Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-00-010
Details
Synopsis: On 8/6/97, 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 on international civil aviation and the provisions of 14 code of federal regulations (CFR) part 129 and was on an instrument flight rules flight plan.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Conduct or sponsor research to determine the most effective use of the monitored approach method and the maximum degree to which it can be safely used and then require air carriers to modify their procedures accordingly.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: NIMITZ HILL, GU, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA97MA058
Accident Reports: Controlled Flight Into Terrain, Korean Air Flight 801, Boeing 747-300, HL7468
Report #: AAR-00-01
Accident Date: 8/6/1997
Issue Date: 1/27/2000
Date Closed: 11/4/2009
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Approach: Monitored

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/4/2009
Response: In response to the first part of this recommendation, to sponsor research to determine the most effective use of the monitored approach method, the FAA sponsored a study at George Mason University to determine the most effective monitored approach procedure. The study obtained pilots’ comments on the strengths and weaknesses of the monitored approach and ways to improve the process. The FAA provided to the NTSB a copy of the final report, Pilot Perspectives of the Monitored Approach: Results from an Internet Survey, which had been presented to the FAA in October 2004. With regard to the second element of this recommendation, to require air carriers to modify their procedures based on the results of the study, the FAA took an alternative approach and refined the requirements, roles, and responsibilities for approaches that emphasize standardization of procedures for the different approach categories. The FAA provided examples of its activities in this regard, including the issuance of advisory circulars (ACs) on Category I and II weather minima and on standard operating procedures for flight deck crewmembers. The FAA believes that revisions to Order 8900.1, Flight Standards Information Management System, have also encouraged these activities. In considering whether the FAA’s activities to encourage appropriate use of the monitored approach have been effective in achieving the intent of the second element of this recommendation, the NTSB has generally found that carriers are increasingly adopting and using the monitored approach technique. Therefore, the NTSB believes that the actions of the FAA have constituted a satisfactory alternative response and, consequently, Safety Recommendation A-00-10 is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

From: FAA
To: NTSB
Date: 5/21/2009
Response: Letter Mail Controlled 5/29/2009 12:11:01 PM MC# 2090340: Lynne A. Osmus, Acting Administrator, FAA, 5/21/09 As recommended, the Federal Aviation Administration sponsored a study through George Mason University to determine the most effective monitored approach procedure. The researchers obtained pilots’ comments on the strengths and weaknesses of the monitored approach and ways to improve the process. Monitored approaches typically call for the aircraft to be flown by the autopilot in the auto-coupled mode. The second-in-command (SIC) manages the autopilot and throttles and maintains instrument reference throughout the approach while the pilot-in-command (PIC) seeks visual references to land. If there are sufficient visual references to land, the PIC assumes control of the airplane and completes the landing. If adequate visual references are not available, the PIC announces a go-around, and the SIC executes the missed approach. The monitored approach was primarily used for Category II approaches. It was not typically used with Category I approaches as the pilot flying, PIC or SIC, usually retained control through to the completion of the landing. It was also rarely used with Category III approaches, as the PIC primarily retained control through to the completion of the landing. As a result, operators developed different procedures depending on the category of approach to be flown. The final report of the study, Pilot Perspectives of the Monitored Approach: Results from an Internet Survey, was presented to the FAA in October 2004 (enclosure 1). This report suggested ambiguity among pilots about the meaning of the term, monitored approach, noting that there were several versions of the procedure. Instead of focusing solely on the effective use of the monitored approach method as recommended, the FAA and industry took an alternative approach and refined the requirements, roles, and responsibilities for approaches that emphasize standardization of procedures for the different approach categories. For example: 1.Advisory Circular (AC) 120-29A, Criteria for Approval of Category I and Category II Weather Minima for Approach (enclosure 2), published in August 2002, recommends operators coordinate their approach procedures to ensure the use of standardized crew policies regardless of the approach type being flown; 2.AC 120-71A, Standard Operating Procedures for Flight Deck Crewmembers (enclosure 3), published in February 2003, includes new guidance on crew monitoring and cross-checking; and 3. FAA Order 8900.1, Flight Standards Information Management System, volume 4, chapter 2, All-Weather Terminal Area Operations (enclosure 4), published in September 2007, has a wealth of information and job aids for FAA inspectors to evaluate and approve low visibility operations. In addition to airport and aircraft requirements, the operator must develop a stabilized approach concept, detail operating practices, and provide supporting training curricula before approval. We believe that current FAA and industry guidance and associated approval processes provide a high degree of safety and are an appropriate alternative to the recommended action. I believe that the FAA has effectively addressed this safety recommendation, and I consider our actions complete.

From: FAA
To: NTSB
Date: 5/20/2004
Response: George Mason University has been chartered to conduct the research, which began 8/11/03, and is projected to end 10/04. The goal of this research project is to address the NTSB recommendation. The specific goal is to obtain information about the monitored approach method as it is currently used (or not used) and to address the following key issues: The extent to which the method is used in commercial aviation; The means by which carriers train the method; and, Pilot opinion about the effectiveness and safety of the method. The data will be analyzed and policy recommendations made based on that analysis. The FAA will issue policy guidance via notice to operators or similar mechanism.

From: NTSB
To: FAA
Date: 1/23/2002
Response: Although the Safety Board is disappointed that almost 3 years will have elapsed since the issuance of this recommendation before the research may begin, the FAA's plan to sponsor this research is responsive to the recommendation. Pending completion of the recommended action, Safety Recommendation A-00-10 remains classified OPEN--ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/21/2001
Response: Letter Mail Controlled 08/29/2001 4:02:04 PM MC# 2010694: The FAA had originally planned to conduct the research under the Safer Skies Agenda on the monitored approach method and its use. However, the FAA determined that the organization conducting the research could not conduct research on this issue in connection with its other ongoing FAA work as originally planned. Consequently, the FAA has requested funding in fiscal year 2003 for this research. I will keep the Board informed of the FAA's progress on this safety recommendation.

From: NTSB
To: FAA
Date: 6/27/2000
Response: The Safety Board is unaware of specific research or action by the FAA under these programs to address the Board's concerns about monitored approaches and pilot proficiency in conducting the current non-precision procedures; however, the Board welcomes additional information from the FAA about these concerns. Pending the results of the FAA's research on use of the monitored approach method and the results of the CFIT team's implementation plan, A-00-10, -11, and -13 are classified "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 4/4/2000
Response: Letter Mail Controlled 04/07/2000 2:43:03 PM MC# 2000502 The FAA is currently conducting research under the safer skies agenda on the issues outlined in these recommendations. Specifically, the controlled flight into terrain (CFIT) joint safety implementation team has developed an implementation plan for precision-like approaches. The purpose of the plan is to identify the means by which all flightcrews can fly an appropriate stabilized vertical path to runway touchdown for all instrument approach procedures, thereby reducing the possibility of a CFIT accident. The plan was approved by the commercial aviation safety team on 3/16/00. I will keep the board informed of the FAA's progress on these recommendations.