Page:KAL801Finalreport.pdf/149

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135
Aircraft Accident Report

2. Analysis

2.1 General

The three Korean Air flight 801 flight crewmembers were properly certificated and qualified in accordance with applicable Korean Civil Aviation Bureau (KCAB) and U.S. Federal regulations, International Civil Aviation Organization (ICAO) standards, and Korean Air company requirements. No evidence indicated that any medical factors affected the flight crew's performance.

The airplane was properly certificated, equipped, and maintained in accordance with applicable KCAB and ICAO standards and Korean Air company procedures. The airplane was authorized to operate in U.S. airspace under the provisions of 14 Code of Federal Regulations (CFR) Part 129. The weight and balance of the airplane were within the prescribed limits for landing. No evidence indicated that the airplane experienced preimpact failures of its structures, flight control systems, or engines.

ATC personnel involved with the flight were properly certificated and qualified as full-performance level controllers. ATC radar and communications equipment were found to be functioning properly, although the FAA-maintained minimum safe altitude warning (MSAW) system had been intentionally inhibited.

This analysis examines the accident scenario, including weather factors, flight crew performance and decision-making, and other relevant factors during the approach, as well as flight crew fatigue issues. The analysis also examines the performance of ATC personnel, the effects of the MSAW system's intentional inhibition, and the timeliness and effectiveness of the emergency response to the accident site. In addition, the analysis examines Korean Air's flight crew simulator training, KCAB oversight of Korean Air's flight training programs, FAA oversight of Korean Air's operations under 14 CFR Part 129, and international efforts to reduce the number of controlled flight into terrain (CFIT) accidents.

2.2 Weather Factors on the Approach

A review of weather data indicated that variable clouds and scattered rain showers associated with a weak eastward-moving low-pressure trough were affecting the Guam area about the time of the accident and that the showers increased in intensity as they moved over the higher terrain of the island. However, Safety Board interviews with flight crewmembers who flew into Guam before and after the flight 801 accident indicated that the lights of the island were occasionally visible from as far away as 150 nm. In addition, CVR data indicated that the accident flight crew made visual contact with the island about 16 minutes before the accident (about 0126:25) when the flight engineer stated "it's Guam, Guam."