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 sets of remains, about 145 sets could not be evaluated for soot in the airway because the condition of the remains precluded an evaluation. Of the 137 remains sets that could be evaluated, soot was found in the airway of 20 sets, no evidence of soot was found in 41 sets, and no definitive observations could be made regarding soot in the airway for 76 sets (in many of these 76 cases, however, the traumatic injuries described would have precluded survival after the impact sequence). Information was not available for the final 15 sets of remains.

A fire erupted during the impact sequence and was sustained by the fuel on board the airplane; the last report of small remaining fires was about 0800. The Safety Board's investigation revealed no evidence of an in-flight fire.

The 747-300 cabin contained a total of 385 passenger seats and was divided into three sections: first class, prestige (business) class, and economy class. The airplane was configured with four rear-facing, double-occupancy flight attendant jumpseats and six rear-facing, single-occupancy flight attendant jumpseats, all of which were equipped with a four-point restraint system. The flight attendant seats were located at each of the four emergency exit doors located on the left and right side of the cabin.

Of the 237 passengers aboard flight 801, 3 were children between 2 and 12 years old, and 3 were children 24 months or younger. Thirty-one airplane occupants were found alive by rescue workers Two passengers died en route to area hospitals. The autopsy report for one of these two passengers did not identify a single cause of death (her remains showed evidence of multiple internal injuries but no burns or soot in her airway). The autopsy report, however, identified that she was alive when medical personnel arrived at the accident scene and that she was treated aggressively as a result of serious injuries. In addition, 3 passengers died of their injuries within 30 days after the accident, bringing the official total number of accident survivors to 26.

Of the 26 survivors of the accident, 7 passengers and 1 flight attendant were seated in the first class section, 1 flight attendant was seated in the prestige class section, 7 passengers were seated in the forward economy class section, and 9 passengers and 1 flight attendant were seated in the aft economy class section. Two of the surviving flight attendants and 13 of the surviving passengers were seated on the right side of the airplane; 6 of these 13 passengers were seated over the right wing. Figure 9 shows the 747-300 cabin configuration and the survivor seat locations.

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 Figure 9. Korean Air flight 801 cabin configuration and survivor seat locations.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

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Safety Board investigators and MOCT officials interviewed a surviving flight attendant and several passengers in a Guam hospital on August 9, 1997. In addition, 11 passengers responded to a Safety Board "Survivor Questionnaire" after returning to Korea. Information obtained from the interviews and questionnaire responses indicated that these survivors either had been ejected from the airplane during the impact sequence or had extricated themselves from the wreckage. Most of these survivors indicated that they were injured as a result of the impact; however, two survivors stated that they were injured by fire. Further, the survivors stated that, during their egress from the airplane, they encountered damaged seats, overhead bins that had fallen, and other unidentified obstacles.

A flight attendant who was seated in the R1 jumpseat (in the first class section) stated that she heard a loud "boom" before the airplane began shaking violently and breaking up. The flight attendant said that she was thrown from the airplane in her jumpseat during the impact. She then unfastened her restraint system, walked about 30 feet beyond the right side of the airplane, and assisted a female passenger.

Several surviving passengers stated that, after the impact, baggage from the overhead bins fell to the floor and that "intense flames and heat swept through the cabin." One survivor, who was seated in the aft economy class section (row 34), stated that her husband was engulfed by fire in the seat next to hers. Another passenger, a professional helicopter pilot, stated he felt what he thought was a "hard landing" but that the airplane then rolled and began to disintegrate. The passenger stated that he exited the burning cabin by walking through a large hole in the fuselage. He also said that a "ball of flame was going down the center of the airplane" and that passengers were screaming and calling for help.

About 0150, the Guam Fire Department (GFD) communications center received an emergency call from a local resident, who reported seeing a fire in the hills near the airport. About 0158, after receiving notification of the accident from the CERAP controller (based on the Ryan International flight crew's observation of a "big fireball on the hillside"), the Agana tower controller alerted ramp control about the crash of Korean Air flight 801. According to airport ramp control logs, ramp control initiated the required emergency notifications at 0202, including a call at 0208 to the Naval Regional Medical Center to place its personnel on standby. According to GFD communications center logs, notification of a downed aircraft was received from the Guam ramp control at 0207. Immediately afterward, the GFD communications center dispatched Engine Company No. 7, which was located about 3 ? miles from the accident site. According to the GFD chief, the departure of Engine No. 7 was delayed because its brakes had been drained to prevent an overnight buildup of condensation in the brake lines. Thus, the brake lines had to be first recharged with air. Engine No. 7 departed the station at 0219 (12 minutes

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 after being notified) and arrived 15 minutes later (at 0234) at the gate to the pipeline/VOR access road (which was the only vehicle ground access to the accident site).

The Federal Fire Department's Station No. 5, located on Nimitz Hill 1 mile away from the accident site, was the nearest fire station. GFD communications center logs indicated that the federal dispatch facility was notified of the accident at 0207, but the federal dispatch facility records indicated that notification was received at 0234 and that Engine No. 5 arrived at the scene at 0239.

The Chief of Staff, Commander, U.S. Naval Forces, Marianas, who was also the wife of the airport director, testified during the public hearing that she first became aware of the crash after an airport official called her husband at 0216 to report that a Korean Air 747 was missing over the Nimitz Hill area. The Chief of Staff went outside and observed a "bright orange glow" in the sky. She then notified the Navy Security Office and Command Duty Officer to activate the Navy's "first responders," search and rescue assets, and hospital mass casualty units.

The GFD incident on-scene commander (OSC) told investigators that he arrived at the accident site about 0234 and proceeded down the access road toward the wreckage. The access road to the site--a narrow (one-lane) dirt and stone road with a drainage ditch on both sides--had been blocked by a section of damaged oil pipe. The pipe, which was located next to the road and elevated about 3 feet, was removed 1 hour later by a truckmounted winch after efforts to remove it by hand were unsuccessful. According to GFD documents, Engine No. 7 became stuck in mud when the driver tried to maneuver around the oil pipe obstruction. The GFD chief stated that, once the broken pipeline had been removed and the fire truck had been towed out of the mud (about 0345), no further blockages of the access road were reported.

In a postaccident interview and at the Safety Board's public hearing, the OSC testified that he and other rescue personnel abandoned their vehicles and approached the accident site on foot. The OSC indicated that he and the rescue personnel carried flashlights, rope, and a trauma kit. The OSC stated that he heard people screaming and could see small areas of fire. The OSC said that the darkness and terrain made access to the accident site difficult.

The OSC stated, "we had to go across all types of vegetation, sword grass, all types of trees...it was very rough getting down to the crash site, especially with no light whatsoever but flashlight alone...we had to deal with all kinds of bugs down there, snakes...we tried to pull out the survivors the best way we could and from what we received in fire-fighting training." The OSC also stated that

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 :the airplane [had been] totally engulfed [in fire] when we got there...already to the point where the fires weren't really bothering the rescuers. The rescue personnel were actually going into the plane checking passengers...who was still alive and who was not.... We had to go back up on those slippery hills without any rappelling gear whatsoever.... We were holding the victims in one arm and holding the tools in the other so we just could make it to the top.... We did this until we could clear a landing site for the choppers....

The OSC stated that a command post was established to the east (on higher terrain) of the main wreckage site, where requests for resources and personnel were relayed by radio to the GFD dispatcher. The dispatcher then relayed the information to the response activity coordination team located at Guam Civil Defense (GCD) headquarters.

The GCD director told Safety Board investigators that he arrived at the access road gate about 0235. The director stated that the GCD owned a command post vehicle but that he did not use the vehicle because it was outdated and had been out of service for several years. He stated that funds were not available to repair and equip the vehicle.

A U.S. Navy emergency medical technician (EMT) assigned to the Naval Regional Medical Center told Safety Board investigators that he received verbal notification of the accident between 0200 and 0230 from personnel at the Guam Naval Activities Station, which is located about 8 miles southwest of Nimitz Hill. The EMT reported that he arrived at the accident site on foot between 0245 and 0300. Upon arrival, the EMT observed the fuselage and interior engulfed in "bright blue flames." The EMT stated that he approached the burning wreckage to within about 150 feet and saw about 14 survivors outside the airplane with various injuries, most of which were burn related. The EMT said that many of these survivors were clustered together and that they appeared to have extricated themselves from the wreckage.

The EMT told investigators that it was difficult to maneuver around the wreckage because of darkness, intermittent rain, soft ground, tall grass, and rugged terrain. Further, the EMT stated that two triage areas had been set up: one near the front of the airplane (near the nose section), and the other between the fuselage wreckage and the access road.

A Guam Department of Public Health physician told Safety Board investigators that she was notified of the accident by GCD about 0245 and arrived at the accident site about 0315. Upon arrival, she noted that the triage and transportation activities were "functioning well" but that medical and evacuation efforts lacked coordination. Additionally, she said that, after assessing the situation, she established another triage area near the VOR, where the terrain was level.

Some of the survivors that had been treated at the triage area near the airplane were evacuated by military helicopters, whereas others had been carried to the triage area near the VOR to be treated and then transported by ambulance via the access road. The OSC

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 stated that the first survivors were transported to hospitals between about 0300 and 0330. The EMT stated that the last survivor was found about 0430. According to hospital records, the first survivor transported by helicopter to the U.S. Naval Hospital arrived about 0334, and the last survivor arrived by helicopter about 0710. Also, hospital records indicated that the first survivor transported to Guam Memorial Hospital arrived by ambulance about 0420 and that 16 other survivors were transported by ambulance to Guam Memorial, the last of which was admitted about 0709. 1.15.3.1 Emergency Response Planning and Exercises

At the Safety Board's public hearing, the GCD director testified that, in April 1997, a joint full-scale disaster drill had been conducted on the airport with Guam airport authorities. The GCD director stated that no off-airport drills had been conducted before the accident but that an off-airport aircraft accident drill had been scheduled for September 1998.

The GCD director added that, after the accident, new radios had been purchased to allow interagency communication and coordination during emergencies. The GCD director also testified that, before the accident, GCD authorities had a memorandum of understanding (MOU) with the U.S. Air Force for emergency response but had not established an MOU with the U.S. Navy or U.S. Coast Guard. The GCD director stated that, after the accident, Guam authorities formed an emergency response committee, which included the Navy, the Coast Guard, and the Air Force, and that an MOU involving all emergency response agencies on the island had been drafted. The director stated that the MOU called for emergency response drills involving all of the agencies.

In June 1999, the GCD acting administrator stated that, instead of the MOU, a final draft of "Joint Standard Operating Procedures for Mutual Civil Emergency Support for Emergencies or Disasters Without Presidential Declaration" was circulated to the GCD office; Commander, Naval Forces Marianas; U.S. Coast Guard Marianas Section; and the U.S. Air Force 43rd Air Base Wing. The acting administrator indicated that the procedures could be implemented by the end of June 1999. The Safety Board's latest information from the GCD office (August 1999) indicated that the procedures had not been implemented.

Officials from the GCD office stated that the planned September 1998 off-airport exercise did not take place. In June 1999, the GCD acting administrator stated that planning for a major off-site exercise had started.

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The Guam government conducted a review of its response to the accident and issued a report, titled Korean Air 801 Incident Report. According to the report, the "focus of the investigation was to identify an accurate timeline of emergency response during the first hours of the incident, and to address issues/questions raised concerning the rescue efforts. Those issues/questions concerned fire suppression, command structure and activity of key members of the rescue team."

Problems discussed in the report included the lack of radio communications between key personnel, which complicated the command situation. The report stated, "...the civilian and military components were on different and incompatible radio systems...radios had to be shared in the command post so that the various agencies could communicate."

Additionally, the report cited the remoteness of the accident site and the difficulty in bringing fire trucks close enough to the site to be effective. However, the report stated that "no fire suppression was used" because it would have "interfered with rescue operations." The report also cited accounts from rescuers that indicated, "...most of the survivors were initially located away from the flames of the aircraft.... It is noted that the first rescuers arrived approximately 55 minutes after the plane had crashed.... If the fire was as intense as originally reported [immediately after impact], fatalities caused by fire and smoke inhalation would have occurred before the rescuers arrived."

Because of advances in computer technology and terrain mapping capabilities, GPWS manufacturers have developed improved terrain avoidance systems. In 1997, the FAA certified a new terrain awareness and warning system (TAWS), also known as enhanced GPWS. (See section 1.18.2.2 for general information about enhanced GPWS.) This system was not installed or required on the accident airplane.

An enhanced GPWS simulation was conducted after the accident to determine the additional forewarning that the flight crew of Korean Air flight 801 would have received if such a system had been installed on the airplane. The simulation revealed that the flight crew would have received an aural "CAUTION TERRAIN" warning and a yellow visual terrain depiction on the weather radar about 60 seconds before impact. In addition,

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 enhanced GPWS would have provided the aural annunciations "TERRAIN, TERRAIN" and "PULL UP" and a red visual terrain indication on the weather radar display about 45 seconds before impact; the annunciations would have sounded continuously until completion of a successful escape or impact with terrain.

In July 1999, Korean Air announced that it would equip all of its aircraft with enhanced GPWS by the end of 2003. The KCAB subsequently confirmed Korean Air's announcement.

An ARTS IIA MSAW simulation was conducted after the accident at the FAA Technical Center in Atlantic City, New Jersey. The simulation indicated that, without the 54-nm-inhibited ring, a visual and aural low-altitude alert would have been generated for flight 801 on the terminal ARTS IIA display at the CERAP facility. Further, the simulation indicated that the visual and aural approach path alert would have been generated at 0141:22, as the airplane was descending through 1,700 feet msl, or about 64 seconds before the airplane crashed.

After the accident, the KCAB and Korean Air conducted a series of independent tests on a Boeing 747 on the ground to determine if spurious radio-frequency energy could induce an abnormal ("false") glideslope indication. These tests were not intended to represent conditions at the time of the accident; rather, the tests were designed to explore ILS system sensitivity to spurious signals. According to Korean Air engineers, the tests revealed that the glideslope deviation needle could be positioned near the middle of the glideslope reference scale, and the warning flag could be retracted by introducing a "335 MHz signal (120 Hz signal modulated at 100 percent)" near the ILS receiver antenna.

The KCAB and Korean Air technical staff demonstrated their test results to the Safety Board and parties to the investigation at a January 1998 meeting. The demonstration, which was conducted using a portable 51-RV5(B) receiver and a signal generator, indicated that a single 120-Hz signal with 100-percent modulation at the Guam ILS frequency resulted in an out-of-view glideslope flag and glideslope indicator movement.

If a glideslope signal is not being generated by the transmitter (resulting in an open frequency channel/band), the airborne glideslope receiver will continue to hunt for a glideslope signal. Although the radio-frequency filters built into the receivers are designed to bias out the majority of spurious radio signals, the postaccident testing by the KCAB and Korean Air revealed that, in the absence of a valid glideslope signal, it is possible for an airborne glideslope receiver to momentarily receive a spurious signal in the frequency

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 band of the glideslope signal. The reception of such a signal could result in the movement of the glideslope receiver needle and present a false indication to the pilot.

1.16.3.1 Guam Instrument Landing System and Potential Interference From Spurious Radio Signals

An FAA National Resource Engineer for Navigation testified at the Safety Board's public hearing about the Guam ILS system and the potential for interference from spurious radio signals. The engineer stated that "the pilot would normally be warned that a signal is not present by the presence of a flag, a warning flag, that indicates that something about the receiver system or something about the ground system is abnormal...." The engineer testified that he assumed that the accident flight crew's remarks regarding the glideslope (as recorded on the CVR) had to do with the presence or absence of flags. He concluded that "...there must have been some sort of flag activity coming into view, disappearing from view, some time during the approach" and that the comments, although they did not convey information about the duration of any flag activity, indicated that "...there must have been enough absence of the flag for the crew to occasionally decide that the system was on the air when in fact it wasn't...."

The FAA engineer also testified that, although the glideslope at Guam International Airport had been removed from its shelter, radio signals generated by some other source could have provided an intermittent signal to the glideslope receiver, which might have prevented the instrument warning flag from remaining in view. The engineer explained that potential external sources of noise and unintended signals, which are normally too weak to be heard, can be heard on an empty channel and that, during airborne flight tests of ILSs in which the localizer or the glideslope is turned off, it has been fairly common for the cockpit instrumentation to record intermittent indications of flag and needle activity. However, he expressed that this sort of activity on the instrumentation (referred to by pilots as "flag pops") is typically intermittent and of very short duration.

The engineer testified about the types of radio signals that could potentially cause a movement of the flag. He stated that the ILS transmits two tones and that the difference in the signal strength of the tones deflects the glideslope fly-up and fly-down needle. The engineer indicated that the receiver has some circuits that look for these two tones and that the fly-up/fly-down needle indicates the difference in strength of those two tones. He added that "...the difference will be zero, and the needle will be centered when the two tones are equal...."

Further, the FAA engineer stated that the flag circuit, the other indication that a pilot sees, is driven by a signal that is the sum of the two circuits or the two signals. He indicated that "as long as the 90 and 150 [Hz] signals are both present at sufficient strength, the flag will remain out of view." The engineer also stated that, if there is no ground station transmitting and no intended ground station but some other signal, then those portions of the signal that contain 90- and 150-Hz tones would still get through those filters and could cause the needles to deflect. The engineer added that, depending on

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 the shape of the filters' response (which varies according to receiver model and manufacturer), the circuits would experience varying amounts of intermittent deflections.

Korean Air evolved from Korean National Airlines, a government-owned carrier established in 1948 to provide domestic air service from Seoul to Pusan. The airline was privatized in 1969 and renamed Korean Airlines. The name was again changed to Korean Air Company, Ltd., d.b.a. Korean Air, in the 1980s.

Korean Air, based at Seoul's Kimpo International Airport, operates domestic routes to 16 airports and international routes to 54 airports, including those in North America, Europe, the Middle East, Southeast Asia, China, Australia, and Japan.

At the time of the flight 801 accident, Korean Air had a fleet of 116 airplanes: 2 Boeing 747-SPs, 15 Boeing 747-200s, 3 Boeing 747-300s, 26 Boeing 747-400s, 2 Boeing 777s, 5 McDonnell Douglas MD-11s, 14 McDonnell Douglas MD-82s, 10 Airbus A-300s, 2 Airbus A-330s, 25 Airbus A-300-600s, and 12 Fokker F.100s. Korean Air stated that its fleet was expected to grow to approximately 175 aircraft by 2005. Korean Air employed approximately 1,600 flight crewmembers at the time of the flight 801 accident. In an interview with Safety Board investigators, Korean Air management personnel stated that pilot recruitment at the company had historically been from the Korean military. However, as the airline grew, the supply of available Korean military pilots could not keep pace with the rapidly increasing demand for pilots at the company. Because of this shortage, Korean Air recruited foreign nationals to supplement its pilot force. At the time of the accident, 167 foreign national pilots were employed by Korean Air. (Most of these foreign pilots were from the United States and Canada and were hired through several crew leasing companies; the pilots' employment was subject to the terms of a renewable contract.) Of the 128 captains assigned to 747-200, -300, and -SP airplanes at the time of the accident, 69 were foreign national pilots. Also, partly as a result of the pilot shortage, Korean Air began what it referred to as an "ab-initio" (that is, from the beginning) program in 1989 that was designed to select and train candidates from zero flight time. According to a Korean Air representative, ab-initiotrained pilots were initially assigned to the smaller airplanes used to fly domestic routes. As the pilots gained experience, they were upgraded to the larger airplanes used primarily to fly international routes. At the time of the accident, 389 pilots had been trained under the ab-initio program, and Korean Air estimated that the first group of ab-initio pilots would be evaluated for possible upgrade to captain during 1998. In September 1999, a KCAB official stated that the first ab-initio-trained pilots were being upgraded to captain.

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 The Korean Air Deputy Director of Flight Operations testified at the Safety Board's public hearing that the Korean economy had been in a recession and that, although 1995 was "a good year," 1996 and 1997 were "in the red." This official also testified that, despite economic pressures, additional funding had been allocated by the company for safety programs. The Deputy Director of Flight Operations, in his closing remarks at the public hearing, stated:

 * 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.

In a March 26, 1998, letter, however, Korean Air requested that the Safety Board remove the Deputy Director of Flight Operations' statement from the public hearing record. In its letter, Korean Air maintained that the deputy director's statement was "personal in nature" and "made in accordance with the Korean custom to express condolences on public occasions to those affected by an accident." The letter also said that "the statement could suggest a finding by [Korean Air] of management deficiencies having been ascertained as a result of internal review" and that "there has been no such finding or review." Further, the letter expressed Korean Air's belief that the company's management structure "is competent to perform its functions." The Safety Board did not delete the statement from the record.

According to the KCAB, Korean Air's president resigned in April 1999 as a result of government criticism. The vice president of Korean Air was subsequently promoted to president and chief executive officer.

On October 9, 1998, the MOCT ordered Korean Air to suspend 138 flights per week on 10 of its domestic routes for 6 months. According to the MOCT, the action followed seven accidents/incidents (including the August 5 and September 30, 1998, events listed in section 1.17.5.2). The MOCT ordered the airline to reduce service on its Seoul to Tokyo route from 28 to 26 flights per week. According to a KCAB representative, "these accidents/incidents were without human casualties, but we mete out the severe punishment as a warning." The KCAB indicated that other administrative actions against Korean Air included the following:
 * increased captain qualification requirements for large aircraft (including the 747),
 * prohibition of initial assignment of large aircraft for first officers.

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 * increased simulator training for CRM and line-oriented flight training (LOFT), and
 * special simulator training for adverse weather conditions.

After the MOCT took action, Korean Air announced that it planned to spend more than $100 million over the next 2 years on safety initiatives, including changes in pilot training and maintenance operations. Korean Air also stated that it planned to accomplish the following:
 * install enhanced GPWS on all new aircraft and upgrade traffic alert and collision avoidance systems (TCAS) on all airplanes;
 * recruit safety specialists to provide safety awareness training to all flight crewmembers;
 * conduct regular aircraft-specific safety and training sessions for flight crews, including an expanded controlled flight into terrain (CFIT) awareness program in both initial and upgrade training;
 * develop a "safety alert system" in which data about incidents, accidents, and irregular operations are gathered from every department and analyzed to identify trends and develop accident prevention strategies;
 * revise simulator scenarios that reflect a variety of situations that may be encountered during line operations, including takeoffs and landings from different airports, TCAS avoidance maneuvers, and ground proximity escape maneuvers;
 * standardize pilot callouts, improve takeoff, approach, and landing checklists, and enhance pilots' knowledge of local terrain; and
 * ensure that all flight crewmembers receive CRM and LOFT classes that require "efficient and effective communication in the cockpit and cabin through simulated situations."

Korean Air also indicated that it planned to mandate a 30-day English language training course and implement a confidential pilot reporting system so that errors and concerns can be reported to the chief pilot without fear of reprisal. In addition, the airline implemented a "maintenance error decision air program" designed to detect potential maintenance anomalies caused by human error.

In May 1999, Korean Air's new president issued a safety policy statement and additional material to support the company's planned safety enhancements. Specifically, Korean Air reevaluated its operational philosophy and adopted a five-point "Immediate Action Plan," which contained safety measures that were designed to "minimize exposure

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 to risk, eliminate known hazards, and curtail operations under circumstances where there may be reduced margins of safety."

First, the Immediate Action Plan imposed operational limits at five airports in Korea to minimize exposure to risk when the margin of safety may be reduced. For example, at three of the five airports, no operations can be conducted at night when the runways are wet or crosswinds exceed 15 knots. Second, the plan contained Korean Air's revised policies and procedures for operations under slippery runway conditions and the use of automation. Third, the plan included Korean Air's decision to outsource flight simulator training.

Fourth, the Immediate Action Plan stated that Korean Air's most important operating priority is safety. According to Korean Air, every company line captain participated in a series of seminars in April 1999 in which the captain's decision-making, authority, and responsibilities were redefined. These seminars reemphasized that the captain "serves as the first, and last, line of quality assurance for [Korean Air], and is charged with final responsibility for the safety of its flight operations." Last, the plan provided senior management's commitment to enhance decisionmaking, especially as it relates to flight safety matters. The plan stated that Korean Air created an Executive Action Council to resolve critical operational and support issues in a timely manner and a Flight Operations Action Team to identify and resolve critical flight operations issues.

According to Korean Air, new flight crew work rules will become effective in October 1999. The new rules are expected to be similar to the duty and rest standards established under 14 CFR Part 121 and the practices of leading airlines in the industry. Korean Air indicated that its goal was to eventually achieve a standard of 80 hours of flying time per month. Also, Korean Air stated that it was in the process of implementing an automated flight crew scheduling system purchased from Sabre Technologies. This new system was designed to monitor crew training and instrument and landing currency and automatically update compliance with flight and duty limitations. The system was expected to be fully implemented by the end of 1999.

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 In addition, Korean Air indicated that it has been revising its Flight Operations Manual, Aircraft Operating Manual for each aircraft type, Operations Data Manual, and Aircraft Restriction Manual from the manufacturer-supplied versions to reflect the company's standard operating procedures and achieve standardization. According to Korean Air, 8 of the total 21 chapters of the Flight Operations Manual were revised and distributed to all flight crewmembers on August 1, 1999, and the rest of the chapters were expected to be revised and distributed during October 1999. Korean Air also indicated that all of the company's Aircraft Operating Manuals had been revised and issued according to each aircraft manufacturer's schedule. A Korean Air representative said in September 1999 that the Boeing 747 operating manual had been revised four times since the flight 801 accident.

1.17.2 Korean Air Flight Crew Training Flight crew training is currently conducted at one of two facilities in Korea. Ground instruction is conducted at the Korean Air Flightcrew Training Center in Seoul, and simulator flight training is conducted at the Korean Air Simulator Flight Training Facility in Inchon. (Korean Air conducts its ab-initio training at the Sierra Academy of Aeronautics in Livermore, California, and then at its Cheju flight training facility.) To become qualified as a Korean Air flight instructor or evaluator, candidates must attend 1 week of ground school, 10 days of simulator observations, 10 days of practice simulator instruction, CRM and LOFT seminars, and check rides. Program managers and senior flight instructors provide supervision and ensure standardization. 1.17.2.1 Basic and Advanced Instrument Flight Course Korean Air provides basic and advanced instrument flight courses for every specific airplane training program. Pilots receive this training before their initial training on the particular airplane for which they are qualifying. Because the captain of the accident flight was initially trained on the Boeing 727, he took the 727 basic and advanced instrument flight courses; likewise, because the first officer was initially trained on the Boeing 747, he took the 747 basic and advanced instrument flight courses. (The captain received training on the 747 in transition courses, which are discussed in section 1.17.2.2.) According to Korean Air's flight training curriculum at the time of the accident, the basic instrument course consisted of eight 4-hour simulator periods and included modules in air work and instrument departures, arrivals, and approaches. The advanced instrument course, which expanded on the procedures taught during the basic course, included avionics operation, standard instrument departures, noise abatement procedures, standard terminal arrivals (STAR), and engine-out procedures. The advanced course consisted of 10 4-hour simulator periods. The countdown/count up DME/localizer procedure, such as the one depicted in the Guam ILS runway 6L localizer-only (glideslope

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 out) approach, was not included in any of the Korean Air simulator training scenarios for either the basic or advanced instrument courses.

1.17.2.2 Boeing 747 Flight Crew Training

Korean Air's Boeing 747 flight crew training includes initial and transition training, which are presented in five units: ground school, cockpit procedures training, simulator flight training, airplane local training (as required), and route training. The captain and the flight engineer on the accident flight were trained according to the 747 transition training syllabus, and the first officer was trained according to the initial training syllabus.

At the time of the accident, the 747 initial and transition ground school training included instruction on general aircraft systems, normal procedures, abnormal and emergency procedures, weight and balance, performance, limitations, differences, Category II instrument approaches, a review period, and a test. The initial ground school training syllabus allocated 177 hours of instruction for both pilots and flight engineers and required about 28 hours of cockpit procedures training. The transition ground school syllabus allocated about 153 hours of instruction for captains and first officers with type ratings on other airplanes and about 157 hours for flight engineers with qualifications on other airplanes. Pilots and flight engineers were required to complete about 24 hours of cockpit procedures training.

Flight training for the initial and transition courses included 40 hours of simulator time (10 4-hour training periods in which each pilot performed as a PF and a PNF for 2 hours) and a 2-hour proficiency check period. At the time of the accident, the Korean Air simulator training syllabus for 747-100, -200, and -300 initial and transition training consisted of 10 profiles that described the events to be accomplished during each training period. Each profile listed the approaches to be performed, including the specific airport, runway, weather, and airplane malfunction, and information on whether the approach would be made to a landing or the reason for a missed approach or go-around. The 10 training profiles consisted of the following approach scenarios: ? ? ? ? 23 ILS approaches to runway 14 at Kimpo Airport; 5 VOR and VOR/DME approaches to runway 32 at Kimpo Airport; 2 NDB approaches, one to a runway at Cheju Airport and one to a runway at another airport; and 1 localizer (LOC) approach to runway 14 at Kimpo Airport.

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 training records indicated that the 11th simulator profile consisted of four ILS approaches to runway 14 at Kimpo Airport and one VOR/DME approach to runway 32 at Kimpo.

The 747-200 Simulator Training Guide for Instructors, dated February 1997, detailed the various training scenarios used in 747-100, -200, and -300 simulator training at the time of the accident. The training guide described only one of the nonprecision approaches: the VOR/DME approach to runway 32 at Kimpo Airport. The description for this approach included the DME distance to initiate gear and flap configuration changes and specific vertical speed settings during step-down fixes on the approach procedure. Also, this nonprecision approach scenario always involved DME that was located on the airport and colocated and frequency paired with the primary approach navigational facility. Thus, all simulator approach scenarios using DME were approaches for which the pilot had to count down toward the MAP.

The simulator training curricula did not contain nonprecision approaches to other airports or with varied or diverse scenarios. For example, no approach scenarios required the pilot to count down to the DME, fly past the DME, and count up to the MAP, which was required for the runway 6L ILS localizer-only (glideslope out) approach to Guam. At the Safety Board's public hearing, Korean Air's Director of Academic Flight Training and a Korean Air check airman testified that the simulator scenarios were to be followed as published in the training curricula. They also indicated that there were no provisions or guidance that enabled instructors to vary the nonprecision approach scenarios from those published.

The Korean Air Simulator Training Guide contained specific approach scenarios to be used during proficiency checks and type rating simulator checks. These approach scenarios were the same ones taught and practiced during the initial and transition training sessions.

After the accident and subsequent discussions with the Safety Board, the KCAB asked Korean Air to modify its simulator training syllabus to include diverse approaches. The Safety Board notes that the Korean Air simulator training now incorporates a variety of approach scenarios, including approaches in which the DME is not colocated with an on-airport navigational facility and approaches involving countdown/count up DME procedures. Also, the simulator training now includes approaches that are likely to be encountered during domestic and international line operations.

1.17.2.3 Crew Resource Management Program

The Korean Air Director of Academic Flight Training stated that the company instituted a CRM training program in December 1986 as a result of the Korean Air shoot down accident in August 1983 off the coast of the Soviet Union. The director stated that the CRM sessions are not graded and that no program records are kept. Pilots are evaluated on CRM during route checks and proficiency check rides. In addition, pilots receive LOFT during simulator sessions once a year and are evaluated based on how

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 they interact in coping with various anomalies during the simulated flight. According to Korean Air, a total of 1,614 flight crewmembers had successfully completed CRM training classes as of May 1999.

The CRM program that was in place at the time of the flight 801 accident was developed from the United Airlines CRM program and adapted with the assistance of an outside contractor. This 4-day program, which was provided to flight crews only, emphasized dilemma resolution and focused on teamwork and leadership in problemsolving at the individual, crew complement, and organizational levels. The CRM program used reading materials, films, and class exercises to help flight crewmembers recognize and improve aspects of their behavior and interaction. The Director of Academic Flight Training testified that this CRM program taught first officers and flight engineers to intervene and challenge the captain if they had safety or operational concerns. He noted that the company had encountered difficulties teaching some first officers and flight engineers to challenge the captain and intervene in safety-of-flight situations. The director also testified that this issue was no longer a problem in training and that captains were being taught to encourage a cockpit environment in which first officers and flight engineers could freely express concerns when necessary.

In May 1999, Korean Air announced it would replace the existing CRM program with a new CRM program that was developed with and adopted from Delta Air Lines. The new program will consist of four courses: a base course, a course for new captains, a recurrent course, and a recurrent joint flight operations/cabin services course. The onetime base course, called "Error Management CRM," will last 5 days: the first 3 days will be classroom instruction, the fourth day will be a jumpseat observation flight, and the fifth day will be a debriefing session. The one-time "In-Command" course for new captains will last 1 day. The 1-hour pilot recurrent course and the 3-hour recurrent joint flight operations/cabin services course will be presented each year. According to Korean Air, the courses will be taught through lectures, class exercises, reading material, and other techniques to impart practical skills for the crews. In addition, Korean Air stated that its new CRM course would add "realism" to training through an audio-visual presentation format. Korean Air indicated that it expected to implement this program by January 2000.

1.17.2.4 Postaccident Changes to Flight Training

In addition to the changes being implemented in response to the MOCT action and as part of the Immediate Action Plan and the new CRM program, Korean Air indicated that it has made other changes in the area of flight training. For example, the company's Flight Standards Branch, within the Flight Operations Department, is now primarily responsible for overall quality assurance for all flight training and checking activities. Other changes are as follows:

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 * Beginning in November 1998, training modules on risk and error management and recovery training for CFIT awareness, GPWS and windshear warnings, slippery runways, and crosswind and icing conditions were added to the recurrent proficiency training curriculum for all airplane types.
 * In January 1999, a policy of training to proficiency in the recurrent training and checking system was implemented. Crewmembers are to be given three opportunities during recurrent training and checks to receive additional instruction and correction while training to the acceptable level of proficiency.
 * Also in January 1999, the Flight Operations Department changed its system for selecting candidates for aircraft transition and upgrade to incorporate "more objective" criteria. The standards for upgrading to captain were also revised. The new standards increase the minimum requirements from 3 years and 3,000 hours to 5 years, 4,000 hours, and 350 landing cycles with the company regardless of previous military or other aviation experience.
 * In April 1999, new standardized flight instruction manuals were issued.
 * A new Line Check Pilot Manual was being developed to include detailed procedures and requirements so that check pilots could consistently apply and enforce company standards and policies. The new manual was expected to be completed in October 1999.
 * The Flight Operations Department developed a new all-volunteer system, to replace the previous assignment system, for all line check pilots. Candidates who volunteer for these positions are to be selected based on their ability to judge deficiencies in training and impart line flying skills. Also, the training requirements for line check pilots were increased so that the check pilots could impart better decision-making and crew coordination skills to the line pilots.

The Korean Air Operations Manual that was in effect at the time of the accident (dated May 21, 1997) stated that crewmembers were to arrive at the company dispatch center at least 1 ? hours before the scheduled departure time for international flights. According to company procedures at the time, flight crewmembers were to receive their paperwork and then gather as a group to study the paperwork. This process, referred to as the "self-briefing," typically lasted about 15 minutes. The flight crewmembers then met with their assigned SOF for the "SOF briefing." Afterward, the captain met with the flight and cabin crewmembers for a "full crew briefing."

Korean Air stated that, in March 1999, it began issuing "flight-specific manual packages" to outbound crews to ensure that pilots possessed updated route information for each trip. In addition, the company said that it developed an airport information program to promote additional route and airport familiarization. Korean Air expected that this program would be completed by the end of 1999 and that it would cover all of the airports serviced by the company's aircraft.

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 1.17.3.1 Supervisor of Flying Program

According to Korean Air officials, the company's SOF program began in 1996. The officials described the SOFs as retired captains and instructors who were among the company's most experienced pilots and had no record of disciplinary action. The officials stated that the purpose of the SOF briefing was to ensure that pilots had reviewed all pertinent materials for the flight, including any NOTAMs. Further, the SOFs were expected to periodically check crewmembers' charts and manuals for currency as well as their airman certificates and passports, which are required documents for international flights. There is no formal checklist of items to be covered in the SOF briefing. The officials stated that the SOF briefings were designed to last 15 minutes but averaged about 10 minutes.

In a postaccident interview with Safety Board investigators, the Korean Air Deputy Director of Flight Operations said that he initiated the SOF program to correct pilot performance deficiencies that were involved in the accident/incident events (see section 1.17.5.1) and violations that the company had been experiencing. Further, the deputy director said that he was not aware of any other air carrier that had a SOF program and that he believed the number of accident/incident events and violations had dramatically declined since the initiation of this program. The SOF for Korean Air flight 801 was a retired company 747 captain. The SOF stated, in a postaccident interview, that he reviewed the flight data and asked the flight crew about the weather conditions en route to and at Guam. The SOF also stated that he and the flight crew discussed a typhoon and the possibility of en route turbulence and that he recommended maximum use of the weather radar. The SOF further stated that he and the flight crew discussed company notices but did not discuss the NOTAMs pertaining to Guam and the out-of-service glideslope associated with the runway 6L ILS approach. The SOF did not check the flight crew's charts for currency. The SOF said that his main concern was to confirm that the flight crewmembers had "looked at the [trip paperwork] items closely."

1.17.3.2 Airport Familiarization Program

Korean Air stated that, in June 1997, it established an airport familiarization program that used audio-visual presentations (purchased from Japan Airlines) to prepare pilots for operations into designated airports. Korean Air requires that an airport familiarization tape be viewed if the company or the FAA list that airport as a "special airport." Title 14 CFR Section 121.445 defines special airports as those that require a special airport qualification for pilots-in-command because of "surrounding terrain,

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 obstructions, or complex approach or departure procedures." Guam International Airport was not classified by Korean Air or the FAA as a special airport; thus, the accident flight crew was not required to view this familiarization tape. However, Korean Air recommends that pilots view a familiarization video if they have not flown into the destination within the preceding 3 months. The airport videotapes are available to pilots 6 days a week. The audio-visual presentation for Guam gave a general description of Guam's weather and topography, including Mount Alutom, located near the outer marker, and Mount Macajna, located north of the NIMITZ VOR. The presentation advised pilots that "...when you report airport-in-sight, you will be cleared for a visual approach." Further, the presentation stated that "...you [the pilot] will be radar-vectored to ILS runway 6L.... Normally, you will be guided from over Apra Harbor to the localizer.... You will then perform a visual approach." The presentation highlighted the visual approach, identified visual cues for the approach to runways 6L and 24R, and advised pilots not to fly over a hospital located northwest of the airport.

1.17.4.1 Briefing and Checklist Usage

A Korean Air instructor pilot testified at the Safety Board's public hearing that the company required the PF to conduct an approach briefing for every approach and that the briefing was to include the division of crewmember duties during the approach procedures. The instructor pilot stated that, if a pilot receives information that a navigational aid, such as a glideslope, was reported to be unreliable or unusable, Korean Air policy requires the pilot not to use that navigational aid to conduct the approach. The Korean Air 747 checklist booklet contained a landing briefing card (dated September 10, 1996), listing the following required items for a landing (or approach) briefing:

LANDING BRIEFING
 * 1) . WEATHER
 * 2) . STAR
 * TOD
 * No 1 & No 2 VOR/ADF Courses
 * ALT [altitude] & SPD [speed] Restrictions
 * Arrival Routes
 * 1) USING RUNWAY, TYPE OF APPROACH, AND TRANSITION LEVEL

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 4. REVIEW OF INSTRUMENT APPROACH PROCEDURES
 * Minimum Safe Altitude
 * Approach Frequency (ILS, VOR, ADF)
 * Approach Course
 * Touch Down Zone Elevation
 * Missed Approach Procedure
 * Holding Procedure

5. CREW ACTION AND CALL OUT

6. PARKING SPOT AND TAXI WAYS
 * DOCKING GUIDANCE SYSTEM

7. OTHER ABNORMAL CONFIGURATION AND CONDITION

TIME: BRIEFING SHOULD BE COMPLETED PRIOR TO ARRIVAL OVER TOD

The Korean Air instructor pilot testified that company pilots were taught to include the following items in a nonprecision approach briefing:
 * ATIS information, including the weather, expected approach procedure, and field NOTAMs;
 * arrival and descent procedure to the IAF; runway, type of approach, and type of transition; transition level;
 * instrument approach procedure in detail;
 * airport name and chart number;
 * approach plate issue and effective dates;
 * minimum safe altitude; airport elevation;
 * special notes;
 * configuration of navigational receivers and how to tune and identify them; crew actions and callouts; *procedure to intercept approach course;
 * step-down altitudes and how they were determined;
 * MDA and how it was determined;
 * MAP;
 * parking spot and taxiways; and
 * instruction to nonflying crewmembers to call out any abnormalities or deviation from procedures.

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 Korean Air's checklist philosophy, as described in its Boeing 747 Guidebook, states the following:

Normal procedures[ ] for each phase of flight are performed by recall, and the normal checklist is used to ascertain that all the safety items have been accomplished. Each response to the checklist challenge should be preceded by the verification of the present configurations, and the crewmembers should check for conformation. If any disagreements have been found between present configuration and checklist response, corrective actions should be taken first before any further checklist challenge.

The Korean Air Boeing 747 Guidebook states that the "descent checklist" is to be performed while the airplane is descending through 20,000 feet to approximately 18,000 feet (or 1,000 feet above transition level in North America). The guidebook also states that the "approach checklist" is to be performed after a speed reduction to 250 knots and while the airplane is descending through 10,000 feet with its inboard landing lights on and that the "landing checklist" is to be performed when the airplane has been configured for landing.

1.17.4.2 Flight Crew Actions and Callouts During Nonprecision Approaches

A Korean Air simulator instructor testified that the company trained its pilots to utilize the step-down rather than the "constant angle of descent" technique when executing nonprecision approaches. However, the instructor stated that captains were permitted to use the constant angle of descent approach technique under visual conditions provided that they did not descend below the published intermediate step-down altitudes. The Korean Air simulator instructor also stated that, at the time of the accident, pilots were trained to fly a nonprecision approach with the autopilot either engaged or disengaged. With the autopilot engaged, the PF was instructed to program the autopilot/FD controls, including vertical speed and the altitude select, unless the PF specifically directed the PNF to perform that function. In addition, the PF was instructed to initiate all heading, course, and altitude changes, including the selection of the step-down altitudes, while executing the approach profile. Further, the PNF was instructed to monitor the approach and challenge the PF when necessary.

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 Korean Air did not provide the Safety Board with any documentation from its operations or training manuals on specific PF and PNF roles and duties taught during ground and simulator training. For approach procedures, the only specified duties for the PNF, as described in Korean Air's Boeing 747 Guidebook and 747 Aircraft Operating Manual (page 04.27.01, dated January 30, 1980), were as follows:
 * Position flap lever as directed.
 * Prior to crossing the outer marker cross-check all flight and navigation instruments, observe all warning flags retracted and all radios tuned to correct frequencies.
 * Position landing gear lever down on command.
 * Use windshield wipers and rain repellant as required.
 * Check AUTO SPOILERS and AUTO BRAKE DISARM lights.

The Korean Air 747 Aircraft Operating Manual (dated October 1, 1984) described the following conditions and locations and the standard callouts for the PNF (with the flight engineer monitoring) during IFR conditions:
 * First positive INWARD motion of localizer bar: "Localizer."
 * First positive motion of glide slope bar: "Glide slope."
 * Final fix inbound (altimeter, instrument, and flag crosscheck): "Outer Marker/VOR/NDB/etc., Time, ____ Feet, altimeters and instruments crosschecked."
 * 1000 and 500 ft above field elevation (altimeter, instrument, and flag crosscheck): "1000/500, altimeters and instruments crosschecked."
 * After 500 ft above field elevation: (Call out significant deviations from programmed airspeed, descent, and instrument indications.)
 * 100 ft above DH [decision height]/100 ft above MDA: "100 above."
 * Reaching DH or MAP: "Minimums, approach/strobe/centerline lights-- runway (or no runway).

Korean Air indicated that Standardization Circular 90-07, "747 Standard Callouts" (dated April 1996), described actions and callouts to be made during a nonprecision approach. The Standardization Circular Manual, which was issued to all pilots, contained general and aircraft-specific information. However, the callouts were not included in Korean Air's Boeing 747 Aircraft Operating Manual, company Operations Manual, or 747 Flight Crew Training Manual. Korean Air indicated in July 1999 that its pilots were trained to use the standard callouts during initial simulator training and were checked for the use of these callouts during simulator and line checks. Korean Air also stated that its pilots "always take this document in flight" and that the document is "readily available to

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 pilots." The callouts presented in the standardization circular for the PF, PNF, and flight engineer (F/E) are as follows:

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 {|
 * colspan=2|After CDI LOC Bar Moving:
 * PF
 * Requests "Set Inbound Heading"
 * BNF
 * Responds "Setting Inbound Heading"
 * F/E
 * N/A
 * colspan=2|Leaving Initial Approach Fix (IAF):
 * PNF
 * States "Leaving IAF (name), Time Check, Altitude"
 * PF
 * Responds "Roger"
 * F/E
 * Monitors Altimeter and Altitude Cross Check, Monitor Instruments
 * colspan=2|Landing Gear Down and Landing Checklist:
 * PF
 * Calls Gear Down, Flaps Down (incrementally), Requests "Landing Checklist"
 * PNF
 * Responds to confirm gear position and flap postion
 * F/E
 * Monitors Altitude, Attitude and Airspeed.
 * colspan=2|Over Final Approach Fix (Call "Time" and Push Clock Button):
 * PF
 * States "Outer Marker/Final Approach Fix"
 * PNF
 * Responds "Outer Marker/Final Approach Fix, Time, Altimeter, and Instrument Cross-Check"
 * F/E
 * Monitors Altitude, Attitude and Airspeed
 * colspan=2|1,000 Feet Above Field Elevation (Altimeter, Instrument & Flag Check):
 * PNF
 * States "One Thousand"
 * PF
 * Responds "No Flag, Gear and Flaps"
 * F/E
 * Responds "No Flag, Gear and Flaps" and Monitors Instruments
 * colspan=2|On Final Approach--Deviation Call: The PNF will call any of the following deviations--Bank 15 degrees at or above, DME & Altitude, CDI Exceeds 1/3 dot, Indicated Airspeed exceeds 10 knots, Below Minimum Altitude, Too High or Low on VASI or PAPI [precision approach path indicator]
 * colspan=2|100 Feet Above MDA:
 * PF
 * Looks for Visual Cues
 * PNF
 * States "One Hundred Above"
 * F/E
 * Monitors Instruments
 * colspan=2|At MDA:
 * PNF
 * States "Minimums"
 * PF
 * Responds "Roger"
 * F/E
 * Monitors Instruments
 * }
 * Responds "No Flag, Gear and Flaps"
 * F/E
 * Responds "No Flag, Gear and Flaps" and Monitors Instruments
 * colspan=2|On Final Approach--Deviation Call: The PNF will call any of the following deviations--Bank 15 degrees at or above, DME & Altitude, CDI Exceeds 1/3 dot, Indicated Airspeed exceeds 10 knots, Below Minimum Altitude, Too High or Low on VASI or PAPI [precision approach path indicator]
 * colspan=2|100 Feet Above MDA:
 * PF
 * Looks for Visual Cues
 * PNF
 * States "One Hundred Above"
 * F/E
 * Monitors Instruments
 * colspan=2|At MDA:
 * PNF
 * States "Minimums"
 * PF
 * Responds "Roger"
 * F/E
 * Monitors Instruments
 * }
 * PNF
 * States "Minimums"
 * PF
 * Responds "Roger"
 * F/E
 * Monitors Instruments
 * }
 * F/E
 * Monitors Instruments
 * }

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 1.17.4.3 Terrain Avoidance Recovery Maneuvers

At the time of the accident, one manual issued to Korean Air flight crewmembers--the company's 747 Aircraft Operating Manual--contained written guidance on when to execute a recovery maneuver to avoid terrain. Under the section entitled "PULL UP/TERRAIN AVOIDANCE," the manual stated:

The published RECOVERY MANEUVER procedure is immediately accomplished by recall whenever the threat of ground contact exists. Either of the following conditions is regarded as presenting a potential for ground contact:
 * Activation of the "PULL UP" warning.
 * Inadvertent windshear encounter or other situations resulting in unacceptable flight path deviations.

Korean Air's 747 Aircraft Operating Manual (page 14.20.02, dated November 2, 1992), required the following procedures for the recovery maneuver:

Aggressively position the thrust levers forward to ensure maximum thrust is attained, disengage autopilot and autothrottle (as installed), and rotate smoothly at a normal rate toward an initial pitch attitude of 15 degrees.

Do not use flight director commands.

Pitch attitudes in excess of 15 degrees may be required to silence the "PULL UP" warning and/or avoid terrain.

Note: In all cases, the pitch attitude that results in intermittent stick shaker or initial buffet is the upper pitch attitude limit (this may be less than 15 degrees in a severe windshear encounter).

Large thrust increases may result in a nose-up pitching tendency requiring forward column pressure and trim.

Monitor vertical speed and altitude. Do not attempt to change flap or gear position or regain lost airspeed until ground contact is no longer a factor.

{{x-lar1.17.5 Korean Air Accident and Incident History

The Safety Board used data provided by Airclaims Limited to compare Korean Air's safety record with the records of five major U.S.-based airlines and five major Asian-based airlines. The total hull loss records for all of these airlines were calculated for a 10-year period ending December 31, 1998, using two measures of activity or exposure to

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 risk: aircraft flight hours and departures. Airclaims Limited defines a total loss as an aircraft that has been destroyed or for which the estimated repair costs rendered the aircraft a total loss under the terms of the insurance contract. (Airclaims Limited notes that some airplanes that became total losses were repaired and returned to service.) Any total loss that resulted from a deliberate violent act was eliminated from the Board's comparison. The results of the comparison are shown in table 3.

Table 3. Loss totals and rates for the 10-year period ending December 31, 1998, by losses per 1 million departures.

As table 3 indicates, eight of the operators had fewer than one hull loss per 1 million flight hours (All Nippon Airways, Singapore Airlines, Japan Airlines, Northwest Airlines, United Airlines, US Airways, Delta Air Lines, and American Airlines). Asiana Airlines had 1.25 hull losses per 1 million flight hours, Korean Air had 2.38, and China Airlines had 4.59.

Seven operators in the comparison group had fewer that one hull loss per 1 million departures (All Nippon Airways, Japan Airlines, Northwest Airlines, United Airlines, US Airways, Delta Air Lines, and American Airlines). Two operators had between one and two hull losses per 1 million departures (Singapore Airlines and Asiana Airlines). Korean Air Lines had 4.79 hull losses per 1 million departures, and China Airlines had 11.74.

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 1.17.5.1 1983 to 1997 Accident History

Between 1983 and the time of the flight 801 accident, Korean Air experienced several accidents that were attributed primarily to pilot performance. Some of these accidents resulted in substantive management, operational, and policy changes initiated by the company to correct deficiencies identified by the accident investigations. The following is a brief description of some of these pilot performance accidents:

 * On August 31, 1983, Korean Air flight 007, a 747-200B, crashed in the Sea of Japan off Sakhalin Island, Soviet Union, killing 269 people. Although the airplane was intentionally shot down, the investigation revealed the flight crew likely made a navigation entry error in the autopilot, causing the airplane to depart from its assigned flightpath without the crew's detection and subsequently enter restricted airspace in the Soviet Union.

 * On December 23, 1983, Korean Air flight 084, a Douglas DC-10 on a scheduled cargo flight, collided head on with SouthCentral Air flight 59, a Piper PA-31 on a scheduled commuter flight, on a runway at Anchorage, Alaska, in heavy fog. Three people received serious injuries, and three people received minor injuries. The Safety Board determined that the probable cause of the accident was the failure of the Korean Air pilot to follow accepted procedures during taxi, which caused him to become disoriented while selecting the runway; the failure of the Korean Air pilot to use the compass to confirm his position; and the decision of the Korean Air pilot to take off when he was unsure that the aircraft was positioned on the correct runway.

 * On July 27, 1989, a Korean Air McDonnell Douglas DC-10-30 crashed in fog about 1.5 kilometers short of the runway at Tripoli International Airport, Libya, during the execution of a nonprecision approach (in which the ILS was out of service). Of the 199 people on board the airplane, 4 crewmembers and 68 passengers died; 6 people on the ground were also killed. The Libyan Civil Aviation Authority determined that the cause of the accident was improper flight crew coordination likely influenced by fatigue.

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 * On August 10, 1994, a Korean Air Airbus A300-620R landed long at a high rate of speed and overran the runway at Cheju Airport, Korea, after an apparent misunderstanding between the flight crewmembers as to whether they should continue with landing or abort and execute a go around. All of the 160 airplane occupants survived the crash. The airplane was destroyed. According to Korean Air personnel, both pilots were jailed temporarily, and neither resumed flight service with the company.

1.17.5.2 1998 and 1999 Accident and Incident History

Since the time of the Korean Air flight 801 crash, the company has experienced several accidents and incidents, some of which are detailed below.

 * On August 5, 1998, Korean Air flight 8702, a Boeing 747-400, HL7496, skidded off the runway and crashed during a landing roll in heavy rain at Kimpo Airport in Seoul. None of the 16 crewmembers were injured, and 65 of the 379 passengers received minor injuries. The accident caused substantial damage to the airplane. The KCAB's investigation determined that the accident was caused by the captain's misuse of the thrust reverser during the landing roll and his confusion over crosswind conditions.

 * On September 30, 1998, Korean Air flight 1603, a McDonnell Douglas MD-82, HL7236, overran a runway at Ulsan Airport, Korea, in heavy rain. None of the 6 crewmembers were injured, and 3 of the 142 passengers received minor injuries. Both engines' fan blades were damaged as a result of the event. The KCAB determined that this event was the result of "high speed over a wet runway."

 * On March 15, 1999, Korean Air flight 1533, a McDonnell Douglas MD-83, HL7570, overran a runway at Pohang Airport, Korea, during a second landing attempt and crashed into an embankment. The accident occurred in stormy weather with strong winds. One of the 6 crewmembers and 15 of the 156 passengers were injured. The airplane received substantial damage as a result of the accident. The KCAB determined that the cause of the accident was the flight crew's "poor action" in bad weather (including gusts and variable winds), misuse of the brake and thrust reverser during the landing roll, and lack of decision-making for executing a go-around and stop. In addition, the KCAB believed that the flight crew received poor ground assistance.

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 * On April 15, 1999, Korean Air flight 6316, a McDonnell Douglas MD-11, HL7373, crashed in a residential area of Shanghai, China, about 6 minutes after takeoff. The two pilots and one mechanic on board the airplane were killed. Additionally, at least 4 people on the ground were killed, and 37 others were injured. The airplane was destroyed by impact forces. The accident is being investigated by the Civil Aviation Administration of China with participation by the Safety Board and the KCAB.

1.17.6.1 Korean Civil Aviation Bureau

As previously stated, the KCAB, a division within the MOCT, is responsible for providing oversight of the Korean civil airlines. The Safety Board found that two KCAB operations inspectors were assigned to provide oversight of Korean Air's flight operations at the time of the accident. Neither of these inspectors were type rated in any of the airplanes operated by Korean Air. According to the KCAB, these two inspectors also had oversight duties at Asiana Airlines, another domestic air carrier.

The KCAB stated that, before the flight 801 accident, it performed an annual 7-day safety inspection, quarterly 7-day regional inspections, and random inspections an average of 40 times per year. The KCAB also said that it frequently relied on Korean Air to selfreport corrective actions taken in response to KCAB inspections.

During testimony at the Safety Board's public hearing, the Korean Air Director of Academic Flight Training stated that the KCAB approved all company aircraft operations manuals, training manuals, training programs, and flight operations procedures. The official also stated that the KCAB provided direct oversight of Korean Air and its training curricula primarily during the annual safety inspection and two to three random operations inspections each year.

Korean Air's Director of Academic Flight Training also testified that the KCAB conducted almost all type-rating proficiency checks on the company's Fokker F.100 and McDonnell Douglas MD-82 airplanes. However, the official said that type-rating proficiency checks on the other airplanes in Korean Air's fleet, including the 747-200, -300, and -SP, were conducted by company check airmen designated by the KCAB.

Korean Air's Director of Academic Flight Training could not recall any direct surveillance by the KCAB on 747 proficiency checks or training sessions. The Korean Air official indicated that, if company records indicated otherwise, he would forward such

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 information to the Safety Board after he returned to Korea. The Board never received any such information from Korean Air.

The KCAB, however, stated that it had written records of such surveillance and that it had given these records to Korean Air. The Korean Air Director of Safety and Security stated that the KCAB provided oversight for the Korean Air simulator training syllabi during the annual safety inspection. This director further stated that, before the accident, he was not aware of any KCAB written criticisms or required changes to the Korean Air flight training program. The Korean Air Director of Academic Flight Training testified that he could not recall any KCAB written record of recommended or required corrective actions as a result of its inspections before the Guam accident. However, the KCAB stated that it has written records of recommended and required actions from its inspections before the accident.

The KCAB stated that, after the flight 801 accident, it hired five inspectors (three of whom were captains), two examiners, and two technical experts. The KCAB also stated that it hired 14 commercial pilots to provide in-house technical expertise. These pilots, however, are not directly involved in oversight activities. In addition, the KCAB inspectors now assigned to Korean Air are type rated in the Boeing 747-400, and they previously flew 747 Classics (that is, the 747-100, -200, -300, and -SP).

Further, the KCAB indicated that, after the accident, it instituted the following changes regarding its oversight of Korean Air: increased simulator training requirements for adverse weather conditions, risk avoidance, GPWS, and terrain awareness; mandated CFIT prevention concepts in recurrent ground school that are to be practiced in simulator training; diversification of training scenarios, including those airports with approach navigational aids that are not colocated with the field of landing; separate localizer and VOR approach requirements included as training items for nonprecision approaches; and a requirement to choose random profiles for check rides.

1.17.6.1.1 Accident and Incident Investigation Authority

The KCAB's Division of Aviation Safety is responsible for aviation accident and incident investigations.

Paragraph 5.4 in Annex 13 to the Convention on International Civil Aviation (Chicago Convention) specifies in part that "the accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct." Further, on November 21, 1994, the Council of the European Union (EU) adopted a directive that specified that EU Member States would ensure, within 2 years, that aviation accident and serious incident investigations were conducted or supervised by a permanent body or entity that is functionally independent of the national aviation authorities responsible for regulation and oversight of the aviation system. According to

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 EU officials, all EU Member States have complied with this directive or are moving toward full compliance.

1.17.6.2 Federal Aviation Administration

Korean Air was granted authority to operate into U.S. airspace under the provisions of 14 CFR Part 129 and International Civil Aviation Organization (ICAO) Annex 6. The FAA approves operations specifications and assigns a principal operations inspector (POI) to each foreign carrier. The POI assigned to Korean Air at the time of the accident was not qualified in any of the airplanes operated by Korean Air, but no international or FAA provisions require that inspectors be qualified or current in any aircraft operated by the foreign air carrier for which they have responsibility. This POI also provided oversight to six other international air carriers. The POI said that, at the time, it was customary for the FAA to rotate inspectors of foreign air carriers so that each foreign airline was assigned a different inspector every 1 to 2 years.

The POI also said that there was no formal interaction between the KCAB and the FAA regarding oversight of Korean Air. Neither civil aviation authority (CAA) was required to formally or informally exchange reports of inspection activities or safety concerns. The KCAB, however, indicated that it and the FAA have an ongoing exchange of reports on inspection activities, violations, and certificate actions as well as safety concerns. Further, the POI assigned to Korean Air said that the FAA's oversight role for Part 129 operators was to approve operations specifications, inspect trip records and facilities, and accomplish ramp inspections of airplanes and crews when they were in the United States or its territories. The POI also stated that the FAA did not inspect, approve, or provide oversight for a foreign airline's training or operations manuals. The Safety Board has not identified any requirement under the Convention on International Civil Aviation or the Federal Aviation Regulations (FAR) that the FAA be provided copies of these manuals. In addition, the POI stated that the FAA did not conduct line checks or en route inspections on board a foreign carrier.

FAA Order 8400.10, "Air Transportation Operations Inspector's Handbook," volume 2, chapter 4, paragraph 297, states that the purpose of surveillance of each foreign air carrier, its aircraft, and its operations is to determine compliance, on a recurrent or rotating basis, with the FARs and the foreign carrier's operations specifications. According to the FAA order, surveillance is conducted if a foreign carrier experiences "a series of accidents, incidents, violations, or complaints (that relate to safety.)" The surveillance includes any "R" (required) items specified in national program guidelines and can also include routine and unannounced ramp inspections.

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 Paragraph 297 of the FAA order also states that routine and unannounced ramp inspections of a foreign air carrier conducting operations with foreign-registered aircraft should be limited to those operations being conducted in the United States. The paragraph also states that the inspections should include the following items: aircraft markings; airworthiness, registration, and crewmember certificates; air traffic compliance; taxi and ramp and passenger enplaning/deplaning procedures; baggage and cargo (especially hazardous cargo); and compliance with the pilot-in-command age 60 policy, which states that a flight crewmember is prohibited from acting as pilot-in-command if he or she has reached age 60.

According to the FAA, the only "R" item required for Korean Air is one annual ramp inspection. The FAA indicated that, since 1996, Korean Air received about 201 operations inspections, 129 maintenance inspections, and 48 avionics inspections.

1.17.6.2.1 International Aviation Safety Assessment Program

The FAA established the International Aviation Safety Assessment (IASA) program in August 1992 in response to concerns about the adequacy of surveillance provided to foreign air carriers. According to an overview of the program posted on the FAA's Web site, the IASA is a foreign assessment program that "focuses on a country's ability, not the [ability of an] individual air carrier, to adhere to international standards and recommended practices for aircraft operations and maintenance established by [ICAO]." The overview indicated that "[t]he purpose of the IASA is to ensure that all foreign air carriers that operate to or from the United States are properly licensed and [are provided] safety oversight [ ] by a competent Civil Aviation Authority (CAA) in accordance with ICAO standards."

According to the overview: A foreign air carrier of a sovereign state desiring to conduct foreign air transportation operations into the United States files an application with the DOT [Department of Transportation] for a foreign air carrier permit under the Federal Aviation Act,...at 49 U.S.C. 41302.... Consistent with international law, certain safety requirements for operations into the United States are prescribed by the FAA's Part 129 regulations (14 CFR part 129). 14 CFR Part 129 specifies that the carrier must meet the safety standards contained in Part 1 (International Commercial Air Transport) of Annex 6 (Operations of Aircraft) to the Convention on International Civil Aviation (Chicago Convention). Before DOT issues a foreign air carrier permit, it notifies the FAA of the application and requests the

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 FAA's evaluation of the respective CAA's capability for providing safety certification and continuing oversight for its international carriers.

Upon DOT notification of a pending foreign air carrier application, if the FAA has not made a positive assessment of that countr[y']s safety oversight capabilities, the FAA Flight Standards Service will direct its appropriate international field office to schedule an FAA assessment visit to the CAA of the applicant's country. Once the assessments visits have been completed, the FAA assessment team will return to the United States to compile the findings. Appropriate notifications to the CAA and other U.S. Government officials of the results of the assessments will be made from Washington, D.C., headquarters as soon as possible.

If a CAA is found to be meeting its minimum safety obligations under the Chicago Convention, the FAA will forward a positive recommendation to DOT. If there is a pending foreign carrier application, DOT will issue the requested economic authority and FAA will issue operations specifications to permit the carrier to begin operations to or from the United States.

When CAA's of countries with existing air carrier service to the U.S. are found to not meet ICAO standards, the FAA formally requests consultations with the CAA. The purpose of consultations is to discuss [the FAA's] findings in some detail and explore means to quickly rectify shortcomings found with regard to ICAO annexes, to enable its air carriers to continue service to the United States. During the consultation phase, foreign air carrier operations from that country into the United States will be frozen at existing levels.[ ] FAA may also heighten its surveillance inspections (ramp checks) on these carriers while they are in the United States. If the deficiencies noted during consultations cannot be successfully corrected within a reasonable period of time, FAA will notify DOT that carriers from that country do not have an acceptable level of safety oversight and will recommend that DOT revoke or suspend its carriers economic operating authority.

When CAA's of countries with existing air carrier service to the United States are found to not meet ICAO standards, the FAA does, of course, undertake consultations. The FAA will notify DOT that the CAA does not have an acceptable level of safety oversight and its application for economic authority will be denied. The FAA will undertake a reassessment of the CAA after evidence of compliance with ICAO provisions has been received. FAA will, of course, be willing to meet with CAA's at any time, as [ ] resources permit. After the assessment visit, consultations (if necessary), and notifications have been completed, the FAA will publicly release the results of these assessments. The FAA plans to periodically revisit CAA's of countries with air carriers operating into the United States to maintain full familiarity of the methods of that country's continued compliance with ICAO provisions. The FAA may also find it necessary to reassess a CAA at any time if it has reason to believe that minimum ICAO standards are not being met.

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418 White Hills, has nearly all disappeared, and the loose and gravelly soil has been so washed by the rains of centuries, as to make it impossible to trace with any certainty, its original outlines. There are still, any number of old churches, scattered here and there all over the wide landscape; but where the one hundred thousand people, who inhabit the little State of Tlaxcala, live, is more than I could see.

The present town, which is mostly Spanish-built, is situated on the flat between the heights, and may contain five thousand people, I should say at a venture. It has many buildings unquestionably dating back to the days of Cortez, and is a place no intelligent traveler in Mexico can afford to omit visiting.

The Governor of Tlaxcala, an intelligent gentleman, apparently of pure Indian blood, with his staff of officials, welcomed Mr. Seward, and escorted the party to the State Palace, an unpretending Old building, in which the Congress or Legislature meets. This building, poor and plain as it is, contains priceless treasures for the antiquarian and student of history.

In the hall of Congress, I noticed portraits, rudely painted in oil, of the four Chiefs of the Republic of Tlaxcala after they had been converted to Christianity. Each has the prefix "Señor Don" before his name, and a Christian name before his unpronunciable Indian surname. They are in full, Indian costume, and by the side of each is his coat of arms. From the mouth of each issues the words he pronounced at his baptism. One says "Viva Jesus!" another Viva Maria!" another "Viva Jose!" and the last "Viva Joachin!" In costume and general appearance they would pass for Navajo or Mojave chiefs of the present day, and I


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 DESIRED OUTCOME: The FAA is working to determine that each country meets its obligations under ICAO and to provide proper oversight to each air carrier operating into the U.S. The continued application of this program will result in a lower number of safety-related problems, including accidents, incidents, and an improved level of safety to the flying public.

The FAA established three ratings for the status of countries at the time of the assessment. These categories and their definitions are as follows: ?
 * Category I Does Comply with ICAO Standards: A country's civil aviation authority has been assessed by FAA inspectors and has been found to license and oversee air carriers in accordance with ICAO aviation safety standards.

 * Category IIConditional: A country's civil aviation authority in which FAA inspectors found areas that did not meet ICAO aviation safety standards and the FAA is negotiating actively with the authority to implement corrective measures. During these negotiations, limited operations by this country's air carriers to the U.S. are permitted under heightened FAA operations inspections and surveillance.

Category III Does Not Comply with ICAO Standards: A country's civil aviation authority found not to meet ICAO standards for aviation oversight. Unacceptable ratings apply if the civil aviation authority has not developed or implemented laws or regulations in accordance with ICAO standards; if it lacks the technical expertise or resources to license or oversee civil aviation; if it lacks the flight operations capability to certify, oversee and enforce air carrier operations requirements; if it lacks the aircraft maintenance capability to certify, oversee and enforce air carrier maintenance requirements; or if it lacks appropriately trained inspector personnel required by ICAO standards. Operations to the U.S. by a carrier from a country that has received a Category III rating are not permitted unless they arrange to have their flights conducted with a duly authorized and properly supervised foreign air carrier appropriately certified from a country meeting international aviation safety standards.

During a June 17, 1999, briefing to Safety Board staff, the FAA indicated that, although the IASA program is intended to determine whether a foreign country's CAA is providing adequate oversight, the program does not directly assess whether foreign carriers are receiving such oversight or are complying with the provisions of Annex 6 to the Convention on International Civil Aviation. The FAA assessment team does not conduct surveillance of foreign air carriers; rather, it collects information and evaluates a foreign CAA's compliance with Annex 6 standards in seven areas: aviation law; aviation regulations; CAA structure; technical inspector workforce; technical guidance; records of certification; and records of surveillance, including followup and corrective actions. The country must be found to meet ICAO Annex 6 standards in all seven areas to be rated as Category I. The FAA offers assistance to those countries that, according to its evaluation, do not comply with ICAO Annex 6.

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 The FAA also indicated that it has completed all of its initial assessments and that the IASA program would soon transition to "Phase 2," which will focus on review and validation of the initial ratings and continued evaluation of the safety compliance capability of foreign CAAs.

According to the FAA, Phase 2 will be accomplished by reviewing each country's rating and all available information relevant to ICAO safety oversight requirements at least every 2 years. However, the FAA indicated that it would reevaluate a country that has air carriers operating into the United States any time there is reason to question whether that country is meeting its international safety oversight obligations. According to the FAA, Phase 2 rating decisions will be based on information gathered by the FAA, either during an on-site visit or through a questionnaire directed to the foreign CAA, or the results of an assessment by another qualified entity, such as ICAO. Also, the FAA intends to eliminate the Category III rating as part of Phase 2; accordingly, countries found not to comply with ICAO Annex 6 will be rated as Category II regardless of whether that country is conducting operations into the United States.

The KCAB was initially assessed in 1996 and was given a Category I rating. As of October 1999, the KCAB had not been reassessed.

1.17.6.3 Department of Transportation Audit Report on Aviation Safety Under International Code Share Agreements

On September 30, 1999, the Department of Transportation Office of Inspector General (DOT/IG) issued a report, titled Aviation Safety Under International Code Share Agreements (Report No. AV-1999-138). The report noted that the number of international code share agreements has more than tripled in the last 5 years and that U.S. carriers are increasingly entering into such agreements with carriers from regions of the world where aviation oversight and safety records are not as strong as those of the United States. The report found that the current process by which code share agreements are approved by the DOT does not adequately address safety implications and that the "FAA has not taken an active role in the approval or safety oversight of international code share agreements, either before or after approval." Specifically, the DOT/IG report stated:

FAA limits its input to advising [the Office of the Secretary of Transportation (OST)] about whether a foreign carrier's homeland, as distinguished from the air carrier involved, has procedures to exercise oversight of its carriers in compliance with international safety standards. FAA staff stated that if they become aware of adverse safety information about a foreign carrier, they will pass that on as well;

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 however, they were able to provide only one example of this kind of advice, and the effort made to assess safety implications appears to be nonexistent. [The DOT/IG's] review found that the Department's current procedures require nothing of the U.S. or foreign carrier that will be parties to the agreement about the foreign carrier's safety. FAA performs no trend or other analysis, and makes no recommendations to OST, as to whether it is satisfied that there are no negative safety implications relative to the foreign carrier that will be involved in the code share agreement....

The DOT/IG's report evaluated the FAA's explanation for its limited oversight role in code share agreements. The report made the following three points:

First, FAA says it is without legal authority to make safety fitness determinations regarding individual foreign carriers. This view has merit. However, the legal situation is quite different when, as here, a U.S. carrier seeks U.S. approval to hold out to the public flights on a foreign aircraft as if they were U.S. flights and to ticket such flights in the name of a U.S. carrier. Furthermore, Federal law requires that "safety" be a paramount consideration in deciding whether to approve agreements like code shares.

Second, FAA correctly points out that it does make determinations [through the IASA program] about the civil aviation authority in the foreign carrier's homeland. This program identifies whether the carrier's homeland provides adequate aviation oversight of its carriers, and has improved international aviation safety by helping foreign civil aviation authorities improve their oversight. However, this is quite different from a judgment about the safety practices of an individual carrier. FAA is itself a civil aviation authority that meets international standards, but that is materially different from a conclusion that all U.S. carriers therefore follow sound safety practices.

The third and most legitimate point FAA raises is that it has limited resources and already is resource-constrained in exercising oversight of U.S. aircraft and U.S. crew operations. Adding code share agreements to the workload would be an additional burden and raise expectations. We believe the answer to this is that U.S. carriers seeking approval for a code share agreement can reasonably be expected to perform most of the work and provide FAA assurances that the foreign carrier that will operate as a U.S. flight is compliant with applicable safety requirements. FAA's role would be to ensure that U.S. carriers have a credible process in place to provide such assurances.

The Department of Defense (DOD) is one of the largest U.S. consumers of air carrier services because of its need to transport military personnel to locations throughout the world. According to the DOT/IG report, DOD's policy has been to use U.S. carriers for this transportation service, and DOD performs a safety review of a U.S. carrier before it can be included on an approved list of authorized military air transport providers. The report also indicated that the U.S. carriers proposed the use of foreign code share carriers for providing military transportation. Because DOD must ensure the safety of foreign code share carriers, it established a program in August 1999 with the Air Transport Association and six U.S. airlines. Under this program, the six U.S. air carriers will perform (or will

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 arrange to have a third party perform) safety assessments of their foreign code share partners to ensure that those partners meet the legal criteria necessary to transport U.S. military personnel. The DOT/IG found that the FAA could build on DOD's program and that the FAA must ensure that safety is "a condition of initial and continued approval for international code share arrangements."

The DOT/IG report made the following recommendations to the DOT and the FAA:
 * Develop and implement procedures requiring that all U.S. carriers perform safety assessments of foreign carriers as a condition of code share approval and continued authorization. These procedures should include requirements that carriers:
 * perform an initial on-site review of all existing, pending, and future code share partners;
 * establish review procedures, to be approved by FAA, that will address the content of the assessments and qualifications of staff conducting the assessments;
 * develop assessment processes that include review and verification that foreign partners have implemented effective procedures in critical safety areas such as maintenance operations, airworthiness of aircraft, crew qualifications, crew training, flight operations, en-route procedures, emergency response plans, security, and dangerous goods;
 * provide copies of safety assessments to FAA for review and acceptance, and make available to FAA, when necessary, information supporting assessment results;
 * submit confirmations from senior safety officials that the assessment results were satisfactory and any deficiencies noted have been corrected; and
 * coordinate reviews to avoid multiple assessments of foreign carriers code sharing with more than one U.S. partner.

 * Coordinate closely with the Department of Defense to maximize the effective use of limited resources between the two agencies, avoid duplication, and establish protocols for the exchange of information about carrier safety assessments. FAA should also consider the safety assessment results in performing IASA reviews.

 * Establish procedures for terminating or restricting the use of code share agreements when (1) the Department of Defense determines that adverse safety information warrants prohibiting U.S. military personnel from using a foreign carrier, (2) the U.S. carrier terminates the agreement, or (3) FAA, on its own initiative, makes a similar determination regarding the transport of U.S. passengers.

The DOT/IG report also recommended that the FAA

 * Develop oversight procedures for FAA to validate U.S. carriers' safety assessment programs. The validation should include:

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