The crash of a Korean Air jumbo jet that killed 228 people when it slammed into a hillside in Guam two years ago was the result of errors by the cockpit crew that might have been prevented if the airline had provided better training for its pilots, the National Transportation Safety Board concluded yesterday.
The safety board also said that the Federal Aviation Administration did not do enough to assess the safety of foreign airlines flying to the United States, and it recommended greater scrutiny of the safety records of foreign carriers. The final report on the Aug. 6, 1997, crash came as the safety board this week began an investigation of an EgyptAir jetliner that crashed early Sunday shortly after taking off from New York en route to Cairo.
The five-member board unanimously determined that the probable cause of the crash of Korean Air Flight 801, a Boeing 747-300 with 254 people aboard, was the captain's failure to adequately brief his co-pilot and flight engineer on instrument landing procedures in the event of bad weather and their failure to countermand his actions just before the crash.
The agency also said that the captain's fatigue--he complained he was sleepy during the five-hour flight, which was due to arrive at 1 a.m.--and the airline's inadequate pilot training contributed to the accident, and that the FAA failed to adequately manage the air control system at Won Pat International Airport. Guam is a U.S. territory.
Oversight of foreign airlines has become an increasing concern among U.S. aviation safety officials. With the growing trend toward "code-sharing," the arrangement where one airline sells a ticket under its name even though at least part of the flight is flown on another airline, U.S. aviation officials are concerned that the U.S. government does not have adequate control over the safety of foreign airlines.
In its conclusions as to the contributing factors in the crash, the board cited the Korean Aviation Bureau for being "ineffective in its oversight of Korean Air's operations and pilot training program." Korean Air has had one of the worst safety records of any major air carrier, but before the accident its operations had not raised warning flags at either the Korean aviation agency or the FAA.
Korean Air has since spent $114 million to overhaul its training system. A company spokeswoman said yesterday that the airline has addressed the training concerns.
The agency also concluded that the FAA's International Aviation Safety Assessment program, which evaluates a foreign government's ability to provide enough oversight of its airlines, "is not adequate to determine whether foreign air carriers operating into the United States are maintaining an adequate level of safety." The program was created after a Colombian jetliner operated by Avianca ran out of fuel and crashed on Long Island in 1990.
In its recommendations resulting from its 27-month investigation of the Korean Air crash, the board called on the FAA to "consider the accident and incident history of foreign carriers as a factor when evaluating the adequacy of a foreign civil aviation authority's oversight and whether a reassessment may be warranted."
Board members acknowledged that the FAA has no authority to actually go overseas and inspect a foreign airline but was restricted to judging the oversight of the foreign aviation agency.
The accident report yesterday showed the crash of Flight 801 to be the result of a series of mistakes that might have easily been avoided. The captain, who had an otherwise exemplary record, was apparently too tired at the start of the flight to adequately brief a new cockpit crew on what to do if they couldn't make a visual landing at the Guam airport. Investigators said the Korean culture doesn't easily tolerate contradicting superiors. And the ground warning system was reprogrammed by the FAA so the alarm system wouldn't bother the air traffic controllers.
"There is evidence the captain was impaired by fatigue," NTSB investigator Malcolm Brenner told the board. He said the captain had been up since 6 a.m. and had a two-hour midday nap before heading to the airport for a five-hour flight from Seoul that would arrive at Guam around 1 a.m.
When the flight neared Guam, the crew could see the lights of the island until they were close to land and ran into a heavy rainstorm.
But the captain, who was flying the jet, continued on a visual flight plan because storms in that region are usually high but narrow and he expected to quickly come out of the clouds. He didn't.
A second storm behind the first one left the crew with limited visibility and the need to switch over to an instrument landing. But part of the airport's instrument landing equipment wasn't working and the captain appeared to become overly concerned even though he had been told it wasn't working before he took off from Seoul.
And with his colleagues in the cockpit saying nothing, the captain failed to use a required "step-down" landing procedure that would have kept the plane at higher elevations for longer periods. Instead, the captain continued on a steady descent right into the hillside.