Flight KAL 801 was scheduled to fly from Kimpo Airport in Seoul, Korea to A.B. Won Guam International Airport in Agana, Guam. The flight crew had met earlier to discuss the flight release, weather conditions and fill out all necessary paperwork. And on August 6th, 1997 at 9:27 PM the Boeing 747-300 departed Kimpo Airport for a three hour and fifty minute trip to Guam. The flight crew consisted of a captain, first officer and a flight engineer.
The captain had several flight hours as a pilot in the Korea Air Force until Korean Air hired him in 1987. Not only did he have many hours flying a 747, he received a flight safety award from the company president, three months prior to the crash. He also earned two excellent evaluations in the simulator proficiency checks and passed the company’s mandatory Level three English test. In addition, the captain along with his first officer watched a video presentation based on the familiarization of the Guam Airport and studied approach charts several hours before the accident. (Krause, 2003)
The first officer had also served in the Korean Air Force before joining the ranks with Korean Air in 1994. Although he was only two years younger than the captain, he had a high number of flight hours as a 747 first officer. However, his performances in the simulator evaluations were slightly above average. One instructor noted that his “altitude management on nonprecision approach was somewhat less than desirable” and adding that he was “somewhat slow to carry out directions” (Krause, 2003)
The flight engineer was also a very distinguished pilot and was hired by KAL in 1979. Similar to the captain, he earned excellent ratings in his evaluations of crew management and simulator tests, and also passed the English proficiency exams. (Krause, 2003)
“a weak low pressure trough is moving slowly [through] the Mariana Islandsresulting in gentle to moderate easterly winds and scattered showers. The effects of the upper level low far to the northeast have diminished during the past 12 hours or so. Light to moderate showers should be expected except for isolated afternoon thunderstorms due to solar heating”, this was the weather report provided by the Guam Weather Station. However, at around 0122, the crew received a message via the Automatic Terminal Information Service (ATIS), “wind calm, visibility seven [clouds] one thousand six hundred scattered, two thousand five hundred scattered, temperature two seven [Celsius], dew point two four, altimeter niner eight six, runway six in use. NOTAMs [Notices to Airmen], runway six left ILS glideslope out of service until further notice[emphasis added].” (Krause, 2003)
Accordingly noted by the received message, the glideslope for runway 6L was out of service, therefore a step-down approach had to be initiated. However, a discussion brewed about the working status of the mentioned glideslope. “Is the glideslope working? Glideslope? Yeah?” the flight engineer asked after seeing some movement by the glideslope needles. (Walters & Sumwalt III, 2000) This continued for several minutes among the crew until it was finally addressed as incorrect. The decent continued in the heavy rain as the captain positioned himself for the nonprecision approach. The plane kept on falling and at five hundred feet the Ground Proximity Warning System alerted the crew of their present position. The flight engineer replied with an astonished, “Eh?!” (Walters & Sumwalt III, 2000) The next remaining feet say the crew struggle to take affirmative actions thus, failing to execute a missed approach and slamming into Nimitz Hill, only three miles from the runway.
KAL 801 during rescue effort for survivors
The SHELL model can be represented in five distinct ways. The interactions between Liveware-Liveware, Liveware-Environment, Liveware-Hardware and, Liveware-Software. These elements have to be smoothly synchronized in order to have a successful and safe flight, and any deviations from the standard norms may result in a crash or disaster.
For example, the interface between Liveware (flight crew) and the Environment of KAL 801 had several conflicting elements. Firstly, when the term Environment is used, it not only defines the physical external conditions, but also refers to the internal conditions of the cockpit, nature or economics of the organization (Korean Airlines) and also, Air Traffic Control (ATC).
The crew was expecting some rain showers along their flight path to the airport in Guam, as advertised before and during the flight. However, although they anticipated the disruptive weather, they could not have predicted that there would be little visibility while vectoring towards runway 6L. As a result, the investigators for the National Transportation Safety Board (NTSB) confirmed that these heavy patches of rainfall might have played a significant role in the crash against the hillside.
In addition to the bad weather, the captain complained to his crew about their hectic flight schedule. “If this round trip is more than a nine-hour trip, we might get a little somethingthey [KAL] work us to maximum, up to maximumProbably this way. Hotel expenses will be saved for cabin crews, and they maximize the flight hours. Anyway, they make us [B-747] classic guys work to maximum.” (Walters & Sumwalt III, 2000) This disgruntled attitude coupled with the fact that he was somewhat fatigued surely had a negative impact while trying to maneuver the plane in low visibility weather.
Air Traffic Control also had some contributing factors towards the crash. They failed to relay important positional information to the crew while on the approach path and the tower did not inform the captain that he was “not in sight” when cleared to land. (Walters & Sumwalt III, 2000) Although viewed as minor errors by NTSB investigators, these “slips” by ATC had an impact on the landing of the plane and may have been the result of a fatigued tower employee, which possibly stemmed from the lack of efficient communication or, poor training of dispatchers.
The Liveware-Software relation also had discrepancies with negative impacts on the flight. Firstly, unlike the Airbus cockpit, Boeing aircrafts are not equipped with displayed checklists but the flight crew fills them out via paper binders. (Sexton, 1988) This leaves another window for human error, since these sheets have to be replaced and updated periodically. KAL 801 had this problem whereby the first officer was using outdated approach charts to monitor the decent of the plane. Moreover, it was discovered that the captain was using the correct version and they never took time to compare charts with each other. Consequently, investigators concluded that the inconsistency of the charts played a significant role in the crash. (Walters & Sumwalt III, 2000)
However, one of the positive things done by the captain and first officer was the fact that they scouted and studied the approach charts for the airport in Guam. (Krause, 2003) Although, this procedure was not required by the airlines, the crew took the initiative to be aware of the dangers with the surrounding terrain, weather and runways.
The Liveware-Hardware scenario basically revolved around the confusion of the operational status of the glideslope. The crew acknowledged that the glideslope was not in service between 0139 and 0141, however, they became involved in a heated discussion over its status. (Krause, 2003) Investigators believed that the glideslope needle might have been moving due to bogus radio signals causing the crew to doubt the announcements of the notices to airmen (NOTAMS), the Guam airport Automatic Terminal Information Service (ATIS), and the air traffic controller on duty. (Walter & Sumwalt III, 2000) In addition, I believe that the main reason that the crew failed to heed to warning signals was the overwhelming fact that the captain was extremely fatigued.
Liveware-Liveware interface is one of the essential elements in the science of aviation but also very significant to the nature of the world. However, not only does this bond deal with the interactions of the crew to work as a unit, but also includes the nature and habitual states of the crew themselves.
KAL 801 had a problem with regards to fatigue. Their captain was a long-serving and dedicated worker in his profession, needless to say, August 6th1997 was a long day for the faithful captain. Firstly, the captain was deprived a lot of sleep from his irregular sleep patterns, making it difficult for him to have a good nights’ rest. Furthermore, he was diagnosed with bronchitis and was prescribed medication to help him sleep. (Krause, 2003) Also, the captain’s schedule before the crash saw him change time zones several times and this, compounded by his medication and erratic sleep times made a perfect combination for disaster.
Secondly, the flight engineer and the first officer while attempting to execute a missed approach monitored the captain poorly. Investigators concluded that they did monitor the captains’ movements but failed to successfully challenge his errors, specifically the premature descents below 2,000 and 1,440 feet and the aggressive missed approach before impact. (Krause, 2003) However, it is my opinion that the age differences as well as flight experience had some influence on the communication level in the cockpit. The captain was older than the first officer by a mere two years, but he had been employed at Korean Airlines for almost ten years; seven more years than the first officer. Furthermore, the flight engineer was the eldest in the cockpit and also had more years at KAL but he had never been a pilot (Walters & Sumwalt III, 2000) Although CRM training requires individuals to work as a team despite age, gender, or seniority; humans will always feel the need to be superior towards each other. The captain proved this by not responding correctly to the callouts of the flight engineer and first officer and deciding to fly the plane “solo” in his fatigued state.
Swiss Cheese Model
The Swiss Cheese model deals mainly with the errors or mishaps down the chain of command or management within an organization. A type of domino effect with mishaps being projected from one level to the next without detection until an accident or disaster is evident. The disaster in Guam was no exception to the rule and left several people dead from the force of the impact or the resulting fire. (Walters & Sumwalt III, 2000)
The first issue was the nature of the flight crew-training program at KAL. Pilots flying the “classic” model (747-300) were required to do ten simulator sessions along with a check ride for certification, however these sessions all had similar fight paths. In other words, instructors never varied or challenged the pilots to be prepared for any unforeseen situation. Accordingly, checklists and specific procedures were never taken seriously and were rarely looked upon for guidance. Therefore, investigators concluded that pilots were relying on memory to fly rather than using appropriate procedures. (Walters & Sumwalt III, 2000) It would seem that necessary procedures and skills were needed to land the plane at the Guam airport on August 6th for the simple fact that the weather was terrible and the glideslope was inoperable thus requiring a precise “step-down” procedure. However, the crew was not fully responsible for the resulting crash because initial and updated training limited their skill level and knowledge of different approach landings.
The rabbit hole goes deeper by exploring the organizational structure of the Korean Civil Aviation Bureau (KCAB). KCAB was responsible for overseeing all the departments of KAL, which included the pilot training program. However, upon investigation it was noted that the Bureau had very little input into the operations of the airliner, with concern being drawn to the training programs and their upgrades. (Walters & Sumwalt III, 2000) This type of situation is prevalent in the society and is the usual victim of a poor communication link between the management levels. Also, a formal investigation was launched about a year after the incident and saw their top officials being questioned regarding the status of their company. As expected, their parent company, Ministry of Civil Transport (MCOT), fined KCAB heavily for their blunders. It took at least eight similar crashes to finally get some action from the transportation ministry and in addition, no documented action has been taken by KAL to restructure the training program. (Walters & Sumwalt III, 2000)
The Federal Aviation Administration (FAA) was also involved in the investigation with their deprived supervision of KCAB coming into focus. In addition, their problems stemmed from the lack of poor communication observed from KCAB to KAL. The FAA usually has a representative observing international airline carriers and at the time of the crash, six were being observed. (Walters & Sumwalt III, 2000) Accordingly, these events made it quite difficult for the Administration to critique the operations of the airline since no recognized link of communication was ever established between the organizations.