agencies, companies, and associations whose participation in the hearing is deemed necessary in the public Interest and whose special knowledge will contribute to the development of pertinent evidence are designated as parties. The parties assisting the Safety Board in this hearing have been designated in accordance with these rules.

As I call the name of the party, I ask its designated spokesperson to please give his or her name, title, and affiliation for the record:

Federal Aviation Administration

Boeing Commercial Airplane Group

Korean Air Company Ltd.

National Air Traffic Controllers Association

Barton ATC International, Inc.

Government of Guam

I want to thank publicly all of the parties for the assistance and cooperation they have displayed to date during the course of this investigation.

Mr. Woo-Jong Lee is the spokesman for the Korean Civil Aviation Bureau. Mr. Lee is representing the government of Korea as part of this investigation in accordance with the provisions of the Convention on International Civil Aviation Annex 13. Annex 13 provides certain rights and obligations to the State of Registry of an airline when it crashes in another State. This investigation has been conducted in full compliance with the spirit of cooperation intended by Annex 13.

On March 22, 1998, the Board of Inquiry held a prehearing conference here in Honolulu. It was attended by the Safety Board's Technical Panel and representatives of the parties to this hearing. During that conference, the areas of inquiry and the scope of the issues to be explored at this hearing were delineated and the selection of the witnesses to testify on these issues was finalized.

Copies of the witness list developed at the prehearing conference are available at the media table. There are numerous exhibits that will be used in this proceeding. Copies of the exhibits arc available at the media table for review. The Safety Board has provided a complete set of exhibits to Kinko's Copy Center. Copies of the exhibits can be obtained on request and at the individual's own expense. See Ms. Dargan or Ms. Wiseman for the address. Also, the hearing exhibits may be found on the Board's web page (www.ntsb.gov).

The witnesses testifying at this hearing have been selected because of their ability to provide the best available information on the issues of aviation safety pertinent to this accident investigation.

The first witness will be the Investigator-in-Charge of the accident investigation who will summarize certain facts about the accident and the investigative activities that have taken place to date.

The remaining witnesses will be questioned first by the Board's Technical Panel, then by the designated spokesperson for each party to the hearing, followed by the Board of Inquiry.

As Chairman of the Board of Inquiry, I will be responsible for the conduct of the hearing. I will make all rulings on the admissibility of evidence, and all such rulings will be final.

The record of the investigation including the transcript of the hearing and all exhibits entered into the record will become part of the Safety Board's public docket on this accident and will be available for inspection at the Board's Washington office. Anyone wanting to purchase the transcript, including parties to the investigation, should contact the court reporter directly.

Mr. Schleede, have all the exhibits been entered in the public docket?

Thank you. Then please, Mr. Schleede proceed to call the first witness.