Case Study: Korean Airlines

Korean Air Flight 801 was a regular flight from Seoul to Guam. The Boeing 747-300

departed the gate about 21:27 and was airborne about 21:53. The captain was pilot-

flying. Upon arrival to the Guam area, the first officer made initial contact with the

Guam Combined Center/Radar Approach Control (CERAP) controller about 01:03,

when the airplane was level at 41,000 feet and about 240 nm northwest of the

NIMITZ VOR/DME. The CERAP controller told flight 801 to expect to land on

runway 06L. About 01:10, the controller instructed flight 801 to "...descend at your

discretion maintain two thousand six hundred." The first officer responded,

"...descend two thousand six hundred pilot discretion."

The captain then began briefing the first officer and the flight engineer about the

approach and landing at Guam: "I will give you a short briefing . . . ILS is one one

zero three . . . NIMITZ VOR is one one five three, the course zero six three, since

the visibility is six, when we are in the visual approach, as I said before, set the VOR

on number two and maintain the VOR for the TOD [top of descent], I will add three

miles from the VOR, and start descent when we're about one hundred fifty five miles

out. I will add some more speed above the target speed. Well, everything else is all

right. In case of go around, since it is VFR, while staying visual and turning to the

right . . . request a radar vector . . . if not, we have to go to FLAKE . . . since the

localizer glideslope is out, MDA is five hundred sixty feet and HAT [height above

touchdown] is three hundred four feet...."

About 01:13 the captain said, "we better start descent;" shortly thereafter, the first

officer advised the controller that flight 801 was "leaving four one zero for two

thousand six hundred." During the descent it appeared that the weather at Guam

was worsening. At 01:24 requested a deviation 10 miles to the left to avoid severe

weather. At 01:31 the first officer reported to the CERAP controller that the airplane

was clear of cumulonimbus clouds and requested "radar vectors for runway six left."

The controller instructed the flight crew to fly a heading of 120°. After this

transmission, the flight crew performed the approach checklist and verified the radio

frequency for the ILS to runway 06L. About 01:38 the CERAP controller instructed

flight 801 to ". . . turn left heading zero nine zero join localizer;" the first officer

acknowledged this transmission. At that time, flight 801 was descending through

2,800 feet msl with the flaps extended 10° and the landing gear up. One minute later

the controller stated, "Korean Air eight zero one cleared for ILS runway six left

approach . . . glide slope unusable." The first officer responded, "Korean eight zero

one roger . . . cleared ILS runway six left;" his response did not acknowledge that

the glideslope was unusable. The flight engineer asked, "is the glideslope working?

glideslope? yeh?" One second later, the captain responded, "yes, yes, it's working."

About 01:40, an unidentified voice in the cockpit stated, "check the glideslope if

working?" This statement was followed 1 second later by an unidentified voice in the

cockpit asking, "why is it working?" The first officer responded, "not usable." The

altitude alert system chime sounded and the airplane began to descend from an

altitude of 2,640 feet msl at a point approximately 9 nm from the runway 06L

threshold. About 01:40:22, an unidentified voice in the cockpit said, "glideslope is

incorrect." As the airplane was descending through 2,400 feet msl, the first officer

stated, "approaching fourteen hundred." About 4 seconds later, when the airplane

was about 8 nm from the runway 06L threshold, the captain stated, "since today's

glideslope condition is not good, we need to maintain one thousand four hundred

forty. please set it." An unidentified voice in the cockpit then responded, "yes." About

01:40:42, the CERAP controller instructed flight 801 to contact the Agana control

tower. The first officer contacted the Agana tower: "Korean air eight zero one

intercept the localizer six left." The airplane was descending below 2,000 feet msl at

a point 6.8 nm from the runway threshold (3.5 nm from the VOR). About 01:41:01,

the Agana tower controller cleared flight 801 to land. About 01:41:14, as the airplane

was descending through 1,800 feet msl, the first officer acknowledged the landing

clearance, and the captain requested 30° of flaps. The first officer called for the

landing checklist and at 01:41:33, the captain said, "look carefully" and "set five

hundred sixty feet" (the published MDA). The first officer replied "set," the captain

called for the landing checklist, and the flight engineer began reading the landing

checklist. About 01:41:42, as the airplane descended through 1,400 feet msl, the

ground proximity warning system (GPWS) sounded with the radio altitude call out

"one thousand [feet]." One second later, the captain stated, "no flags gear and

flaps," to which the flight engineer responded, "no flags gear and flaps." About

01:41:46, the captain asked, "isn't glideslope working?" The captain then stated,

"wiper on." About 01:41:53, the first officer again called for the landing checklist, and

the flight engineer resumed reading the checklist items. About 01:41:59, when the

airplane was descending through 1,100 feet msl at a point about 4.6 nm from the
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runway 06L threshold (approximately 1.3 nm from the VOR), the first officer stated

"not in sight?" One second later, the GPWS radio altitude call out sounded: "five

hundred [feet]." About 01:42:14, as the airplane was descending through 840 feet

msl and the flight crew was performing the landing checklist, the GPWS issued a

"minimums minimums" annunciation followed by a "sink rate" alert about 3 seconds

later. The first officer responded, "sink rate okay". At that time the airplane was

descending 1,400 feet per minute. About 01:42:19, as the airplane descended

through 730 feet msl, the flight engineer stated, "two hundred [feet]," and the first

officer said, "let's make a missed approach." About one second later, the flight

engineer stated, "not in sight," and the first officer said, "not in sight, missed

approach." About 01:42:22, as the airplane descended through approximately 680

feet msl, the nose began to pitch up and the flight engineer stated, "go around."

When the captain stated "go around" power was added and airspeed began to

increase. As the airplane descended through 670 feet msl, the autopilot disconnect

warning sounded. The GPWS radio altitude call outs continued: "one hundred . . .

fifty . . . forty . . . thirty . . . twenty [feet]." About 01:42:26, the airplane impacted hilly

terrain at Nimitz Hill, Guam, about 660 feet msl and about 3.3 nm from the runway

06L -threshold. It struck trees and slid through dense vegetation before coming to

rest. A post-impact fire broke out. It was established a.o. that the software fix for the

Minimum Safe Altitude Warning (MSAW) system at Agana Center Radar Approach

Control (CERAP) had rendered the program useless. A software patch had been

installed since there had been complaints of the high rate of false MSAW alarms at
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Guam. This made KAL801's descent below MDA go undetected at the Agana

CERAP.