Korean Air Flight 801

Korean Air Flight 801 (KE801, KAL801) was a scheduled international passenger flight operated by Korean Air. The flight crashed on August 6, 1997, on approach to Antonio B. Won Pat International Airport, in the United States territory of Guam, killing 229[lower-alpha 1] of the 254 people aboard. The aircraft crashed on Nimitz Hill in Asan, Guam, while on approach to the airport.[2] The National Transportation Safety Board cites poor communication between the flight crew as probable cause for the crash, along with the captain's poor decision-making on the non-precision approach.[1]

Korean Air Flight 801
Korean Air flight 801 crash site
Accident
DateAugust 6, 1997 (1997-08-06)
SummaryControlled flight into terrain due to pilot error, ATC error, insufficient training and fatigue
SiteNimitz Hill, Asan, Guam
13°27′19″N 144°43′58″E
Aircraft
Aircraft typeBoeing 747-3B5
OperatorKorean Air
IATA flight No.KE801
ICAO flight No.KAL801
Call signKorean Air 801 heavy
RegistrationHL7468
Flight originKimpo International Airport
DestinationAntonio B. Won Pat International Airport, Guam
Occupants254
Passengers237
Crew17
Fatalities229[lower-alpha 1]
Injuries25
Survivors25 (Initially 26)

Aircraft and crew

Aircraft
The aircraft involved in the accident, HL7468, taxiing at Paris Charles de Gaulle Airport in 1985

Flight 801 was normally flown by an Airbus A300; since Korean Air had scheduled the August 5–6 flight to transport Chamorro athletes to the South Pacific Mini Games in American Samoa,[3] the airline designated HL7468, a 12-year-old Boeing 747-300 delivered to Korean Air on December 12, 1984,[1]:16,28 to fly the route that night.[3][4]

Crew

The flight was under the command of 42-year-old Captain Park Yong-chul (Korean: 박용철, Hanja: 朴鏞喆, RR: Bak Yong-cheol. M-R: Pak Yongch'ŏl)[5] The captain had close to 9,000 hours of flight time (with 3,192 of them on the Boeing 747) and had recently received a Flight Safety Award for negotiating a 747 engine failure at low altitude.[6] Park had originally been scheduled to fly to Dubai, United Arab Emirates; since he did not have enough rest for the Dubai trip, he was reassigned to Flight 801.[1]:3,15 The first officer was 40-year-old Song Kyung-ho (Korean: 송경호, Hanja: 宋慶昊, RR: Song Gyeong-ho, M-R: Song Kyŏngho), who had more than 4,000 hours' flying experience (with 1,560 hours on the Boeing 747), and the flight engineer was 57-year-old Nam Suk-hoon (Korean: 남석훈, Hanja: 南錫薰, RR: Nam Seok-hun, M-R: Nam Sŏkhun),[7] a veteran pilot with more than 13,000 flight hours, including 1,573 hours on the Boeing 747.[1]:12

Accident

Flight 801 departed from Seoul-Kimpo International Airport (now Gimpo International Airport) at 8:53 p.m. (9:53 p.m. Guam time) on August 5 on its way to Guam. It carried three flight crew members (the two pilots and the flight engineer), 14 flight attendants, and 237 passengers from 4 countries,[1]:11,23 a total of 254 people. Of the passengers, three were children between the ages of 2 and 12 and three were 24 months old or younger.[1]:45,57 Six of the passengers were Korean Air flight attendants, who were deadheading.[1]:3,15

The flight experienced some turbulence, but was uneventful until shortly after 1:00 a.m. on August 6, as the jet was preparing to land. There was heavy rain at Guam so visibility was significantly reduced and the crew attempted an instrument landing. The glideslope Instrument Landing System (ILS) for runway 6L was out of service; Captain Park believed it was in service, however, and at 1:35 am managed to pick up a signal that was later identified to be from an irrelevant electronic device on the ground. The crew noticed that the aircraft was descending very steeply, and noted several times that the airport "is not in sight." Despite protests from flight engineer Nam that the detected signal was not the glide-slope indicator, Park pressed on[8] and at 1:42 am, the aircraft crashed into Nimitz Hill, about 3 nautical miles (3.5 mi; 5.6 km) short of the runway, at an altitude of 660 feet (200 m).

Of the 254 people on board, 229 died as a result of the crash. One survivor, 36-year-old Hyun Seong Hong (홍현성, also spelled Hong Hyun Sung) of the United States, occupied Seat 3B in first class, and said that the crash occurred so quickly that the passengers "had no time to scream"[9] and likened the crash to "a scene from a film."[1]:45[10]

Rescue
Wreckage of HL7468 burns at the Sasa Valley crash site.

The rescue effort was hampered by the weather, terrain, and other problems. Emergency vehicles could not approach due to a fuel pipeline destroyed by the crash and blocking the narrow road. United States Navy Seabees of NMCB40 were some of the first on the scene as they utilized their earth moving equipment (staged by NMCB133) to clear roadways and timber from the crash site approach. The Seabees used backhoes to crack open the still-burning plane to rescue survivors and erected mortuary tents for first responders. There was confusion over the administration of the effort; the crash occurred on land owned by the United States Navy but civil authorities initially claimed authority. The hull had disintegrated, and jet fuel in the wing tanks had sparked a fire that was still burning eight hours after impact.[1]:9,45–48

Rika Matsuda

Governor Carl T.C. Gutierrez found 11-year-old Rika Matsuda, from Japan, who boarded the flight with her mother, 44-year-old Shigeko.[11][12] They were heading to Guam on vacation. Rika Matsuda described what happened to her and her mother to interpreters.[9] Shigeko could not free herself from the aircraft and told Rika to run away. Luggage piled on the girl and her mother as the crash occurred; Rika Matsuda said her mother, unable to free herself, asked her to leave.[9] Shigeko died in the fire. After escaping from the aircraft, Rika discovered a surviving flight attendant, Lee Yong Ho (이용호). They stayed together until Gutierrez discovered them.[13] Rika Matsuda, treated at Guam Memorial Hospital in Tamuning, was released on August 7, 1997, and was reunited with her father, Tatsuo Matsuda. The two were then escorted to the Governor House where they were the guests of Gutierrez and the First Lady of Guam, Geri Gutierrez, for several days; afterwards Rika and Tatsuo Matsuda flew to Japan.[2][14]

Investigation and probable cause

The U.S. National Transportation Safety Board (NTSB) investigated the accident.

A special weather observation made at 01:32, ten minutes before the impact, reported:

Wind 090° at 6 knots; visibility—7 miles; present weather—shower vicinity; sky condition—scattered 1,600 feet, broken 2,500 feet, overcast 5,000 feet [above ground level]; temperature—27° C; dew point—25° C; altimeter setting 29.85 inches Hg; remarks—showers vicinity northwest-northeast.[1]:20

Another special weather observation made at 01:47, five minutes after the impact, reported:

Wind variable at 4 knots; visibility—5 miles; present weather—light rain shower; sky condition—few 1,500 feet, scattered 2,500 feet, overcast 4,000 feet; temperature 26° C; dew point 24° C; altimeter 29.85 inches Hg.[1]:21

The crew had been using an outdated flight map that was missing a 724 foot obstruction symbol depicted at the NIMITZ VOR and that map stated the Minimum Safe Altitude while crossing the NIMITZ VOR for a landing aircraft was 1,300 feet (400 m) as opposed to the updated altitude of 1,440 feet (440 m).[1]:36 Flight 801 crashed near the NIMITZ VOR, which is situated on Nimitz Hill at a height of 680 feet (210 m) at 1:42 am, when it descended below the minimum safe altitude of 1,440 feet (440 m) during its landing approach. The report also identified that the captain may have mistakenly believed that the airplane was closer to the airport than it was and that there may have been confusion about the location of the Distance Measuring Equipment (DME) in relation to the airport, with the crew anticipating the VOR/DME to be located at the airport. The DME was sited at the NIMITZ VOR some 3.3 nmi (3.8 mi; 6.1 km) from the airport and such a configuration had not been part of Korean Air's simulator training, the crew's training for such non-precision approaches having been carried out in scenarios where the DME was located at the airport. Nevertheless the correct DME distances were shown on the approach chart.[1]:144

The NTSB was critical of the flight crew's monitoring of the approach, and even more critical of why the first officer and flight engineer did not challenge the captain for his errors. Even before the accident, Korean Air's Crew Resource Management program was already attempting to promote a free atmosphere between the flight crew, requiring the first officer and flight engineer to challenge the captain if they felt concerned.[1]:59 However, the flight crew only began to challenge the captain six seconds before impact, when the first officer urged the captain to make a missed approach. According to the cockpit voice recorder (CVR), the flight crew had suggested to the captain that he made a mistake, but did not explictly warn him.[15] The flight crew had the opportunity to be more aggressive in his challenge and the first officer even had the opportunity to take over control of the aircraft and execute a missed approach himself, which would have prevented the accident, but he did not do this. Despite examining Korean Air's safety culture and previous incidents, the NTSB was unable to determine the exact reasons why the flight crew failed to challenge the captain, but at the same time noted that "problems associated with subordinate officers challenging a captain are well known."[1]:145–148

Air Traffic Control error also played a role in the accident. The approach controller, 39-year-old Kurt James Mayo, did not give a position advisory to the flight crew, which would have advised them to cross check their position on radar with that of other flight instruments.[1]:152[16][17] In addition, he was supposed to monitor the flight even after they switched to the tower frequency, which could have allowed him to alert the rescue response. Mayo did not monitor the flight on the terminal radar display which showed the terrain in the area because radar service had been terminated at the time.[1]:152–156 The tower controller, Marty Irvin Theobald (also 39), was also criticized for not alerting the crew, as Mayo had been unaware of the aircraft's low altitude, and did not provide an alert to him.[1]:173–174

The Hawaii Convention Center, where the NTSB held its public hearings for Flight 801.

The NTSB presented its findings on March 24, 25 and 26, 1998, at the Hawaii Convention Center in Honolulu.[18][19][20]

The section of the report entitled "Probable Cause" concluded:

The National Transportation Safety Board determines that the probable cause of this accident was the captain’s failure to adequately brief and execute the non-precision approach and the first officer’s and flight engineer’s failure to effectively monitor and cross-check the captain’s execution of the approach. Contributing to these failures were the captain’s fatigue and Korean Air’s inadequate flight crew training. Contributing to the accident was the Federal Aviation Administration’s intentional inhibition of the minimum safe altitude warning system at Guam and the agency’s failure to adequately manage the system.[1]:xi,175

The investigation report stated that a contributing factor was that the ATC Minimum Safe Altitude Warning (MSAW) system at Antonio B. Won Pat International Airport had been deliberately modified so as to limit spurious alarms and could not detect an approaching aircraft that was below minimum safe altitude.[1]:175 The probable cause of the accident was the captain's poor execution of the non-precision approach,[1]:175 the captain's fatigue, poor communication between the flight crew, and Korean Air's lack of flight crew training.[1]:175

Passengers
Locations of the survivors (Greyscale version for colorblind persons)

Deaths and injuries

Of the 254 people on board, 223 – 209 passengers and 14 crew members (all three flight crew and 11 cabin crew) – were killed at the crash site.[1]:45,57

Of the 31 occupants found alive by rescue crews, two died en route to the hospital and a further three in hospital.[1]:3,15,45,57 Among the survivors, 16 received burn injuries. The 26 survivors were initially treated at Guam Memorial Hospital (GMH) in Tamuning or at the U.S. Naval Hospital in Agana Heights. Four were subsequently transferred to the U.S. Army Burn Center in San Antonio, Texas.[2][21] and eight to University Hospital in Seoul. On October 10 of that year, one passenger died of their injuries, bringing the number of fatalities to 229 and the number of survivors to 25.[22][23][24][25][26]

There were 22 passengers and three flight attendants who survived the crash with serious injuries.[1]:11,23,45,57

Notable passengers

Shin Ki-ha, a four-term South Korean parliamentarian and former leader of the National Congress for New Politics, traveled with his wife and around 20 party members. Shin and his wife were both killed.[27][28]

Identification and repatriation of bodies

On August 13, 1997, twelve sets of remains were brought to Guam's airport to be readied to be flown back to Seoul. Clifford Guzman, a governor's aide, said that two of the 12 were taken back to the morgue. Of the 10, one was misidentified and had to be switched before takeoff. The 10 bodies transported to Seoul were those of seven passengers and three female flight attendants. On the same date, an NTSB family affairs official named Matthew Furman said that in total, by that date, 46 bodies had been identified.[29]

After the crash
Korean Air Flight 801 Memorial in Asan, Guam

After the crash occurred, the airline provided several flights for around 300 relatives so that they could go to the crash site.[30]

On August 13, 1997, fifty protesters staged a sit-in at Guam Airport, saying that the recovery of the dead was taking too long; they sat on blankets and sheets of paper at the Korean Air counter.[29]

Legacy

On August 5, 1998, the first anniversary of the crash, a black marble obelisk was unveiled on the crash site as a memorial to the victims.

After the accident, Korean Air services to Guam were suspended for more than four years, leading to reduced tourist spending in Guam and reduced revenues for Korean Air.[31] When Seoul-Guam services resumed in December 2001,[32] the flight number was changed to 805. The flight number for its Seoul-Guam route is now 111 and operates out of Incheon instead of Gimpo, using a Boeing 777-300 or an Airbus A330.

In 2000, a lawsuit was settled in the amount of $70 million United States dollars on behalf of 54 families against the airline.[33]

New Zealander Barry Small, a helicopter pilot and a survivor of the accident, lobbied for safer storage of duty-free alcohol and redesigns of crossbars on airline seats; he said that the storage of duty-free alcohol on Flight 801 contributed to spreading of the fire and the crossbars injured passengers to the point where they could not escape from the aircraft (Small himself was injured when he broke his leg on one of the crossbars during the crash, but was still able to escape the aircraft).[6][34]

The Government of Guam moved its website about the Korean Air crash after the Spamcop program alerted the government that advance fee fraud spam from Nigeria used the website link as a part of the scam.[35] Scam e-mails used names of passengers, such as Sean Burke, as part of the fraud.[36]

Following the Korean Air 801 crash, it was brought to the NTSB's attention that foreign carriers flying in and out of the US were not covered by the Aviation Disaster Family Assistance Act of 1996 and Korean Air did not have a plan to deal with the situation they encountered. As a result, US Congress passed the Foreign Air Carrier Family Support Act of 1997 to require those carriers to file family assistance plans and fulfill the same family support requirements as domestic airlines. Not only does the Act ensure that all victims and family members will be treated equitably, regardless of the carrier they use; it also impels many carriers that may not have thought about family assistance issues to give them due consideration in their emergency response plans.[37]

  • Malcolm Gladwell discusses the crash in the context of cultural effects on power structures in his book Outliers.[38]
  • The Discovery Channel Canada / National Geographic TV series Mayday (also called Air Crash Investigation or Air Emergency) dramatized the accident in a 2007 episode titled "Final Approach," although it was also titled "Missed Approach" for the episode on Air Disasters,[6] and "Blind Landing" for the UK.

See also

Notes
  1. This figure includes a 229th fatality that occurred on October 10th, more than 30 days after the accident. The NTSB however classifies them as a survivor with "serious" injuries in accordance with 49 CFR 830.2.[1]:1

References

Notes

  1. "Controlled Flight Into Terrain Korean Air Flight 801 Boeing 747-300, HL7468 Nimitz Hill, Guam August 6, 1997" (PDF). ntsb.gov. Washington D.C.: National Transportation Safety Board. January 13, 2000. NTSB/AAR-00/01. Retrieved October 19, 2015.
  2. "Korean Air Flt 801 - Official Guam Crash Site Information Web Center". ns.gov.gu. Retrieved January 11, 2019.
  3. "Transcripts Between Guam Airport Tower and KA801 before Crash." Government of Guam. Retrieved on August 30, 2010.
  4. "Official Guam Crash Site Center – Korean Air Flt 801," Government of Guam
  5. "Two Systems Down in KAL 801 Crash". Honolulu Star-Bulletin. March 25, 1998.
  6. "Final Approach". Mayday. Season 4. 2007. Discovery Channel Canada / National Geographic Channel. Retrieved June 26, 2009.
  7. "Operations/Human Performance 2 - Exhibit No. 2F - Letter - Level 3 Pilot English Test" (PDF). ntsb.gov. National Transportation Safety Board.
  8. Wald, Matthew L.; Onishi, Norimitsu (July 8, 2013). "In Asiana Crash Investigation, Early Focus Is on the Crew's Actions". The New York Times. ISSN 0362-4331. Retrieved July 22, 2019.
  9. Pollack, Andrew (August 8, 1997). "Pilot Error Is Suspected in Crash on Guam". The New York Times. ISSN 0362-4331. Retrieved July 22, 2019.
  10. Anger and tears as Guam crash families beg to see dead Archived December 16, 2008, at the Wayback Machine, The Independent
  11. "Honeymoon flight that ended in horror." The Independent. Thursday August 7, 1997. Retrieved on August 30, 2010.
  12. "Jet hell Rika's scars will last forever.," Daily Record
  13. "Korean Air Survivor – Rika's Miracle Archived 2007-11-26 at the Wayback Machine," Government of Guam
  14. "Korean Air Survivor – Rika's Miracle Archived 2007-11-26 at the Wayback Machine." Government of Guam. Retrieved on February 13, 2009.
  15. "Cockpit Voice Recorder 12 - Group Chairman's Factual Report" (PDF). National Transportation Safety Board. March 1, 1998. Retrieved June 19, 2020.
  16. "Cockpit Confusion Preceded Airliner Crash in Guam". Los Angeles Times. March 25, 1998. Retrieved June 19, 2020.
  17. "ATC 3 - Exhibit No. 3A - Group Chairman Factual Report" (PDF). National Transportation Safety Board. February 19, 1998. Retrieved June 19, 2020.
  18. "Public Hearing in Connection with the Investigation of Aircraft Accident Korean Air Flight 801, B-747-300 Agana, Guam August 6, 1997 - Transcript 1" (PDF). ntsb.gov. National Transportation Safety Board. March 24, 1998.
  19. "Public Hearing in Connection with the Investigation of Aircraft Accident Korean Air Flight 801, B-747-300 Agana, Guam August 6, 1997 - Transcript 2" (PDF). ntsb.gov. National Transportation Safety Board. March 25, 1998.
  20. "Public Hearing in Connection with the Investigation of Aircraft Accident Korean Air Flight 801, B-747-300 Agana, Guam August 6, 1997 - Transcript 3" (PDF). ntsb.gov. National Transportation Safety Board. March 26, 1998.
  21. "Airplane Crash in Guam, August 6, 1997: The Aeromedical Evacuation Response."
  22. "One Crash Victim Dies, Three Cling to Life at Burn Center." U.S. Department of Defense.
  23. Wiechmann, Lori. "Last member of Atlanta family on downed Korean jet dies." Athens Daily News. August 12, 1997. Retrieved on July 1, 2011.
  24. "Daily Briefing." The Seattle Times. Tuesday September 2, 1997. Corrected on September 8, 1997. "Two more people who initially survived last month's crash of a Korean Air jumbo jet in Guam have died, bringing the death toll to 228, a South Korean foreign ministry spokesman said today. Korean flight attendant Han Kyu-hee died on Saturday at Brooke Army Medical Center in San Antonio, Texas. Another South Korean, Jung Young-hak, a passenger, died on Sunday in the same facility."
  25. Gillert, Douglas J. "One Crash Victim Dies, Three Cling to Life at Burn Center." U.S. Department of Defense. Retrieved on June 30, 2011. "The other victims brought here were Se Jin Ju, 28; Kyu Hee Han, 29; and Young Hak Jung, 39, all South Korean citizens. Along with Chung, they were the most severely burned survivors and needed the kind of treatment the Brooke Army Medical Center burn unit here provides."
  26. "Safety Recommendation Date: January 27, 2000 In reply refer to: A-00-19 and -20." National Transportation Safety Board. Retrieved on June 30, 2011. " A passenger with serious injuries died at the U.S. Army Medical Center in San Antonio, Texas, on October 10, 1997, but is not officially listed as a fatality because the passenger’s death occurred more than 30 days after the accident"
  27. "Rescuers search smoldering jet wreckage in Guam for survivors". CNN. Archived from the original on March 6, 2005. Retrieved March 6, 2005.
  28. Gargan, Edward A. (August 7, 1997). "For Relatives Of Victims, Anger Adds To Anguish". Retrieved February 5, 2018 – via NYTimes.com.
  29. Coleman, Joseph (August 13, 1997). "Guam Crash Aftermath Upsets Kin". The Seattle Times. Associated Press.
  30. Coleman, Joe. "Survivors recount the fiery last moments Archived 2012-03-24 at the Wayback Machine." The Associated Press at the Savannah Morning News. Thursday August 7, 1997. 10A. Retrieved on July 1, 2011.
  31. "Specifics of Crash Site Information Archived 2008-12-16 at the Wayback Machine." Guam Government. Retrieved on December 9, 2008.
  32. "Korean Air resumes service to Guam for the first time in 4 years." Honolulu Star-Bulletin. Friday December 28, 2001. Retrieved on April 29, 2009.
  33. "Our Work and Past Cases". speiserkrause.com. Retrieved February 5, 2018.
  34. "Exhibit 16C – Korean Air Flight 801" (PDF). National Transportation Safety Board. Retrieved June 26, 2009.
  35. "This webpage has been cancelled." [sic] Government of Guam. Retrieved on April 29, 2009.
  36. Larson, Aaron. "False Promises of Inheritance – Spam Email Fraud." Law Offices of Aaron Larson at ExpertLaw. July 2004. Retrieved on May 13, 2009.
  37. "Remarks before the International Symposium on Family & Victim Assistance for Transportation Disasters, Arlington, Virginia". ntsb.gov. National Transportation Safety Board. September 28, 1998. Retrieved February 5, 2018.
  38. Outliers ch 7, The Ethnic Theory of Plane Crashes, pp 209–223

Bibliography

Further reading

External images
Photos of HL7468 at Airliners.net
Photos of HL7468 at JetPhotos.net
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