Safety Board believes that the FAA should provide user groups, along with Form 8260, draft plan and profile views of instrument procedures to assist the groups in effectively evaluating proposed new procedures.
2.9 Oversight Issues
2.9.1 Korean Air
As discussed in sections 1.17.2.3 and 1.17.5.1, Korean Air established a CRM program and undertook several other safety initiatives in response to previous accidents. The company also had supervisor briefing and airport familiarization programs, both of which exceeded Korean regulatory requirements. (For more information about these programs, see section 1.17.3.)
The Safety Board recognizes that these efforts indicated a positive approach to safety. However, the supervisor briefing, which could have assisted the flight crew in preparing for the approach, did not review important items, such as NOTAMs or the currency of approach charts. Also, the airport familiarization video did not adequately prepare the crew for the possibility of a nonprecision approach in IMC, nor did it note that the DME was not colocated with the localizer. Further, as discussed previously, some of Korean Air's training and operational procedures, such as the limited number and variety of approach scenarios, lack of an interactive role for the nonflying pilot, and lack of documented cockpit approach procedures that clearly defined crewmember duties, contributed to the flight crew's deficiencies in this accident.
Korean Air experienced a series of accidents (beginning before and continuing after the Guam accident) involving crew coordination and performance (see section 1.17.5). These accidents raise broader questions about the adequacy of the company's training and operational procedures. The airline did take action in response to some of these accidents to address the safety problems brought to light. However, the continued occurrence of crew error accidents called for a broad in-depth assessment of the airline's flight operations to determine how best to mitigate opportunities for such errors.
At the Safety Board's public hearing, the Korean Air Deputy Director of Flight Operations appeared to recognize that, before the accident at Guam, Korean Air had not been placing sufficient emphasis on flight safety and particularly on pilot training. He testified:
- Looking back upon this accident we feel that most of our management up to now has been [ ] perhaps too short-term, short-[sighted], and superficial in its nature. ...from this point on for the purpose of ascertaining safe flight operations we plan to make long-term plans and spare no resources in [attaining] this final objective of flight safety. Accordingly, we will adjust our management systems and invest all the more heavily into training and program development.[1]
- ↑ Korean Air officials subsequently asked that this statement be removed from the public record and disagreed that there were deficiencies in Korean Air's management approach. However, the statement may well have been an adequate assessment of the company's shortcomings, and the Safety Board is disappointed that Korean Air officials apparently failed to recognize this possibility.
