Talk:Korean Air Flight 801/NTSB files in English

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Files[edit]

Public docket[edit]

http://www.ntsb.gov/events/kal801/docket.htm

PUBLIC DOCKET: KAL Flight 801

An accident investigation docket is maintained for each accident the Safety Board investigates, and is used to establish the permanent record of an accident. The docket for KAL Flight 801 is scheduled to be released 3/23/98 11:00 a.m. EST.

Copies of the docket may be purchased from General Microfilm, Inc. (GMI). Access to the docket is also available in the Reference Room at NTSB Headquarters in Washington, D.C.

The exhibits at the public hearing are a subset of the full docket. The latest information about exhibit items is also available on-line.

Tech Panel[edit]

http://www.ntsb.gov/events/kal801/bios.htm BIOGRAPHIES FOR KAL Flight 801 PUBLIC HEARING BOARD OF INQUIRY AND TECHNICAL PANEL MEMBERS

Benjamin A. Berman Chief, Operational Factors Division Office of Aviation Safety

Experience

Mr. Berman has been employed by the National Transportation Safety Board for eight years. As Chief of the Operational Factors Division, he is responsible for managing the Safety Board’s major accident investigations in the areas of flight operations, air traffic control, and meteorology. Previously, Mr. Berman served as a senior air carrier operations investigator assigned to the Safety Board "Go-Team" as Operations Group Chairman. Mr. Berman also led Safety Board research projects on flightcrew performance and air safety in Alaska, both of which were adopted and published by the Board as Safety Studies.

Prior to joining the Safety Board staff, Mr. Berman served as an airline captain. He holds an Airline Transport Pilot certificate with type ratings in the Boeing 737, Embraer 120, and Dornier 228.

Education

Mr. Berman received the A. B. degree summa cum laude in Economics from Harvard College in 1979.

Malcolm W. Brenner Senior Human Performance Investigator Operations/Human Performance Group Chairman

Experience

Dr. Brenner has been employed with the National Transportation Safety Board for approximately 12 years. Prior to joining the Safety Board, he conducted research on human factors for the National Aeronautics and Space Administration (NASA) and the Brooks Laboratory of the United Stated Air Force. He served as an expert witness on human factors for the Senate Judiciary Committee, and consultant for law firms representing both defense and plaintiff positions in the aviation litigation. Since joining the Safety Board, Dr. Brenner provided human performance support to numerous major aviation investigations and has taught the human performance investigation in the NTSB Accident Investigation School.

Dr. Brenner is a private pilot. He served as president of the San Francisco chapter of the International Society of Air Safety Investigators.

Education

B.A., Boston University M.A., Stanford University Ph.D., University of Michigan

Pat Cariseo Transportation Safety Specialist Office of Safety Recommendations and Accomplishments

Experience

Mr. Cariseo is a transportation safety specialist in the Office of Safety Recommendations and Accomplishments. For the previous three years, Mr. Cariseo had been the Safety Board's public affairs representative on site at nine major transportation accidents, including several highly-publicized aviation accidents: ValuJet DC-9 accident in Miami, TWA 747 midair explosion off Long Island, and United Express runway collision in Quincy, Illinois, all in 1996, and the Fine Air cargo accident in Miami in 1997. He has also been the Safety Board's public affairs representative at four accident investigation public hearings and two safety symposiums that focused on the dangers of human fatigue in all modes of transportation, and the human factors and technological challenges of marine integrated bridge systems.

Prior to coming to the Safety Board, Mr. Cariseo was with the Federal Aviation Administration for six years where he managed a team of media specialists in the Office of Public Affairs and worked on a task force to reshape the agency's internal communications procedures. He also served as the FAA's public affairs representative on site at the crash of USAir flight 427 in Pittsburgh and as the U.S. Secretary of Transportation's public affairs representative at the USAir flight 1016 accident Charlotte, NC, both in 1994.

For eight years, he was on the staff of two members of Congress, serving as a press secretary and transportation legislative assistant. He is a Vietnam veteran and served in the U.S. Army for two years.

Education

Bachelor's degree from Rutgers College, New Jersey; Master's from Boston University.

John Clark Deputy Director, Office of Aviation Safety

Experience

Mr. Clark has been at the Safety Board for 16 years. He began his career at the Board as the manager of the Safety Board’s General Aviation Crashworthiness Project. During his tenure he has held the positions of airplane performance engineer, Chief of the Vehicle Performance Division, Deputy Director of the Office of Research and Engineering, and is currently the Deputy Director of the Office of Aviation Safety. Mr. Clark has extensive experience with general aviation crashworthiness investigation and airplane performance investigations. Prior to his employment with the Safety Board, he worked on airplane simulator design with Flight Safety International, and spent 13 years at Beech Aircraft Corporation working on target drone design/simulation and flight test, airplane accident investigations, and general aviation crashworthiness investigations.

Education

Mr. Clark received a BSAE from Wichita State University in 1970.

Scott J. Dunham Air Traffic Control Investigator

Experience

Mr. Dunham has been employed with the National Transportation Safety Board since October 1997, serving as an air traffic control investigator in the Operational Factors Division. Mr. Dunham came to the NTSB after eight years with the MITRE Corporation, where he served as an air traffic control systems consultant providing technical advice and system engineering services to the Federal Aviation Administration, the United Kingdom’s National Air Traffic Service, Eurocontrol, and other European ATC authorities. Mr. Dunham also has ten years experience as an FAA air traffic controller, including assignments to training and airspace and procedures positions.

Mr. Dunham holds a private pilot certificate with an instrument rating, and is also an advanced and instrument ground instructor.

Education

Master of Arts in Computer Resources and Information Management Bachelor of Arts in Computer Studies

Gregory A. Feith Senior Air Safety Investigator Investigator-In-Charge (IIC) of Korean Air Flight 801 investigation

Experience

Mr. Feith has been employed with the National Transportation Safety Board for approximately 18 years. He has served as a Field Air Safety Investigator, Operations Group Chairman, Regional Office Unit Supervisor and Regional Director; and is currently a Senior Air Safety Investigator in the Major Investigations Division. Mr. Feith has been the IIC for more than 500 domestic aircraft incident/accident investigations, and has been the U.S. Accredited Representative on approximately 100 foreign aircraft incidents/accidents. Some of the notable recent investigations include the USAir DC-9 that killed over 30 people in Charlotte, North Carolina in July 1994, the American Eagle ATR 72 that crashed in Roselawn, Indiana, due to a unique airframe icing phenomena; and the Valujet DC-9 that crashed in the Florida Everglades because of an in-flight fire in the cargo compartment caused by improperly packaged oxygen generators.

Mr. Feith holds an Airline Transport Pilot (ATP) certificate with single and multi-engine airplane ratings, and has accumulated over 2,100 hours of flight time.

Education

Bachelor of Science in Aeronautical Studies from Embry-Riddle Aeronautical University

Gary Hammack Air Safety Investigator Office of Safety Recommendations

Experience

Mr. Hammack has been employed with the National Transportation Safety Board for approximately 14 years. For his first seven years, he served as an investigator in the Survival Factors Division where he investigated the survivability and cabin safety aspects of accidents, as well as the emergency response to accidents. Some of the notable accidents he investigated include the 1985 and 1988 Delta Airlines accidents at Dallas/Fort Worth, and the 1989 accident involving USAir flight 5050 at La Guardia when a Boeing 737 went off the departure end of the runway into Flushing Bay following an aborted take off. He also investigated the United Airlines accident in Sioux City, Iowa and participated in the TWA flight 800 investigation.

Before coming to the Safety Board, his career was in the fire service. He began as a volunteer in 1964, then served 10 years as a professional fire fighter in a metropolitan city fire department where he also served as an instructor in the training academy. Mr. Hammack also represents the Safety Board on the National Fire Protection Association's Committee on Aircraft Rescue and Fire Fighting.

Mr. Hammack holds a single- and multi-engine Commercial Pilot license and an instrument rating, and is a flight instructor in single and multi-engine airplanes, and is also an instrument flight instructor.


Paul R. Misencik Air Safety Investigator - Operational Factors Operations Group Chairman of Korean Air Flight 801 investigation

Experience

Captain Misencik has been employed with the National Transportation Safety Board since July 1996 He has served as Operations Group Chairman for more than a dozen domestic and international aircraft accident investigations.

Captain Misencik has over 30 years experience as an airline pilot with approximately 26,000 flight hours. He has flown as Captain with Eastern Air Lines, Evergreen International Airlines, Express One International, USAfrica Airways and American International Airlines. He has been a check-airman, flight instructor, simulator instructor, Director of Flight Standards, Director of Training and Chief Pilot.

Captain Misencik holds an Airline Transport Pilot (ATP) certificate with B-727 and MD-11 type ratings. He holds a Flight Engineer Turbojet and Turboprop certificate and a current Certified Flight Instructor and Instrument Ground Instructor certificate.

Education

Bachelor of Arts, University of Akron

Monty L. Montgomery Electronics Engineer

Mr. Montgomery has been employed with the Safety Board since 1980. As Chief of the Information Technology Division in the Office of Research and Engineering, he is currently responsible for central computer management, LAN management, systems, database and applications programming. Previously, he supervised the CVR and FDR labs and vehicle performance staff, and has written flight recorder, computer graphic animation, and vehicle performance analysis programs. From 1976 to 1980, Mr. Montgomery participated in the FAA's Concorde SST Noise Monitoring Project, running the lab equipment and writing acoustical and radar data reduction programs.

Education

BS Electrical Engineering, Lowell Technological Institute (1975) Graduate studies in Electrical Engineering and Computer Science


Charles M. Pereira Aerospace Engineer Aircraft Performance Group Chairman Experience

Mr. Pereira has been employed by the Safety Board for approximately 7 years. He has served as the Aircraft Performance Group Chairman on numerous major aviation, including, the American Eagle ATR 72 at Roselawn, Indiana and the TWA Boeing 747 at Moriches, New York. In addition, Mr. Pereira has been the Group Chairman for numerous railroad and marine accident investigations. During his undergraduate study, he worked for 2 years at Gulfstream Aerospace Corporation, focusing primarily on the G-IV Flight Test program, and Stability and Control group projects.

Education

B.S. in Aeronautical Engineering from Embry-Riddle Aeronautical University (1989). Current study towards M.S. in Aeronautical Science at Embry Riddle Aeronautical University.

Gregory J. Phillips Senior Air Safety Investigator Systems Group Chairman of Korean Air Flight 801 investigation

Experience

Mr. Phillips has been employed with the National Transportation Safety Board for approximately 10 years. He has served as an Aerospace Engineer (Systems), National Resource Specialist-Airworthiness Engineering, and is currently a Senior Air Safety Investigator in the Major Investigations Division. Mr. Phillips has been the Systems Group Chairman for over 40 incident/accident investigations. Some of the notable recent investigations include the USAir Boeing 737 that crashed near Aliquippa, Pennsylvania in September 1994, the United Airlines DC-10 that crashed in Sioux City, Iowa, and the Avianca B-707 that crashed in New York as a result of fuel exhaustion.

Prior to joining the Board, Mr. Phillips worked as a design engineer for Cessna Aircraft in Wichita, Kansas and Northrop Aircraft in Los Angeles, California. In these positions he was responsible for the design of aircraft structures, flight controls, hydraulic, pneumatic, and environmental control systems.

Mr. Phillips holds a Commercial Pilot certificate with instrument and single-engine airplane ratings for land and sea.

Education

Bachelor of Science in Engineering (1979), University of Evansville, Evansville, Indiana. Master of Arts in Management (1985), University of Redlands, Redlands, California.

Ronald L. Schleede Deputy Director, Office of Aviation Safety International Aviation Safety Affairs

Experience

Mr. Schleede has been an investigator and manager at the NTSB for over 25 years, and has been Deputy Director of the Office of Aviation Safety for over 3 years. Before that, he served as the Chief of the Major Accident Division for 10 years, supervising the senior air safety investigators who lead U.S. major airline accident investigations, manage public hearings, write the major accident reports, and lead the U.S. teams supporting overseas governments' major investigations involving U.S. airlines or U.S.-manufactured aircraft. Mr. Schleede's other positions at the Safety Board include Deputy Director, Bureau of Accident Investigation, Chief of the Human Performance Division, major team Investigator-in-Charge, regional investigator, and human factors specialist. In the past 15 years, he has participated in, or been closely associated with, virtually every major airline accident in the U.S., as well as many major accidents outside of the U.S. Mr. Schleede has been the NTSB's International Aviation Liaison program manager for the past 15 years, working with the International Civil Aviation Organization and other international organizations. He spent over 5 years in the U.S. Air Force as a fighter pilot, maintenance test pilot, and accident investigator; he holds a commercial pilot certificate with multi-engine privileges and has accumulated over 2,000 hours of flying time.

Education

B.S. in Natural Sciences from the University of Akron, Ohio.

Richard J. Wentworth National Resource Specialist (ATC) Air Traffic Control Group Chairman of Korean Air 801 investigation

Experience

Mr. Wentworth has been employed with the National Transportation Safety Board for almost 13 years. He has served as a investigator, senior investigator and Assistant Chief for Air Traffic Control since his employ with the Board. His ATC career started with the US Army in 1966 which included a tour in Viet Nam. He later worked as a controller in a contract tower for Ross Aviation for a year and then began federal employment as an air traffic controller with the Federal Aviation Administration (FAA) in 1970 at the Atlanta Air Route Traffic Control Center (ARTCC). Mr. Wentworth worked in the Jacksonville ARTCC; the Charlotte ATC Tower and Approach Control; the Asheville, North Carolina, TRACAB (Tower and Approach Control) and the Miami ATC Tower and Approach Control. Mr. Wentworth aspired to the positions of training specialist and supervisor.

He has served as the Group Chairman for numerous aviation accidents and incidents, including the Avionica Boeing 707 in Cove Neck, New York, and the ValuJet DC-9 in Miami, Florida. Mr. Wentworth has also conducted several special investigations at ARTCC facility in Chicago, Illinois and the Coast TRACON, El Toro, California.

In addition, Mr. Wentworth has investigated or participated in a numerous Safety Board surface accident investigations at Atlanta, Georgia, Detroit, Michigan, Newark, New Jersey, Los Angeles, California, and Miami, Florida.

Education

BS in Management from Jones College, Jacksonville, Florida

Animation[edit]

http://www.ntsb.gov/events/kal801/anim_summary.htm

KAL Flight 801 - Animation


Disclaimer: These reconstructions were developed using digital flight data recorder information, cockpit voice recorder information, recorded radar data, and geographical data. Weather and visibility conditions at the time of the accident are not depicted. 

Realvideo animation of Flight 801 descent [3.5M]

Summary: The animation shows the airplane on approach to runway 06L, descending to impact on Nimitz Hill approximately 3.5 nautical miles from the runway. Time is displayed as Coordinated Universal Time (UTC). Altitude was derived from the flight data recorder and is displayed in feet above mean sea level. Text from the cockpit voice recorder transcript is displayed in an abbreviated format above the airplane.


QuickTime animation of last 64 seconds of flight [5M]

Summary:

This animation depicts a top and side view of the topography of Guam for the flight path of the airplane within a 12 nm x 4 nm area, from 12 nm out from Runway 06L threshold for FL801 on approach to Agana A/P. The top view is to scale (in nautical miles) for both the x and y axes, and is oriented so that the x axis parallels the centerline of Runway 06L and the y axis is perpendicular to the runway centerline, with distances measured from left and right of the runway. The side view is displayed at an expanded vertical scale with each horizontal line representing 200 feet MSL altitude. The y axis is MSL altitude divided by 100, in feet. The x axis coincides with the x axis for the top view and is in nautical miles. An abbreviated-verbatim CVR transcript is displayed between the top and side views, with text appearing in groupings for readability and for as near as possible real time display. Time is displayed as local time in the top view.

Top View: Both the x and y axes are nm. The top view shows the approach of FL801 from the north and west of Guam, intercepting the localizer near the Flake intersection and continuing in towards Runway 06L at Agana A/P. The locations for Flake Intersection, Outer Marker, DME VOR, and Middle Marker are displayed in this view. The localizer full fly left/right limits are also displayed here.

Side View: The side view displays the topographical profile of the island along an extended centerline from the runway, from 12 nm miles from the runway threshold towards approach to 2 nm in the opposite direction. The side view indicates the step altitudes for the approach, as shown for 2600, 2000, 1440, and 560 feet, respectively. A simulated ARTS II MSAW Alert (initiating at 64 sec before impact and at 1700 feet MSL altitude) is also displayed. Distances along the extended centerline from the DME VOR to the Flake Intersection, Outer Marker, and Middle Marker are also displayed. A glide slope is not displayed since it was not usable at the time of the accident.


NTSB Home Page | News & Events | KAL flight 801

Public hearing exhibits[edit]

http://www.ntsb.gov/events/kal801/exhibit.htm 

KOREAN AIR

FLIGHT 801, B-747-300 AGANA, GUAM AUGUST 6, 1997

PUBLIC HEARING EXHIBIT LIST The following exhibit items are part of the public docket, and were either scheduled for presentation at the Public Hearing in Hawaii, March 24-26, 1998, or were added following the hearing (marked ). All documents listed below are in the Adobe Portable Document Format (PDF) and require the free Acrobat Reader 3.0 from Adobe or later for viewing; when printing, use the "shrink-to-fit" Adobe print option for best results. (File size is less than 2MB, unless otherwise indicated.)

Not all items from the docket are available here - additional material may include large attachments, video tapes, etc. The complete docket may be obtained from General Microfilm Incorporated (GMI). Please note that material may continuously be added to the docket as long as it is open.

Note: if you have difficulty accessing the documents through your browser, right-click to save to disk, then open directly in the Acrobat Reader window.

1A Order of Hearing 1B Designation of Hearing Officer 1C Notice of Hearing 1D Designation of Parties to the Hearing 1E Notice of Designation of Chairman Board of Inquiry

2A Operations/Human Performance Group Chairman’s Factual Report 2B Flight Papers 2C Interview Summaries (Guam-Seoul, Korea, August 1997) 2D English Text of Guam Audio Visual Presentation 2E Korean Text of Guam Audio Visual Presentation 2F Letter - Level 3 Pilot English Test 2G Forensic Toxicology Report 2H Outline of B-747 Initial and Transition Training 2I Copy of B-747-200 Simulator Training Guide 2J Copy of Checklist 2K Copy of Landing Briefing Card 2L Airport Diagram 2M Copies of Approach Plates from Accident Airplane 2N Copy of August 2, 1996, ILS 6L Approach Plate 2O Accident Crewmember’s Flight Schedule (June, July, August 1997) 2P United States D.O.D. Capability Survey of Korean Air 2Q Captain’s Flight Activity Record (Aug. 3-4, 1997) 2R Interview Summaries (Guam, January 13, 1998) 2S Flight Safety Bi-Monthly Magazine Excerpts Presented by Korean Air 2T Approach Procedure Charting 2U Captain Paul Woodburn Witness Presentation 2V ALPA Presentation on TERPS Criteria for Instrument Approaches 2W Instrument Approach Chart Comparison 2X KAL Letter to Robert Francis - dated March 26, 1998

3A Group Chairman’s Factual Report 3B Transcripts from GERAP 3C Air Traffic Control Transcript - Tower 3D CERAP Layout 3E Tower Layout 3F Weather Observations 3G Accident Notification Record - CERAP 3H Accident Notification Record - Tower 3I Excerpts from FAA Order 7110.65 Air Traffic Control (1.4M) 3J Excerpts from FAA Order 7210.3 

    Facility Operation and Administration

3K Excerpts from Agana FCT Standard Operating Procedures, June 1, 1996 3L FAA’s Response to NTSB Questions 

    Regarding MSAW at Guam CERAP and Tower

3M Executive Summary and Fact Finding Review 

    of National MSAW Program, September 1997

3N NTSB Staff Review and Conclusions of FAA’s MSAW Program 

    Evaluation Program of 10 Air Traffic Control Facilities

3O FAA’s Review and Corrective Actions Concerning National MSAW Program 3P FAA’s Facility Evaluation of the Guam CERAP - 1995 and 1997 3Q Briefing Memorandum dated January 26, 1998, 

    MSAW Altitude Settings for Houston Intercontinental Airport

3R Safety Recommendation Letter to FAA 

    dated November 21, 1994, and Response

3S Safety Board Recommendation Letter to the FAA 

    dated November 30, 1995, and Responses

3T Safety Board Recommendation Letter to the FAA 

    dated April 13, 1997, and Responses

3U Guam ARTS-IIA Chronology dated October 17, 1997 3V Post-Accident Report on MSAW at the Guam GERAP 3W FAA Standards and Guidelines to Define and Adapt 

    Values for MSAW and Conflict Alert Site Variables (A2.08)

3X FAA Form 6030-1, Facility Maintenance Logs Outer Marker, 

    VOR, Localizer , Glideslope VASI and MALS (2.8M)

3Y FAA Memorandum dated June 9, 1997, Concerning 

    Controller Refresher Training on MSAW Procedures

3Z FAA Order 7010.1, Air Traffic Evaluations and Checklists (3.9M) 3AA Guam CERAP Order 7220.10C, dated July 29, 1997, 

    Guam GERAP Positions of Operation and Responsibilities

3BB FAA Memorandum dated August 14, 1997, 

    Subject: Responses to NTSB Questions

3CC Personnel Statements 3DD Microprocessor En Route Automated Radar Tracking System 

    MICO-EARTS) dated October 1996

3EE MICRO-EARTS MSAW Alerts on KAL 801, August 6, 1997 3FF AOS MSAW Briefing

5A Meteorology Group Chairman’s Factual Report 5A Attachment 26 - Other Weather Documents 5B Weather Radar Composite Reflectivity Product for 1543 UTC

6A Survival Factors Group Factual Report of Investigation 6A Addendum 1 - Injury Chart and Photographs 6B NTSB Survivor Questionnaire (1.9M) 6C KAL Flight 801 Cabin Configuration & Emergency Equipment 

    Flight Attendant Basic & Recurrent Training and General Declaration
    Diagram of Body Locations Removed by Guam Rescue Personnel

6D KAL Flight 801 Survivor Seat Locations

7A Structures Group Chairman’s Factual Report 7B Wreckage Plot, Plan View and Profile View 

    Data Table for Plot
    Macro of Terrain with Wreckage Plot Overlay

7C Structures Group Photographs

8A Powerplants Group Chairman’s Factual Report

9A System’s Group Chairman’s Factual Report 9B System’s Group Chairman’s Factual Report 

    Attachment 1-Accident Site Photographs

9C System’s Group Chairman’s Factual Report 

    Attachment 2-Cockpit Panel Layout Diagrams

9D System’s Group Chairman’s Factual Report 

    Attachment 3-GPWS Summary Test Data Excerpts

9E System’s Group Chairman’s Factual Report 

    Attachment 4-ILS General Description

9F System’s Group Chairman’s Group Factual Report 

    Attachment 5- Korean Air Post Accident Tests

9G Basic ILS Receiver

10A Group Chairman’s Factual Report - Flight Data Recorder 10B Addendum to Group Chairman’s Report - Flight Data Recorder 10C HG-7468 FDR Parameter List 10D HG-7468 FDR Parameter Retrofit Documentation 10E Excerpted Plots of Flight Data Recorder Information

11A Maintenance Records Group Chairman’s Factual Report 11B Attachments to the Maintenance Records Group 

    Chairman’s Factual Report (2.6M)

12A Cockpit Voice Recorder Transcript

13A Airplane Performance Study Korean Air Flight 801 (1.1M) 13B Simulated 3.0 degree glideslope depiction Korean Air Flight 801 13C Verbatim Radar/CVR Data Overlays 13D Don Bateman Witness Presentation

16A Emergency Management Specialist’s Factual Report 16B GFD After Action Report 16C Office of the Governor of Guam Korean Air 801 Incident Report Summary 16D Excerpts of Interviews from Survival Factors Group Field Notes 16E After Action Report on U.S. Naval Hospital MCI Reponse to KAL 801 Crash 16F Comnavmarianas Navy Lessons Learned KAL Flight 801 Crash 16G Guam International Airport Authority Airport Emergency Plan 16H Guam Territorial Emergency Plan 16I Maps and Diagrams

Public hearing opening statement[edit]

Public Hearing - KAL Flight 801

Opening Statement of Gregory A. Feith Investigator-In-Charge


Accident Notification

On August 6, 1997, about 0142 Guam Local Time, a Korean registered Boeing 747-300, operated by Korean Air Company, Ltd., as Korean Air flight 801, crashed about 3 nautical miles southwest of the Guam International Airport in Agana, Guam, while executing the Instrument Landing System (ILS) approach to runway 6 left.

The Safety Board was notified of the accident on August 5, about 1200 noon eastern daylight time. I was assigned as the Investigator-in-Charge, and the Go-Team assembled at Andrews Air Force Base (AFB) in Maryland, and departed later that evening via a United States Air Force C-141 transport airplane to Fairchild AFB in Washington. The trip to Guam was subsequently completed on a KC-135R, and the team arrived in Guam about 0830 Guam time, on August 7. The Board Member on duty at the time of the accident was George Black and he accompanied the team to Guam.

The investigative team consisted of various specialists from the Safety Board's headquarters, the South Central Regional and Southwest Regional Offices. The specialty areas were: Aircraft Operations, Human Performance, Structures, Systems, Powerplants, Maintenance Records, Air Traffic Control, Survival Factors, Aircraft Performance, Meteorology, and Search/Fire/Rescue. Specialists were also assigned to conduct the readout of the flight data recorder (DFDR) and transcribe the cockpit voice recorder (CVR) in the Safety Board's laboratory in Washington, D.C. The initial CVR transcript was produced in English by the group members. However, the CVR group reconvened and produced a more detailed transcript in both English and Korean languages.

The following organizations were given party status and provided technical assistance to the Safety Board: the Federal Aviation Administration, Korean Air Company, Inc., Boeing Airplane Company, Pratt & Whitney Engines, the National Air Traffic Controllers Association, the United States Navy, and emergency response personnel from Guam.

In addition, Mr. Ham of the Korean Civil Aviation Bureau (KCAB) was designated as the Accredited Representative and leader of the Korean delegation in accordance with the provisions of Annex 13 to the Convention on International Civil Aviation. Annex 13 dictates the procedures for cooperation during the investigation of international aviation accidents.

Further, two Air Safety Investigators from the Australian Bureau of Air Safety Investigations (BASI) participated in the investigation as technical observers.

History of Flight

Korean Air flight 801 was a regularly scheduled passenger flight that departed Kimpo Airport, in Seoul Korea, at 2153. The flight proceeded uneventfully en route to Guam. An audio examination of the CVR revealed that the captain was the "flying pilot" and the First Officer (F/O) was performing the radio communications and non-flying pilot duties at the time of the accident.

At 0103, the first officer contacted the Guam Air Traffic Control Center and Radar Approach Control (CERAP) and stated that they were at flight level (FL) 410 (41,000 feet) and over MIXSS intersection, which is located about 240 nautical miles northwest of the Nimitz VOR.

About 0111:51, the CVR recorded the captain briefing the other flightcrew members about the approach to Guam. The captain stated, in part, "I will give you short briefing...since the visibility is six [miles] when we are in the visual approach, as I said bcfore, set the VOR on number two and maintain the VOR for the TOD [top of descent]... in case of go-around, since it is VFR, while staying visual and turning to the right... request a radar vector...since the localizer glideslope is out, MDA [minimum descent altitude] is five hundred sixty feet and HAT [height above touchdown] is three hundred four feet..."

At 0122, the Guam CERAP controller informed flight 801 that the automatic terminal information scrvice (ATIS) report was "uniform" and the current altimeter setting was "29.86." The first officer acknowledged the transmission and said, "checking uniform," however, he did not acknowledge the altimeter setting.

At 0124, flight 801 began deviating around cumulonimbus clouds that were scattered along their route of flight. About 6 minutes later, the first officer reported to the Guam CERAP they were clear of the weather and requested radar vectors to runway 6 left.

At 1031, the CERAP controller provided radar vectors to flight 801 and approximately 7 minutes later the controller transmitted, "Korean Air eight zero one, turn left heading zero nine zero, join the localizer." The first officer acknowledged the transmission.

At 0139, the CERAP controller transmitted," Korean Air eight zero one...cleared for thc ILS runway six left .. glideslope unusable." The first officer responded, Korean eight zero one roger .. cleared ILS runway six left," however, he did not acknowledge that the glideslope was unusable.

Shortly after being cleared for the ILS approach, the CVR recorded the flight engineer say, "is the glideslope working..." to which the captain responded "...yes, yes, it's working." At 0139:58, the CVR recorded an unidentified flightcrew member say, "check the glideslope if working," followed by "why is it working." The first officer rcsponded, "not useable." About 23 seconds later thc CVR recorded an unidentified flightcrew member say, " glideslope is incorrect."

At 0140:33, the first officer stated, "approaching fourteen hundred." The captain responded, "since today's glideslope condition is not good, we need to maintain one thousand four hundred forty. Please set it." Approximately 20 seconds later the sound of the altitude alert was recorded on the CVR.

At 0141:14, the controller cleared flight 801 to land on runway six left. The first officer acknowledged the clearance and the crew began to reconfigure the airplane for landing. About 0141:42, the CVR recorded the ground proximity warning system announcing "one thousand [feet]; and the captain saying, "no flags, gear, flaps." About 4 seconds later the captain said, "isn't glideslope working." However, there was no acknowledgement of this statement recorded on the CVR. The crew continued to complete the landing checklist items and at 1542:15 the CVR recorded the GPWS announcing "minimums" followed by "sink rate." This announcement was followed shortly thereafter by the first officer saying "sink rate okay," and the flight engineer announcing "two hundred [feet]."

At 0142:19, the first officer said "let's make missed approach," and the flight engineer said "not in sight, missed approach." These two comments were followed immediately thereafter by both the first officer and the flight engineer saying "go-around." Approximately 1 second later the CVR recorded the sound of the auto-pilot disconnect and the altitude announcements by the GPWS. The sounds of the airplane impacting the ground were recorded by the CVR at 0142:25

The published approach procedure for the ILS to runway 6 Left with the glideslope inoperative depicts a series of "step down" altitudes that the pilot is required to maintain during the execution of the approach. The step down altitudes ensure sufficient obstruction/terrain clearance. The lowest altitude for the first segment is 2,000 feet until 1.6 nautical miles from the VOR; this is followed by a step down to 1,440 feet until the VOR. Upon crossing the VOR, the pilot can descend to 560 feet, which is the minimum descent attitude or MDA. Once the pilot descends to the MDA, he/she must have visual contact with the airport environment/runway to continue the descent. If visual contact with the airport does not occur within 2.8 miles of crossing the VOR, or visual contact cannot be maintained, the pilot must execute a missed approach.

According to data recorded by the DFDR, flight 801 began to descend from 2,600 feet when the airplane was about 5 miles from the VOR, or 8.5 miles from the airport. The DFDR and radar data indicate that flight 801 descended at a rate of approximately 950 feet per minute and continued at this rate through the intermediate altitudes of 2,000 and 1,440 feet. The airplane struck rising mountain terrain about one tenth of mile west of the VOR.

Mr. Chairman, in an effort to present a clear picture of the accident related events, I would like to present a video that depicts both the flight track and the flight path of flight 801 as it approached Guam. The video will run approximately 10 minutes and you will see a split-screen view showing the plan and profile views.

QuickTime animation of last 64 seconds of flight [5M]

Text summary of video Flight 801, while in U.S. airspace, was being operated under 14 Code of Federal Regulations (CFR) Part 129. Of the two pilots, one flight engineer, one purser, 19 flight attendants (including 6 deadheading flight attendants) and 231 passengers that were aboard at the time of the accident, 225 received fatal injuries. Further, of the 25 passengers and 4 flight attendants that survived the accident with minor to serious injuries, 2 passengers and one deadheading flight attendant succumbed to their injuries in the 30 day period following the accident.

The Investigation

The following are a brief synopsis of some of the facts revealed thus far:

The captain had been a pilot in the Korean Air Force prior to his employment with Korean Air in November 1987. During his tenure with the airline, he flew the Boeing 727 and the Boeing 747, and had accumulatcd 8,932 hours of total flight time; 3,192 hours in the Boeing 747 and 1,718 hours as a 747 captain. According to company records, the captain had operated a Boeing 727 into Guam for approximately one year in 1993. His last video familiarization training and line experience into Guam occurred on July 4,1997, and was conducted in thc Boeing 747 during night-VFR conditions.

The first officer was also a pilot in the Korean Air Force prior to his employment in January 1994 with Korean Air. He had accumulated 4,066 hours of total flight time, with 1,560 hours as a first officer and in the 747. The first officer received familiarization training for operations into Guam on July 8' 1997, and had previous operating experience in the Boeing 747 in 1995.

The flight engineer was a navigator in the Korean Air Force prior to his employment with Korean Air, May 1979. He had flown as engineer on the Boeing 727, Airbus A-300, and Boeing 747, and had had accumulated approximately 13,000 hours of total flight time, of which over 11,000 was as a civilian flight engineer.

One issue developed during the investigation evolved from the operational status of the glideslope portion of the ILS approach. On August 6, the glideslope portion of the ILS was out-of service and only the localizer was available for lateral guidance to the runway. However, the CVR recorded statements by various flightcrew members questioning the operational status of the glideslope, thus, the Safety Board became concerned about the possibility of "spurious" radio signals and the influence that these radio signal may have had on the aircraft navigation Systems. We will have a witness testify about this issue later in the hearing.

The investigation team also examined the weather conditions at the time of the accident and found that the reported conditions were: wind from 090 degrees at 6 knots; the visibility was 7 miles in rainshowers; there were scattered clouds at 1,600 feet, a broken layer of clouds at 2,500 feet and an overcast layer at 5,000 feet. However, examination of weather data, doppler radar images, other weather satellite information, and witness statements, indicated there was a rain shower event occurring along the final approach path when flight 801 was executing the approach. Based on these data, this weather event produced heavy rain, gusting wind conditions and reduced visibility.

The en route and approach radar positions at Guam are typically performed by one controller using two independcnt radar systems. Both systems are equipped with a minimum safe altitude warning (MSAW) system that is designed to alert the controller both aurally and visually when an aircraft, in a predetermined geographic area, is below or predicted to be below a specified safe altitude. The investigation revealed that the MSAW system at Guam was not operating as designed or intended at the time of the accident. Detailed information about the MSAW system and its operation, both at Guam and nationwide, will be addressed by several witnesses testifying later today.

The Safety Board found during the investigation that the post-accident emergency response to the accident site was delayed several minutes because the air traffic controller was not immediately aware that flight 801 had crashed off the airport. In addition, the emergency response vehicles were delayed in arriving on-scene because access to the accident site was initially stopped by a fenced gate that encircled the property where the accident occurred; response was further hampered by a narrow paved road that was blocked by a broken pipeline that had been struck by the airplane and disable parked vehicles that congested the access road and prevented fire trucks from maneuvering close to the wreckage. Several witnesses will testify regarding these issues later in this public hearing.

In addition, the Safety Board will also be examining several other issues, including flightcrew training, crew resource management or CRM, and instrument approach procedures and charting.

Post-Accident Investigative Activities

Although the Safety Board's investigation team completed the on-site wreckage examination August 28, 1997; several other investigative activities have either been completed or on-going. These activities involved examination and tear down of various electronic components, an aircraft performance study and video simulation, follow-up demonstrations of the FAA's MSAW system, and the detection of "spurious" radio signals in the vicinity of Guam International Airport.

The latter issue regarding the spurious signals led the Safety Board to convene a meeting at Boeing Aircraft Company to discuss spurious radio signals and discuss the effect that these unwanted radio signals may have on aircraft navigation systems. A witness from the FAA will testify during the hearing to discuss this issue.

In addition to the investigative activities, a meeting was convened in Guam in January 1998, and was attended by all of the parties. The purpose of the meeting was to review the progress of the investigation, review the draft group chairman factual reports, and determine future work items. Since this meeting, all of the parties and the KCAB have reviewed the factual reports and their comments have been either addressed or incorporated in the respective reports.

The issues stated by the Chairman in his opening remarks, and those described briefly in this statement, will be addressed by the witnesses that were selected based on their expertise, experience or extensive knowledge of the relevant subjects or issues. Their testimony will provide additional factual information which the Safety Board will use in its analysis of the accident and its determination of the probable cause.

Before I conclude my statement, I would like to take a moment to publicly thank Mr. Ham and the Korean delegation for their continuing support and active participation in this investigation; the Safety Board's investigative staff who continually go above and beyond the call of duty to complete the investigative activities in a timely manner under very difficult and stressful conditions, the U.S. Air Force and Navy for their cooperation and logistical support, and finally, the officials and citizens of Guam for their support and generous hospitality while the team was on-scene.

Mr. Chairman, this concludes my remarks. The record of investigation is contained in the documents in our public docket and the court reporter has been provided a list of such materials.

WhisperToMe (talk) 04:43, 27 June 2011 (UTC)[reply]

Witness list and schedule[edit]

http://www.ntsb.gov/events/kal801/witnesses.htm

PUBLIC HEARING - Witness List and Schedule 

KOREAN AIR

FLIGHT 801, B-747-300 AGANA, GUAM AUGUST 6, 1997

March 24 | March 25 | March 26 subject to revision

March 24, 1998


Mr. Kurt Mayo Approach Controller Federal Aviation Administration Guam CERAP

a. Duties, responsibilities, and qualifications b. Handling and observations of KAL 801; c. Weather observations during approach of KE801; d. Knowledge and use of MSAW at Guam; e. Accident notification for search and rescue.

Exhibits: 3A thru 3EE, 13A Questioned by: Richard Wentworth



Mr. Marty Theobald Local Controller Barton ATC International, Inc. Agana Contract Air Traffic Control Tower

a. Duties, responsibilities, and qualifications; b. Handling and observations of KE801; c. Weather observations during approach of KE801; d. NOTAMS and NAV/AID status at Agana; e. BRITE display knowledge and operation; f. Accident notification for search and rescue.

Exhibits: 3A thru 3EE, 13A Questioned by: Richard Wentworth


Ms. Sherrie Ewert Air Traffic Manager Barton ATC International, Inc. Agana Contract Traffic Control Tower

a. Duties, responsibilities, and qualifications; b. Knowledge and operation of BRITE display and MSAW; c. NOTAMS and status of NAVAIDs at Agana; d. Accident notification for search and rescue.

Exhibits: 3A thru 3EE Questioned by: Richard Wentworth



Thomas Howell Acting Manager National Field Support Division, AOS-600 FAA Technical Center Atlantic City, New Jersey

a. Duties, responsibilities, and qualifications; b. General overview and operational characteristics of MSAW; c. Specific history of operations and modifications to Guam MSAW system; d. Post-accident actions at Guam and national review of MSAW systems.

Exhibits: 3A thru 3EE, 13A Questioned by: Scott Dunham/Charlie Pereira


Sabra Kaulia Deputy Director Air Traffic Operations Program, ATO-2 Federal Aviation Administration Washington, D.C.

a. Duties, responsibilities, and qualifications; b. Air traffic requirements and policies for MSAW; c. FAA MSAW action plan - post accident at Guam; d. FAA MSAW action plan - on-going and long term;

Exhibits: 3A thru 3EE, 13A Questioned by: Scott Dunham


David Canoles Manager Evaluations and Investigations Staff, AAT-20 Federal Aviation Administration Washington, D.C.

a. Duties, responsibilities, and qualifications; b. General overview and operational knowledge of MSAW; c. Post-accident actions at Guam and national review of MSAW systems; d. Air Traffic Quality Assurance Programs - both general and Guam specific.

Exhibits: 3A thru 3EE, 13A Questioned by: Scott Dunham


Carl Schellenburg Director Potomac Tracon Development, ATS-20 Federal Aviation Administration Washington, D.C.

Duties, responsibilities, and qualifications; FAA action plan - post accident at Guam; FAA action plan - on-going and long term.

Exhibits: 3A thru 3EE, 13A Questioned by: Scott Dunham


8. Lewis Zeigler KAL Principal Operations Inspector (POI) FAA Flight Standards District Office San Francisco, California

Duties, responsibilities, and qualifications; General overview and knowledge of FAA Part 129 oversight program; Corrective actions in Part 129 program; Interaction with Korean Airlines and MOCT POI; Discrepancy resolution with Korean Airlines and MOCT; Post accident actions at Korean Airlines and FAA

Exhibits: 2A thru 2R, 12A, 13A Questioned by: Paul Misencik


(END OF FIRST DAY)

March 25, 1998


9. Captain Lee, Jung Taek Flight Crew Operation Korean Air Seoul, Korea

a. Duties responsibilities, and qualifications; b. Simulator training curriculum, simulator training modules (profiles) and training scenarios; c. Flight training procedures, crew coordination, and standard operating procedures; d. Flight check procedures, standards, and evaluation of flight crew performance; e. Description of route qualifications and initial operating experience (IOE); f. Crew briefings and checklist usage; g. Crew Resource Management (CRM) between flight crewmembers, emphasis on conducting approaches; h. Non-precision approach procedures; i. Automated and manually flown approaches, role and duties of flying pilot, non-flying pilot, and flight engineer; j. Post accident actions at Korean Air.

Exhibits: 2A thru 2R, 12A, 13A Questioned by: Paul Misencik/Malcolm Brenner


10. Park, Chun Sik Director, Academic Flight Training Korean Air Seoul, Korea

a. Duties, responsibilities, and qualifications; b. Training philosophy and how it was developed; c. Training curriculum - precision and non-precision approaches; d. Unusual approach training - automated vs. manually flown approaches; e. Crew Resource Management (CRM) between pilots, emphasis on conducting approaches; f. Initial operating experience (IOE) philosophy - describe line flying; g. Automated and manually flown approaches; h. Post accident actions at Korean Air; i. Crew briefing, philosophy and procedures; j. Post accident actions at Korean Air.

Exhibits: 2A thru 2R, 12A, 13A Questioned by: Paul Misencik/Malcolm Brenner


11. Captain Park, Pyung-Woo Deputy Director, Flight Operations Korean Air Seoul, Korea

a. Duties, responsibilities, and qualifications; b. Korean Air flight operations and management structure; c. Management oversight responsibilities; d. Assessment of accident flight crew and events related to the accident flight; e. Interaction with Korean Air and MOCT POI; f. Accident prevention actions taken by Korean Air.

Exhibits: 2A thru 2R, 12A, 13A Questioned by: Paul Misencik/Malcolm Brenner


12. Juan Rosario Director Guam Civil Defense Agana, Guam

a. Duties, responsibilities, and qualifications; b. Guam Emergency Response Plan and the standard operating procedures, including notification system; c. Incident Command; d. Post-accident response to accident site; e. Coordination with other local and federal agencies - MOUs; f. Post-accident changes.

Exhibits: 16A, 16B, 16C, 16H, 16I Questioned by: Gary Hammack


13. Ciriaco C. Sanchez Deputy Fire Chief Guam Fire Department Agana, Guam

a. Duties, responsibilities, and qualifications; b. On-scene command activities; c. Guam Fire Department Emergency Response Plan and Disaster Preparedness Plan, including notification system; d. Equipment/Fire Truck Maintenance Plan; e. Post-accident changes.

Exhibits: 16A, 16B, 16C, 16I Questioned by: Gary Hammack 14. Joseph Mafnas Deputy Chief of Police Guam Police Department Agana, Guam

a. Duties, responsibilities, and qualifications; b. Officer training for emergency response; c. Coordination with Guam Civil Defense and participation in Disaster Plan Exercise; d. Post-accident changes.

Exhibits: 16A, 16D, 16I Questioned by: Gary Hammack


15. Captain Mary Humphreys-Sprague Inspector General U.S. Navy Southern Command Miami, Florida

a. Duties, responsibilities, and qualifications; b. Observation and comments regarding the events related to accident response, both initially and post-accident; c. Navy Emergency Response Plan; d. Interaction/participation with Guam Disaster Preparedness Plan, including notification system; e. Post-accident changes.

Exhibits: 16A, 16D, 16E, 16F, 16I Questioned by: Gary Hammack

(END OF SECOND DAY)


March 26, 1998

16. Nelson Spohnheimer National Resource Engineer for Navigation Federal Aviation Administration Renton, Washington

a. Duties, responsibilities, and qualifications; b. Overview of avionics construction; c. FAA avionics design criteria; d. Methods used for prevention of spurious or unwanted frequency interference; e. Evaluation of Flight 801 post-accident testing;

Exhibits: 9A, 9E, 9F Questioned by: Gregory Phillips


17. Paul Woodburn British Airways Chairman, ICAO, CFIT Steering Committee London, England

a. Duties, responsibilities, and qualifications; b. Overview of Controlled Flight Into Terrain (CFIT)issues; c. CFIT Training and aircraft equipment; d. Stabilized approach philosophy and crew coordination techniques; e. Evaluation of Flight 801 and "classic" CFIT scenario;

Exhibits: 2A thru 2R, 12A, 13A Questioned by: Malcolm Brenner/Paul Misencik


18. Don Bateman Chief Engineer, Flight Safety Systems Allied Signal, Inc. Redmond, Washington

a. Duties, responsibilities, and qualifications; b. Overview of Ground Proximity Warning Systems (GPWS) and Enhanced Ground Proximity Warning Systems (EGPWS); c. Evaluation of Flight 801 GPWS and EGPWS simulations; d. EGPWS availability and certification issues.

Exhibits: 2A thru 2R, 12A, 13A Questioned by: Charlie Pereira/Malcolm Brenner


19. William Henderson Manager Western Flight Procedures Development. Branch FAA Western Pacific Regional Office Los Angeles, California

a. Duties, responsibilities, and qualifications; b. Overview of TERPs and application to approach criteria; c. Certification of the Guam ILS Runway 6L approach; d. Instrument approach charting design, limitations, information; e. Interaction with chart vendors; f. Approach charting quality assurance; g. Initiatives for future charts, procedures, etc.

Exhibits: 2A, 2L, 2M, 2N, 12A, 13A Questioned by: Paul Misencik/Gregory Feith


20. James Terpstra Sr. Corporate Vice President Flight Information Technology and External Affair Jeppesen Sanderson, Inc. Englewood, Colorado

a. Duties, responsibilities, and qualifications; b. Instrument approach charting design, limitations, information; c. Interaction with FAA regarding charting information; d. Approach charting quality assurance; e. Initiatives for future charts, procedures, etc.

Exhibits: 2A, 2L, 2M, 2N, 12A, 13A Questioned by: Paul Misencik/Gregory Feith


21. Captain Wallace Roberts Former Chairman, ALPA CHIPS Committee Air Line Pilots Association (ALPA) Herndon, Virginia

a. Duties, responsibilities, and qualifications; b. Review of FAA instrument approach charting design, limitations, procedures; c. TERPS criteria used to develop instrument approach; d. Initiatives for future charts, procedures, etc.

Exhibits: 2A, 2L, 2M, 2N, 12A, 13A Questioned by: Paul Misencik/Gregory Feith WhisperToMe (talk) 05:18, 27 June 2011 (UTC)[reply]

Who's Who[edit]

http://www.ntsb.gov/events/kal801/who.htm

Board of Inquiry | Technical Panel | Expert Witnesses | Parties to the Hearing

Members of the Board of Inquiry (at the time of the hearing):

Robert Francis II Vice-Chairman, National Transportation Safety Board Hearing Chairman

Ronald Schleede Deputy Director, Office of Aviation Safety

Pat Cariseo Office of Safety Recommendations and Accomplishments

Monty Montgomery Chief, Information Technology Division, Office of Research and Engineering

Benjamin Berman Chief, Operational Factors Division, Office of Aviation Safety


NTSB Technical Panel Some of the Safety Board investigators that have participated in the investigation serve on the Technical Panel. Depending on the topics to be addressed at the hearing, the panel often includes specialists in the areas of aircraft performance, powerplants, systems, structures, operations, air traffic control, weather, survival factors, and human factors. Those involved in reading out the cockpit voice recorder and flight data recorder, and in reviewing witness and maintenance records also might participate in the hearing.

Gregory Feith Investigator-In-Charge (IIC) of Korean Air Flight 801 investigation

Paul Misencik Malcolm Brenner Gregory Phillips Richard Wentworth Scott Dunham Charlie Pereira Gary Hammack


Expert Witnesses

Expert witnesses are called to testify under oath on selected topics to assist the Safety Board in its investigation. The testimony is intended to expand the public record and to demonstrate to the public that a complete, open and objective investigation is being conducted. The witnesses who are called to testify have been selected because of their ability to provide the best available information on the issues related to the accident.

Witness List and Schedule


Parties to the Hearing

Parties to the hearing are designated by the Safety Board Member who is the presiding officer of the hearing. They include those persons, governmental agencies, companies, and associations whose participation in the hearing is deemed necessary in the public interest and whose special knowledge will contribute to the development of pertinent evidence are designated as parties. Typically, they include the Federal Aviation Administration, operator, airframe manufacturer, engine manufacturer, pilots union, and any other organization that can assist the Safety Board in completing its record of the investigation. Except for the FAA, party status is a privilege, not a right. Parties are asked to appoint a single spokesperson for the hearing.

Federal Aviation Administration Boeing Commercial Airplane Group Korean Air Company, Ltd. National Air Traffic Controllers Association Barton ATC International, Inc. Government of Guam

Summary of Animation[edit]

http://www.ntsb.gov/events/kal801/anim_summary.htm

KAL Flight 801 - Animation


Disclaimer: These reconstructions were developed using digital flight data recorder information, cockpit voice recorder information, recorded radar data, and geographical data. Weather and visibility conditions at the time of the accident are not depicted. 

Realvideo animation of Flight 801 descent [3.5M]

Summary: The animation shows the airplane on approach to runway 06L, descending to impact on Nimitz Hill approximately 3.5 nautical miles from the runway. Time is displayed as Coordinated Universal Time (UTC). Altitude was derived from the flight data recorder and is displayed in feet above mean sea level. Text from the cockpit voice recorder transcript is displayed in an abbreviated format above the airplane.


QuickTime animation of last 64 seconds of flight [5M]

Summary:

This animation depicts a top and side view of the topography of Guam for the flight path of the airplane within a 12 nm x 4 nm area, from 12 nm out from Runway 06L threshold for FL801 on approach to Agana A/P. The top view is to scale (in nautical miles) for both the x and y axes, and is oriented so that the x axis parallels the centerline of Runway 06L and the y axis is perpendicular to the runway centerline, with distances measured from left and right of the runway. The side view is displayed at an expanded vertical scale with each horizontal line representing 200 feet MSL altitude. The y axis is MSL altitude divided by 100, in feet. The x axis coincides with the x axis for the top view and is in nautical miles. An abbreviated-verbatim CVR transcript is displayed between the top and side views, with text appearing in groupings for readability and for as near as possible real time display. Time is displayed as local time in the top view.

Top View: Both the x and y axes are nm. The top view shows the approach of FL801 from the north and west of Guam, intercepting the localizer near the Flake intersection and continuing in towards Runway 06L at Agana A/P. The locations for Flake Intersection, Outer Marker, DME VOR, and Middle Marker are displayed in this view. The localizer full fly left/right limits are also displayed here.

Side View: The side view displays the topographical profile of the island along an extended centerline from the runway, from 12 nm miles from the runway threshold towards approach to 2 nm in the opposite direction. The side view indicates the step altitudes for the approach, as shown for 2600, 2000, 1440, and 560 feet, respectively. A simulated ARTS II MSAW Alert (initiating at 64 sec before impact and at 1700 feet MSL altitude) is also displayed. Distances along the extended centerline from the DME VOR to the Flake Intersection, Outer Marker, and Middle Marker are also displayed. A glide slope is not displayed since it was not usable at the time of the accident.

Tuesday March 24, 1998[edit]

http://www.ntsb.gov/events/kal801/trans_980324.htm

NATIONAL TRANSPORTATION SAFETY BOARD

PUBLIC HEARING IN CONNECTION WITH THE INVESTIGATION OF AIRCRAFT ACCIDENT KOREAN AIR FLIGHT 801, B-747-300 AGANA, GUAM AUGUST 6, 1997

Hawaii Convention Center Ballroom A, B and C 1833 Kalakaua Avenue Honolulu, Hawaii 96815 Tuesday, March 24, 1998 9:00 a.m.

Chairman, Board of Inquiry THE HONORABLE ROBERT T. FRANCIS

Board of Inquiry

RONALD L. SCHLEEDE Deputy Director, International Aviation Safety Affairs Office of Aviation Safety

BEN BERMAN Chief, Operational Factors Division Office of Aviation Safety

MONTY MONTGOMERY Chief, Information Technology Division Office of Research and Engineering

PAT CARISEO Transportation Safety Specialist Office of Safety Recommendations and Accomplishments

Technical Panel

GREGORY FEITH Investigator-in-Charge

PAUL MISENCIK Operational Factors Investigator

MALCOLM BRENNER Human Performance Investigator

GARY HAMMACK Airport Crash/Fire/Rescue Investigator

GREGORY PHILLIPS Aircraft Systems Investigator

CHARLES PEREIRA Aircraft Performance Investigator

RICHARD WENTWORTH National Resource Specialist, ATC

SCOTT DUNHAM Air Traffic Control Specialist

Public Information Officer

PAUL SCHLAMM Office of Government, Public and Family Affairs

General Counsel

DAVID BASS Office of General Counsel

Parties to the Hearing

FEDERAL AVIATION ADMINISTRATION Harold Donner, Spokesman

BOEING COMMERCIAL AIRPLANE GROUP Kevin Darcy, Spokesman

KOREAN AIR COMPANY, LIMITED Captain Sang Rok, Kim, Spokesman First Officer Steven Chung, Official Assistant to Captain Kim

NATIONAL AIR TRAFFIC CONTROLLERS ASSOCIATION Charles Mote, Spokesman

BARTON ATC INTERNATIONAL, INC. Edward Montgomery, Spokesman

GOVERNMENT OF GUAM Ron Dervish, Spokesman

A G E N D A

AGENDA ITEM:

Opening Statement by the Chairman, Board of Inquiry: Robert T. Francis

Introduction of the Board of Inquiry

Introduction of the Parties to the Hearing

Introduction of the Technical Panel

Description of the Investigation by the Investigator-in-Charge

Calling of Witnesses, Witnesses Sworn and Qualified by the Hearing Officer, and Witness Questioning

Kurt Mayo, Approach Controller Federal Aviation Administration Guam CERAP

Marty Theobald, Local Controller Barton ATC International, Inc. Agana Contract Air Traffic Control Tower

Sherrie Ewert, Air Traffic Manager Barton ATC International, Inc. Agana Contract Traffic Control Tower

Afternoon Session Continuation of Witness Questioning

Thomas Howell, Acting Manager National Field Support Division, AOS-600 FAA Technical Center Atlantic City, New Jersey

Sabra Kaulia, Deputy Director Air Traffic Operations Program, ATO-2 Federal Aviation Administration Washington, D.C.

David Canoles, Manager Evaluations and Investigations Staff, AAT-20

Carl Schellenberg, Director Potomac Tracon Development,

Lewis Zeigler Korean Air Geographic Operations Inspector FAA Flight Standards District Office San Francisco, CA

Adjournment

P R O C E E D I N G S

9:00 a.m.

Opening Statement

CHAIRMAN FRANCIS: Good morning, everyone.

I'm Bob Francis. I'm vice chairman of the NTSB, and I'm chairing this hearing.

As you know, this is a hearing -- public hearing which is part of our process on an aircraft accident on August 6th, 1997, in Agana, Guam involving Korean Air Flight 801.

The purpose of the hearing is to supplement the factual record of this accident investigation for the NTSB. We thus have the NTSB witnesses, we have party witnesses, and we have some outside witnesses. All of these people have technical expertise to be able to bring to the factual portion of this investigation.

This hearing will not deal, I repeat, will not deal with any analysis of what happened nor will it deal with any causal issues. This is a factual hearing not dealing with analysis or cause.

There are five issues about which we'll be talking here today. The first is controlled-flight-into-terrain accidents and efforts on the part of the aviation community to deal with the controlled-flight-into-terrain accidents.

The second is operation of navigational devices at the Guam airport.

The third is Minimum Safe Altitude Warning systems and practices related to this system at Guam and nationwide.

Fourth, rescue and recovery operations.

And fifth, governmental oversight of foreign air carriers operating into the United States.

Before I proceed further I'd like to introduce three people who are here. First is the congressman from Guam, Congressman Underwood, who is sitting over here at our observer table. Second, a member of the National Transportation Safety Board, John Hammerschmidt, and third, a colleague and member also, George Black. They're all sitting over here.

I'd like to take a minute and talk about controlled-flight-into-terrain. Controlled-flight-into-terrain or CFIT as it is called in the industry is the major killer of people on a worldwide basis in commercial aviation. This has been the case for some time, and there are no indications statistically that it is not continuing to be the case. It's an enormously, enormously important issue for those of us who are involved in the aviation safety business to be dealing with, and it's something that I personallyspend a great deal of my time working on and something that the industry I think is more and more focusing on as one of the real places where we can make gains in safety.

So, we'll be talking here about a number of issues that relate to controlled-flight-into-terrain. These include issues that can be dealt with by airlines, by air traffic control authorities, by equipment manufacturers. There are -- the entire community can be involved in this.

And I'd like to mention that the Flight Safety Foundation and a large portion of the international community have over the past five years or so been doing some very good work in this area. There's an educational package that's come out that's being distributed worldwide to airlines which is the kind of work that hopefully will be done by the community internationally and voluntarily to try to deal with this issue. But it's the kind of thing that -- that allows us to make gains in an area -- this particular area that's so important.

So, I think that -- that we should be focusing on this. We will be focusing on air traffic control, we will be focusing on training, we will be focusing on airline cultures, we will be focusing onnew technology which will hopefully let us deal with this issue. But I personally think that this is enormously important, and -- and I'm delighted that we're going to be spending so much time on it.

Let me conclude by one note here. We've had some confusion I think in communications in terms of dealing with the families and some of the people who were -- were survivors of the aircraft, and I think that we're going to make an effort to -- to do a better job with this communication. I'm going to meet with the families after -- after this meeting, and we will be giving them information on how they can communicate with us more directly because we have had some problems in the past and -- and I'm sorry that that was the case.

Let me now introduce Ron Schleede, who is the hearing officer, and he will introduce a number of the people who are going to be key to this hearing.

Introduction of the Board of Inquiry

MR. SCHLEEDE: Thank you, Mr. Chairman. Thank you.

My name is Ron Schleede. I'm a deputy director, Office of Aviation Safety for International Affairs.

The Board of Inquiry up here, I have with meMr. Monty Montgomery, chief of our Information Technology Division, Office of Research and Engineering.

To my far right, that's Mr. Pat Cariseo, safety specialist in the Office of Safety Recommendations.

To his left is Mr. Ben Berman, chief, Operational Factors Division.

There's other NTSB staff here today sitting in that location and this location. First, we have John Clark, deputy director of Office of Aviation Safety for Investigations and Technical Matters.

We have three public affairs officers here. Mr. Paul Schlamm, Keith Holloway, and Ted Lopatkiewicz.

The report-writer for this case, Mr. Gerard Stichen.

Behind us we have Ms. Denise Daniels, special counsel to the vice chairman; Ms. Maria Sturniolo, confidential assistant to the vice chairman; and David Bass, chief counsel -- or deputy chief counsel for the NTSB.

From our Office of Government Affairs we have Ms. Betty Scott. From the Office of Family Affairs, Elizabeth Cotham and Matt Furman. We also have Ms. Alice Park with us today from the NTSB Office ofResearch and Engineering. She is providing interpreting services for us.

For administrative matters and logistics regarding this hearing, we have three people seated over here to the left, Ms. Carolyn Dargan, Candi Wiseman, and Ann -- I forget the last name. Sorry, Ann.

All these people are available to assist during any part of the hearing. If you have questions please approach one of them.

Introduction of the Parties to the Hearing

MR. SCHLEEDE: I'd like now to switch to the people in front of us and ask the party spokesman, as I call each party, to identify their -- their name and their title, beginning with the Federal Aviation Administration.

MR. DONNER: Yeah, Mr. Chairman, my name is Bud Donner. I'm the manager of the Accident Investigation Division, Federal Aviation Administration.

MR. SCHLEEDE: Thank you.

Boeing Commercial Airplane Company?

MR. DARCY: The name is Kevin Darcy, and I'm chief investigator, Air Safety Investigation.

MR. SCHLEEDE: Thank you.

Korean Air Company, Limited?

CAPTAIN KIM: Sang Rok Kim, deputy director, Safety and Security Department.

MR. SCHLEEDE: Thank you, Captain Kim.

National Air Traffic Controllers Association?

MR. MOTE: Good morning, Mr. Schleede and Mr. Chairman. My name is Charles R. Mote. I'm a senior safety investigator with NATCA and air traffic control specialist.

MR. SCHLEEDE: Barton ATC International?

MR. E. MONTGOMERY: Good morning. My name is Ed Montgomery. I'm the president of Barton ATC.

MR. SCHLEEDE: And the Government of Guam?

MR. DERVISH: Good morning. My name is Ron Dervish. I'm the deputy chief of police, Guam Police Department and spokesman for the Government of Guam.

MR. SCHLEEDE: Thank you, Mr. Dervish.

And now I'd like to turn to the Civil Aviation Bureau of Korea spokesman, please. Please state your name and title.

MR. LEE: (responds in Korean)

MR. SCHLEEDE: And also at that table is Mr. Ham, who is the designated accredited representative for the Government of -- of Korea during the on-scene investigation.

I'd like to mention that the KCAB is representing the Government of Korea as part of this investigation in accordance with the provisions of the convention on International Civil Aviation and Annex 13 to that convention. Annex 13 provides certain rights and obligations on the state of registry of an airline when it crashes in another country. This investigation has been conducted in full compliance with the spirit of cooperation intended by Annex 13. I want to thank publicly our colleagues from the KCAB for their assistance in this investigation.

Introduction of the Technical Panel

MR. SCHLEEDE: The Board of Inquiry will be assisted by a Technical Panel of specialists from the NTSB, led by Mr. Greg Feith, the investigator-in-charge. I'd like Mr. Feith to now introduce the Technical Panel.

MR. FEITH: Thank you, Mr. Schleede.

With us at the Technical Panel is Mr. Charles Pereira. He is an aircraft performance specialist in the Office of Research and Engineering. He did the aircraft performance study for this accident.

Sitting to his left is Mr. Scott Dunham. He is a air traffic control specialist in the Office of Aviation Safety.

Sitting next to Mr. Dunham is Mr. Richard Wentworth. He is a national resource specialist for air traffic control in the Office of Aviation Safety, both of whom have done extensive work on this investigation.

At our back table sitting directly behind me is Mr. Paul Misencik, Captain Misencik. He was the operations group chairman for this investigation.

Sitting to his left is Mr. Malcolm Brenner --Dr. Malcolm Brenner, who did the human performance aspect of the investigation in conjunction with the operations group.

Sitting next to Dr. Brenner is Mr. Greg Phillips. He did the aircraft systems portion of the investigation and also did the aircraft structures. Our aircraft structures specialist is not present today, and so, Greg will discuss any structural questions if they do arise.

And then sitting next to Mr. Phillips is Mr. Gary Hammack, and he will be addressing the crash/fire or search/fire/rescue aspects of this investigation.

CHAIRMAN FRANCIS: Let me introduce one other extraordinarily important person here, Teddy Brown, who makes certain that we can all communicate one with another in this room. He works for us with the NTSB inWashington.

Now I'd ask Greg Feith, the investigator-in-charge, he's got a prepared statement to come as -- as the first witness.

Description of the Investigation by Mr. Feith

MR. FEITH: Good morning, Mr. Chairman, Board of Inquiry, colleagues on the Technical Panel, parties, ladies and gentlemen.

On August 6th, 1997, about 01:42 Guam time a Korean-registered Boeing 747-300 operated by Korean Air Company, Limited as Korean Air Flight 801 crashed about three nautical miles southwest of the Guam International Airport in Agana, Guam while executing the ILS approach or Instrument Landing Systems approach to runway 6-left.

The Safety Board was notified of this accident on August 5th about 12 noon Eastern Daylight time. I was assigned as the investigator-in-charge. The go-team assembled at Andrews Air Force Base in Maryland and departed later that evening via United States Air Force C141 transport aircraft to Fairchild Air Force Base in Washington state. The trip to Guam was subsequently completed on a KC 135R, and the team arrived in Guam about 8:30 in the morning Guam time on August 7th.

The Board member on duty at the time was George Black, and he accompanied the team to the crash site.

The investigative team consisted of various specialists from the Safety Board's headquarters, the south central region, and southwestern regional offices. The specialty areas were aircraft operations, human performance, aircraft systems, structures, power plants, maintenance records, air traffic control, survival factors, aircraft performance, meteorology, and search/fire/rescue. There were also specialists assigned to conduct the read-out of the flight data recorder and to transcribe the cockpit voice recorder in the Safety Board's laboratory in Washington, D.C.

With regard to the CVR, the initial CVR --transcript was produced in English by the initial group members that convened in Washington. The CVR group then later reconvened and produced a more --

CHAIRMAN FRANCIS: Greg -- Greg, what we're doing in simultaneous interpretation here so you're going to have to go a little slower --

MR. FEITH: Okay.

CHAIRMAN FRANCIS: -- those ladies back there are going to be in trouble.

MR. FEITH: Okay. The initial CVR transcriptwas produced in English by the group. However, the CVR then reconvened and produced a more detailed and -- and detailed transcript in both English and Korean languages.

The following organizations were given party status and provided technical assistance to the Board: the Federal Aviation Administration; Korean Air Company, Limited; Boeing Commercial Airplane Company; Pratt-Whitney Engines; the National Air Traffic Controllers Association; the United States Navy; and emergency response personnel from Guam.

In addition, Mr. Ham of the Korean Civil Aviation Bureau was designated as the accredited representative and the leader of the Korean delegation in accordance with the provisions of Annex 13 to the Convention on International Civil Aviation.

Further, two air safety investigators from the Australian Bureau of Air Safety Investigations, or BASI as they're more commonly known, participated in the investigation as technical observers.

Now, to give you a brief history of flight. Korean Air Flight 801 was a regularly scheduled passenger flight that departed Kimpo Airport in Seoul, Korea at 21:53 or approximately 9:53 in the evening. The -- the flight itself proceeded uneventfully enroute to Guam. An audio examination of the CVR revealed that the captain was what we call the flying pilot and that the first officer was performing the radio communications and those duties required of the non-flying pilot at the time of the accident.

At 01:03 the first officer contacted the Guam Air Traffic Control Center and Radar Approach Control, or more commonly known as CERAP, and stated that they were at flight level 410 or 41,000 feet over Nimitz Intersection, which is a reference point -- a navigation reference point located about 240 nautical miles northwest of the VOR -- Nimitz VOR which is in close proximity to Guam International Airport.

About 01:11:51 the CVR recorded the captain briefing the other flight crew members about the approach to Guam. The captain stated in part, quote, "I will give you a short briefing. Since the visibility is six miles, when we are in visual approach, as I said before, set the VOR on number two and maintain the VOR for the top of descent. In the case of a go-around, since it is VFR while staying visual and turning to the right request a radar vector. Since the localizer glide slope is out, the minimum descent altitude is 560 feet and the height above touchdown is 304 feet."

At the conclusion of this briefing, a short time later at 01:22, the Guam CERAP controller informed Flight 801 that the Automatic Terminal Information Service or ATIS report, which is a prerecorded report of the weather conditions at Guam were as follows: that the current weather was uniform and that the current altimeter setting was 29.86.

The first officer acknowledged the transmission and said, "Checking uniform." However, he did not acknowledge the altimeter setting.

About two minutes later Flight 801 began deviating around cumulo-nimbus clouds that were scattered along their route of flight. About six minutes later the first officer reported to the Guam CERAP controller that they had cleared the weather and requested radar vectors to runway 6-left.

At -- at 01:31 the CERAP controller provided radar vectors to Flight 801, and approximately seven minutes later the controller transmitted, quote, "Korean Air 801 turn left heading 090. Join the localizer." The first officer acknowledged this transmission.

About eight minutes later the CERAP controller transmitted, quote, "Korean Air 801 cleared for the ILS runway 6-left. Glide slope unusable." Thefirst officer responded, "Korean 801, roger. Cleared ILS runway 6-left." However, the first officer did not acknowledge the glide slope was unusable.

Shortly after being cleared for the ILS approach, the CVR recorded the flight engineer saying, quote, "Is the glide slope working?" to which the captain responded, "Yes, yes. It's working."

At 01:39:58 the CVR recorded an unidentified flight crew member say, "Check the glide slope if working," followed by "Why is it working?"

The first officer responded, quote, "Not usable."

About 23 seconds later, the CVR recorded an unidentified flight crew member say, "Glide slope is incorrect."

At 01:40 the first officer stated that they were approaching an altitude of 1400 feet. The captain responded, quote, "Since today's glide slope condition is not good we need to maintain 1440. Please set it."

Approximately 20 later -- 20 seconds later, the sound of the altitude alert, which is an alert in the cockpit with a predetermined altitude set in, was recorded on the CVR.

At 01:41 and 14 seconds, the controller cleared Flight 801 to land on runway 6-left. The firstofficer acknowledged the clearance and the crew began to reconfigure the airplane for landing.

About 01:41 and 42 seconds the CVR recorded the ground proximity warning announcing 1000 feet and the captain beginning a checklist item saying, "No flags, gear, flaps."

About four seconds later the captain said, "Isn't glide slope working?" There was no response to this statement by the captain.

The crew continued to complete the landing checklist items, and at 01:42 the CVR recorded the ground proximity warning system announcing, quote, "Minimums" followed by "sink rate." This announcement was followed shortly thereafter by the first officer saying, quote, "Sink rate okay," and the flight engineer announcing, "200 feet."

At 01:42:19 the first officer said, quote, "Let's make a missed approach," and the flight engineer said, quote, "Not in sight, missed approach."

These two comments were followed immediately thereafter by both the first officer and the flight engineer saying, quote, "Go around."

Approximately one second later the CVR recorded the sound of the auto-pilot disconnect chime and the altitude announcements on the GPWS or GroundProximity Warning System.

The sound of the airplane impacting the ground were recorded by the CVR at 01:42 and 26 seconds.

The published -- excuse me. The published approach procedure for the ILS to runway 6-left with the glide slope inoperative depicts a series of step-down altitudes that the pilot is required to maintain during the execution of the approach. What you will see is the step-down altitudes which will ensure sufficient terrain and obstacle clearance.

(Slide)

MR. FEITH: Unfortunately, I don't have a pointer, but if you'll look at --

(Pause)

MR. FEITH: In this box right here is a profile view of the approach where this being 2600 feet will be the initial intercept altitude. There is a step-down to an altitude of 2000 feet with another step-down to 1440 feet and then a final step-down to the minimum descent altitude of 560 feet.

These step-down altitudes ensure that the pilot will maintain an obstacle and terrain clearance during this portion of the approach.

(Slide)

MR. FEITH: The lowest altitude for the first segment is 2000 feet until 1.6 nautical miles, so the aircraft would be at 2000 feet until this point right here. This would be followed by a step-down to 1440 feet until crossing the VOR.

(Slide)

MR. FEITH: And then stepping down to the final MDA of 560 feet.

If visual contact with the airport does not occur within the 2.8 miles after crossing the VOR or visual contact cannot be made, the pilot must execute a missed approach.

According to the data recorded by the flight data recorder Flight 801 began to descend from 2600 feet when the airplane was about five miles from the VOR or about 8.5 miles from the airport. The flight data recorder and radar data indicated that Flight 801 had been descending at a rate of approximately 950 feet per minute and continued at this rate through the intermediate altitudes of 2000 and 1440 feet. The airplane struck the rising mountainous terrain about one-tenth of a mile west of the VOR.

And at this time, Mr. Chairman, I think that because this is a bit complicated we do have a video depiction which will show both a plan view and aprofile view of the aircraft as it traversed the terrain, and this information is based on the flight data recorder and radar data that was collected during the course of the on-scene investigation, and I'd like to show that now.

CHAIRMAN FRANCIS: That's very helpful. Let's do that.

(Mr. Feith narrates the scenes from the video.)

MR. FEITH: What we're going to see -- and this video is approximately 10 minutes long. The first part of the video itself will be a -- a still or just a picture of the terrain in the area of Agana Airport in Guam. And then you will see a profile plan. And what you have is the terrain looking down on Guam. Here is Agana, Guam International Airport, runway 6, the coastline.

This is the middle marker, which is one of the navigational aids that is part of the Instrument Landing System Approach.

This is the VOR that we've been referencing. It sits up on Nimitz Hill, and it is also an integral part of the Instrument Approach Landing System approach for this runway. And then the outer marker, which is also another navigational point for the ILS approach.

Flake Intersection is a navigational reference point at which the airplane will initially intercept the localizer, which in this case because the glide slope portion which provides the pilot with a vertical guidance to the runway was out of service, the only navigational aid associated with the ILS on this particular night was the localizer which provides lateral guidance to the pilots. So, the lateral guidance would keep it within this -- these two lines -- this band to the runway.

In the profile you see depicted here the step-down altitudes as they are depicted on the approach procedure for this runway. And again, this is a terrain profile. You have nautical miles across the bottom to the airport. You have altitude in feet above sea level, not above the ground.

And you will see in this animation the airplane as it begins its trek into the localizer flight path and then proceeds towards the airport. At the same time, you will see what it is doing in the vertical and you will watch the airplane as it comes through the various altitudes on its flight profile all the way to the impact point.

All of this information was derived from radar data that was accumulated and the flight datarecorder data from the aircraft. So, what you're seeing is the actual profile of what the airplane did prior to the accident.

The CVR text will be depicted right in the middle, and what we've done so that you can read it because it starts to scroll pretty quickly is that you'll see this played in half-speed so it will not be real time so that you can read the CVR data. We then played -- replayed the -- the animation again at regular speed or full speed so that you will be able to see it in real time. But you will have had an idea of what was transpiring in the cockpit with the flight crew during the -- during the flight path demonstration.

CHAIRMAN FRANCIS: Could -- could we stop for just a second? We're going to show this animation, and -- and I would just say to those here, particularly family members, this is not -- this -- this shows the -- the actual flight of the aircraft. It's possible that -- that you could find this disturbing, and if you would like we'll leave a second here if you'd like to go out of the room while we do this.

(Pause)

CHAIRMAN FRANCIS: Okay. Go ahead.

MR. FEITH: You'll see the airplane enteringthe picture. And again, this is looking down on the airplane as the airplane is beginning its intercept of the localizer. It'll join the localizer and then begin a trek towards the airport. At the same time the airplane has entered the picture up here in the left corner and is tracking along this altitude line of 2600 feet. And as you can see from the note that they will remain at 2600 feet or should remain at 2600 feet until passing the Flake intersection, this point right here. And you will see where they intercept, which is just inside of Flake.

(Pause)

MR. FEITH: Now, again, because of -- excuse me. Because of the information that would be necessary such as you see here for this demonstration, terrain information is not typically depicted on approach plates. So, this information has been derived off of topographic maps and is in pretty much of a -- a direct relationship to the flight path and its relative position to the airport. But again, we're talking in an expanded vertical scale so that you can see the actual movement of the aircraft.

And as you can see right here, the airplane has passed Flake intersection in both views and will then begin the descent because they've now been clearedfor the ILS approach.

(Pause)

MR. FEITH: One of the things that we found during the course of the investigation was that although the weather conditions were reported as VFR or visual there were some areas of thunderstorm build-up around the airport area and included a thunderstorm build-up off the approach-end of the runway, which the aircraft did in fact fly into because on the CVR we do hear the sound of the windshield wipers on the aircraft being turned on. And so, we know that the aircraft had flown into a rain event. And I will talk briefly about that later on.

But you see the -- the airplane will now begin a descent. These are intermediate altitudes of 2000 feet, 1440 feet, and then on down to 560 feet once the high terrain is cleared, and that would be the altitude that the aircraft would remain at until the pilots had a visual cue on the airport and then would make a normal landing.

(Pause)

MR. FEITH: Again, they referenced a 1440. The airplane is on its way down.

(Pause)

MR. FEITH: Another integral part of thisapproach is the VOR, and the reason it is critical is because the captain would typically fly with his navigation instruments set for the localizer. So he would be tracking the lateral guidance while the first officer would typically be monitoring the distance-measuring equipment on board that reads off the mileage from the station digitally. And so, he would be monitoring the digital countdown because you're counting down from seven nautical miles at Flake intersection to zero at the VOR. Then you would --once passing the VOR would begin your count back up to 2.8 to the runway.

As you see, as the airplane continues its trek now over land the airplane has gone through the 2000-foot altitude and continues on a steady state descent down to 1440.

Typically, the airplane would fly -- now, this MSAW alert that you just saw flash right here, this is the Minimum Safe Altitude Warning system that the FAA has. It is a system that works in conjunction with the radar at this airport and other airports around the nation, United States.

And what we have demonstrated here is that if the system, which we will talk about and we will have witnesses addressing later on, had been working as itwas intended, the controllers would have had a Minimum Safe Altitude Warning alert right here when the airplane exceeded this 2000-foot step-down at the 1700-foot level. However, because the system did not work as designed the controllers did not receive the MSAW alert and that information was not forwarded to the crew while they were doing the approach.

As you see, the airplane continues in a steady state descent as it's approaching the outer marker. And again, it has gone through the intermediate altitude of 1440 feet.

The crew is going through checklist items. The first officer, which is the Cam-2 position, does not see the -- what we believe is the runway, says "not in sight." They're continuing their checklist items.

(Pause)

MR. FEITH: You can see that the GPS is starting to call the sink rate and the minimums. However, the first officer says that the sink rate is okay.

There's the 200-foot call. They don't see the airport. They're in the process of going around.

Disconnect. That is the countdown between the airplane and -- and ground. And the airplane impacts the hill in the vicinity of the VOR.

(Pause)

MR. FEITH: And as you will see now, the --the real time animation will run at a quite a bit faster speed.

(Pause)

MR. FEITH: Okay. Again, you have the airplane entering the picture, both at altitude and then over the water as it intercepts the localizer.

(Pause)

MR. FEITH: Had the glide slope portion of the ILS been working -- the glide slope projects an invisible radio beam at about a three degree angle projected upward, which once the airplane intercepts that glide slope electronically, the flight crew then would follow its instruments. As long as the airplane was on the glide slope it would bring it down to the runway at a -- at a -- approximately three-degree angle, which would clear all of this terrain.

But because the glide slope was inoperative, there is a different set of minimums, altitudes that the -- the flight crew must follow, a different set of procedures, which is this step-down so that they can systematically fly over this area of high terrain. But it is critical that these navigational aids be used as a gauge when crossing this area of high terrain duringthe course of the approach.

And as I had briefly spoke in the earlier part of my statement, there was a -- a discussion amongst the flight crew members about the glide slope. Although the glide slope had been NOTAM'd, and that is Notice to Air Men. It's a piece of information put out by the FAA that the glide slope was out of service. There was still some question by the flight crew as they were proceeding on the approach about the operational status of the glide slope. And because of that, that is one of the issues that the Safety Board Operations and Human Performance group has looked into with regard to why the crew would have been questioning that given the fact that it was in fact inoperative.

And you see the MSAW alert flashing. This would be typically where we would have expected the controller to have received the MSAW alert that the airplane had gone through this 2000-foot altitude which it should have been at, and they would have then provided a low altitude warning alert to the crew.

(Pause)

MR. FEITH: A couple other notes about this particular area. In talking to pilots that fly into this area quite a bit, especially at night, this is what we call a -- a black hole. That is, the terrainaround here is such that there are no lights as you would typically see looking out the window here in Honolulu with all the lights of the building. To contrast that, there are very few if any lights in this area and you cannot really distinguish the terrain from the black of night, so it looks like a black hole.

All of these things are considerations that the Human Factors and Operations group had to look at during the course of their investigation, and that is just parts of their investigative process with -- with regard to the crew and the operation of this airplane.

(End of video)

MR. FEITH: Hopefully you have a little better idea now of what the aircraft was doing. You do have some sense of what the flight crew was doing at various times during the course of the approach.

The investigation is a very complex process. There are a lot of aspects that need to be looked at. And while this public hearing tends to focus on five of the issues that the chairman has discussed, I'd just like to give you a little bit of information on some of the other things that -- that we are looking at and some information that we've revealed thus far during the course of the investigation.

To begin, the captain had been a pilot in theKorean Air Force prior to his employment with Korean Air in November 1987. During his tenure with the airline he flew the Boeing 727 and the Boeing 747. He had accumulated about 9000 hours of total flight time with 3000 hours in the Boeing 747 and about 1700 as a captain in the 747.

According to company records the captain had operated a Boeing 727 into Guam for approximately one year back in 1993. There were no other records of him flying into Guam until he received video familiarization for operations into Guam and a line experience trip or a line trip into Guam which occurred on July 4th, 1997. This operation was conducted in a Boeing 747. It was done at night in VFR conditions.

The first officer was also a pilot in the Korean Air Force prior to his employment with Korean Air in 1994. He had accumulated about 4000 hours of total time and about 1500 hours as a first officer in the 747. The first officer received his familiarization training for operations into Guam on July 8th, 1997, and had previously operated into Guam in the 747 back in 1995.

The flight engineer had been a navigator in the Korean Air Force prior to his employment with Korean Air in May of 1979. He had flown as an engineeron the Boeing 727, the Air Bus A300, and the Boeing 747. He had approximately 13,000 hours of total flying time, of which 11,000 was over a period as a civilian flight engineer.

Several issues that we have looked at as the investigative team include the development of the -- an issue that was developed during the course of the investigation evolved from the operational status, as I mentioned, of the glide slope portion of the Instrument Landing System. On August 6th the glide slope portion of the ILS was out of service and only the localizer was available. Because of the comments that the crew had made regarding the operational status as you saw during the course of the animation, the discussion that they had regarding the operational status of the glide slope, we became concerned what may have caused them to have this discussion.

One of the aspects that we're looking at is what we call spurious signals or radio signals that may have influenced the navigation equipment on the airplane. That is an aspect that our aircraft systems group is currently looking into.

The investigative team also examined the weather conditions as I had said earlier. At the time of the accident the reported conditions at the airportwere generally good with light winds from the east. Visibility was about seven miles in a rain shower, and there were broken clouds. However, based on data that we were able to obtain from Doppler radar, from satellite imaging, and from witnesses, we found that there was a thunderstorm on the approach end of the airport at the time that the airplane -- that Flight 801 had been traversing through and that this thunderstorm was of -- was capable of producing heavy rain and gusty winds and reduced visibility. We are also looking at that and -- from an aspect of what that may have done to influence the crew in their decision-making.

The en route and approach radar positions at Guam are typically performed by one controller using two independent radar systems. And as I had mentioned earlier, that's what we characterize or call the CERAP. Both systems are equipped -- that is, the radar systems are equipped with a Minimum Safe Altitude Warning system, as I pointed out, with the alert that you saw in the demonstration and that when the airplane exceeded the minimum altitudes or a predetermined altitude the controller would typically get this warning.

We want to know why the system was notworking as it was intended. That is one of the focal points of this investigation. And we will have witnesses that will be testifying to this issue later on in the hearing.

The Safety Board also found during the investigation that the post-accident emergency response to the accident site was delayed several minutes because the air traffic -- because the air traffic controller was not immediately aware that Flight 801 had crashed off the airport.

In addition, emergency response vehicles were delayed in arriving on the scene because access to the accident site was initially stopped by a fenced gate around the property where the airplane had crashed and then further hampered by a narrow paved road which was blocked by some emergency vehicles that were disabled thus preventing the fire trucks from getting close --into close proximity to the accident site itself.

Again, we will have witnesses that will be talking to these issues later on in this hearing.

In addition to this, the Safety Board will also be examining several other issues, including the crew's training at Korean Airlines, crew resource management or how the crew works together, and instrument approach procedures and charting. Is therea way to look at these approach procedures that the crew must follow during periods of -- of bad weather or reduced visibility that will give them better information so that we will not have what the chairman has talked about, and that is controlled-flight-into-terrain type accidents.

Although the Safety Board investigative team completed the on-site wreckage examination August 28th, 1997, several other investigative activities have either been completed or are ongoing. These in --activities involve the examination and tear-down of various electronic components, as I referenced earlier, the navigation equipment. These activities involve the study of aircraft performance, the follow-up on the MSAW system, and of course, the detection of spurious signals in the area around Guam.

In addition to the investigative activities, a meeting was convened in Guam back in January of 1998 and was attended by all of the parties. The purpose of this meeting was to review the progress of the investigation thus far, to review all of the reports that have been produced by the National Transportation Safety Board group chairman thus far, and then to determine future work items that are necessary as far as the investigation process is concerned. Since thismeeting, all of the parties and the KCAB have reviewed the factual reports and their comments have either been addressed or incorporated into the respective reports.

The issues stated by the chairman in his opening remarks and those described briefly in this statement will be addressed by witnesses that were selected based on their expertise, their extensive knowledge, or -- excuse me, or their experience as they relate to the subjects and the issues. Their testimony will provide additional factual information which the Safety Board will use in its analysis of this accident and its determination of the probable cause.

And before I conclude, Mr. Chairman, I would just like to take a moment to publicly thank some people and some organizations. First, Mr. Ham and the Korean delegation for their continuing support and assistance in the investigative process. It's been a -- a very difficult situation, especially because of the distance that we need to communicate, but we've been able to coordinate our activities and our efforts, and it's worked out thus far.

I'd also like to thank my colleagues here at the Board, the investigators that worked very diligently under very stressful conditions to get the work done in very short order given the fact that,unfortunately, we've had numerous accidents of recent late and we were all pulling double duty.

I'd also like to thank the U.S. Air Force for giving us transport to the accident site and the Navy for their cooperation and the logistical support while we were at the accident site.

And I'd also like to thank the officials and the citizens of Guam who extended the team while we were on-scene for almost a month for their generosity and their hospitality. We were -- we were treated very well there, and people pitched in and volunteered a lot of service to us and we do appreciate them.

Mr. Chairman, this concludes my remarks. The -- the record of investigation is contained in the documents in our public docket, and the court reporter has been provided a list of such materials.

CHAIRMAN FRANCIS: Thank you, Mr. Feith.

We will now go ahead and call our first witness, who is Mr. Kurt Mayo, approach controller, FAA, Guam CERAP.

Whereupon,

KURT MAYO

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF KURT MAYO APPROACH CONTROLLER FEDERAL AVIATION ADMINISTRATION GUAM CERAP

MR. SCHLEEDE: Mr. Mayo, please state your full name and business address for our record.

THE WITNESS: My name is Kurt Mayo. My business address is Guam CERAP, Anderson Air Force Base, Guam, Building 18011.

MR. SCHLEEDE: And by whom are you employed?

THE WITNESS: I work for the Federal Aviation Administration.

MR. SCHLEEDE: Okay. And what is your position at the --

THE WITNESS: I'm an air -- I'm an air traffic control specialist.

MR. SCHLEEDE: And how long have you worked as air traffic specialist?

THE WITNESS: 19 and a half years.

MR. SCHLEEDE: Could you provide us a brief summary of your training and experience that qualifies you for your present position?

THE WITNESS: I started my career as an air traffic controller in 1978 with the United States Navy. I was assigned to the Naval Air Station, Cubie Point in the Philippines where I was qualified as a full performance level controller in the radar approach control as well as the control tower. I was also qualified as the facility watch supervisor. I worked there for three and a half years.

I began my career with the Federal Aviation Administration as an air traffic controller in 1982. I was assigned to the Los Angeles Terminal Radar Approach Control where I was a full performance level controller. I worked for the Los Angeles TRACON from May 1982 until February 1994, at which time we relocated our office to San Diego, California to the Southern California Terminal Radar Approach Control.

I worked in the Southern California TRACON from February 1994 until September 1995 in the Los Angeles area as a full performance level air traffic controller.

In September 1995 I transferred to the Guam Center Radar Approach Control where I currently work as a full performance level controller until this day.

MR. SCHLEEDE: Thank you very much, Mr. Mayo. Mr. Wentworth will proceed with the questioning.

MR. WENTWORTH: Thank you, Mr. Schleede.

Good morning, Mr. Mayo. Thank you forcoming.

THE WITNESS: Good morning.

MR. WENTWORTH: Mr. Mayo, are you currently certified -- medically certified as a controller?

THE WITNESS: Yes, sir. I am.

MR. WENTWORTH: Okay. Do you have any waivers or limitations?

THE WITNESS: No, sir. I do not.

MR. WENTWORTH: And when was your last medical?

THE WITNESS: In December of 1997.

MR. WENTWORTH: Thank you.

Okay. Teddy, 3D, please?

And would you go to 3D also, Mr. Mayo, please?

(Pause)

MR. WENTWORTH: And this is a layout of the radar approach control.

(Pause)

MR. WENTWORTH: Mr. Mayo, if you'd just look at the very top of the view there. Would you please show us where you were operating and would you explain the radar systems that you had to -- to work with there?

THE WITNESS: I was working at the R4position here in front of the long-range radar scope. Directly to my right is the ASR radar scope, approximately one foot to my right. To my left is the D3 position where I have the teletype printer, flight progress strips, and this is the position where I normally answer land-line calls.

MR. WENTWORTH: Okay, sir. And where -- was the other associate at that particular time you were on duty? Was he out of the room?

THE WITNESS: Yes, sir. He was.

MR. WENTWORTH: And how would you have been expected to reach him if you needed him?

THE WITNESS: I would call him on the intercom telephone.

MR. WENTWORTH: And where was that located?

THE WITNESS: Here on the supervisor's desk behind me approximately eight feet.

MR. WENTWORTH: Okay. Did you receive or take any telephone calls while you were on duty prior to the accident?

THE WITNESS: You're referring to non-business-related calls?

MR. WENTWORTH: Yes, that's correct.

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: Or anything to do with thephone on the supervisor's desk which would have taken you away from the operation?

THE WITNESS: No, sir. I do not recall receiving any phone calls from the telephone on the supervisor's desk.

MR. WENTWORTH: Thank you.

Thank you, Teddy.

Now, when you came on duty could you tell us what was not functional while you were working?

THE WITNESS: The primary radar on the long-range radar system was out of service, and the glide slope portion of the ILS was out of service.

MR. WENTWORTH: And the impact of not having the primary, did that have anything to do with your being able to depict weather?

THE WITNESS: Yes, there was no weather depicted on the long-range radar system.

MR. WENTWORTH: However, it would have been depicted on the ASR 8?

THE WITNESS: Yes, sir, which I normally set at a 60-mile range and the long-range radar set for a 250-mile range.

MR. WENTWORTH: Was a staffing complement of two controllers on duty that morning? To your knowledge, was that a standard staffing level?

THE WITNESS: Yes, sir. It was.

MR. WENTWORTH: Now, based on your knowledge of the weather that prevailed throughout the area that morning, is that -- were those weather conditions pretty standard or -- for that time of the season or that time of the year?

THE WITNESS: Yes. During that time of the year we have frequent rain showers in the area ranging from light rain showers to heavy thunderstorms.

MR. WENTWORTH: And based on the fact that the glide slope was out of service you advised the crew that it was unusable. Is this terms relevant to air traffic control phraseology?

THE WITNESS: Yes, sir. I used the phrase exactly out of our handbook. "Glide path or glide slope unusable."

MR. WENTWORTH: In your view, did the crew acknowledge the fact that it was unusable?

THE WITNESS: Yes, sir. The pilot acknowledged my clearance by the use of the word "Roger" in addition to a partial read back of the clearance.

MR. WENTWORTH: To your knowledge, is there any requirement for you to receive every word of a clearance that you issued to a flight crew?

THE WITNESS: I must ensure that the pilot acknowledges my clearance and the pilot make acknowledge of the clearance by use of terms such as "Roger," "Wilco," "Affirmative," or other words or phrases.

MR. WENTWORTH: But if he does not parrot it back to you, in other words, speak every particular phrase that you issued and does in fact give a -- a reply with a "Roger" or the aircraft call sign or something of that nature, does that indeed constitute acknowledgement?

THE WITNESS: The word "Roger" it -- in and of itself according to our handbook means that the pilot received and understood my last clearance in its entirety.

MR. WENTWORTH: Mr. Mayo, prior to this accident did you or your colleague receive any pilot reports of any NAV/AID difficulties or outages?

THE WITNESS: No, sir. We did not.

MR. WENTWORTH: To your knowledge, did any other aircraft execute the ILS to runway 6-left and safely land?

THE WITNESS: I do not recall at this time aircraft executing an ILS prior to the Korean Airlines. The most -- closest previous arrival was 35 minutesearlier, and the aircraft executed visual approach.

MR. WENTWORTH: Now, you relieved a colleague at that position. If he had received a report of difficulties with that particular approach would he have been required to advise you of such?

THE WITNESS: Yes, sir. He would have been.

MR. WENTWORTH: And I take it that he did not?

THE WITNESS: No, I did not receive any briefing to that effect.

MR. WENTWORTH: Thank you. Are any of the NAV/AIDs that serve the Guam International Airport monitored by your facility?

THE WITNESS: In our radar room we only monitor the VOR or the VORTAC.

MR. WENTWORTH: And if an alarm occurs is there a way in which you would receive it?

THE WITNESS: The monitor provides an oral and a visual alert. Yes, sir.

MR. WENTWORTH: And during the period that you were on duty did you receive any such alarms?

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: Moving to the approach clearance that was issued to Korean Air 801, is there specific information which must be issued to the crewwhen he's cleared for a specific instrument approach procedure such as the ILS?

THE WITNESS: Generally speaking, the elements of the clearance are aircraft call sign, aircraft position, perhaps a vector, an altitude to maintain -- until established on the final approach course, and then any appropriate remarks -- including the approach clearance.

MR. WENTWORTH: And would you explain for us on the long-range radar are any of the elements of the ILS to runway 6-left at Guam depicted, such as the outer marker or the extended center line for the runway?

THE WITNESS: We have a map that we can display on the long-range radar. At the time it was not displayed on the long-range radar.

MR. WENTWORTH: Would it have been displayed on the ASR 8?

THE WITNESS: Yes, it was.

MR. WENTWORTH: It was, sir?

THE WITNESS: Yes, it was, sir.

MR. WENTWORTH: Okay. Can you tell me what the purpose or rather how the extended center line is depicted, first of all?

THE WITNESS: The extended runway center lineor the final approach course is an extension of the runway out to approximately 12 miles from the airport depicted by dashed lines in one-mile increments.

MR. WENTWORTH: Now, based on the clearance that was issued to Korean Air 801, it's noted that they were not issued an altitude to maintain. Can you tell us why that might have occurred?

THE WITNESS: I observed the aircraft established on a segment of the approach at the assigned altitude and I thought it would have been redundant.

MR. WENTWORTH: We also noted that the crew was not given their position relative to the outer marker. Can you tell us why that occurred?

THE WITNESS: No sure -- no, sir. I should have given them their position.

MR. WENTWORTH: At what point did you transition from the long-range radar to the ASR 8 in determining the position of Korean Air 801?

THE WITNESS: Well, I was continually scanning back and forth between the two radar systems. When I issued the vector for the intercept I'm certain I was looking at the short-range radar, the ASR 8, and when I switched frequencies to the Agana Tower I'm certain I was observing the aircraft on the ASR 8.

MR. WENTWORTH: At the time that you issued the approach clearance to the crew of Korean Air 801, were there any weathers of area being depicted on the terminal radar system?

THE WITNESS: Yes, sir. There was.

MR. WENTWORTH: Can you describe for us your observations?

THE WITNESS: There was an area of weather approximately from three to six miles on final -- on the approach course.

MR. WENTWORTH: That was along the approach course, sir?

THE WITNESS: Yes, sir. It was on the approach course.

MR. WENTWORTH: Did you have any idea of what the intensity level might have been?

THE WITNESS: No, sir. I did not. I had not received any information of any significant weather in the area.

MR. WENTWORTH: Did you advise the crew of Korean Air 801 about your observations of this weather?

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: Did you advise the local controller at Agana Tower about the weather?

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: Is there any requirement for you to have done so?

THE WITNESS: Yes, sir. There is.

MR. WENTWORTH: Can you tell us why that did not occur?

THE WITNESS: I assume that the flight crew was using their cockpit radar as they had twice previously asked for deviations around weather while I was working with them. And their cockpit radar is more accurate and more precise than the radar that I have.

And the tower, I -- I failed to inform them --

(Pause)

MR. WENTWORTH: All right. Mr. Mayo, when was your last observation of the target in the data block of Korean 801 on radar? When did that occur?

THE WITNESS: The last time I remember observing the data block was when I switched them to the tower. I'm certain that I scanned back to the data block at some time later. But I don't recall precisely when that might have been.

MR. WENTWORTH: When you advised the crew to go to the tower, did you look at the data block at that particular time? Is that what I understood?

THE WITNESS: Yes, sir. I did.

MR. WENTWORTH: What was the altitude of the aircraft at that time? Do you recall?

THE WITNESS: To my best memory, 2200 feet.

(Pause)

MR. WENTWORTH: Did you observe the data block on radar go into coast at any point?

THE WITNESS: No, sir. I did not.

(Pause)

MR. WENTWORTH: Prior to being advised by the local controller that he was no longer in contact with the flight, did you continue to monitor the aircraft's progress to the airport in any manner?

THE WITNESS: Yes, sir. I -- I scanned my radar scopes and I'm sure that I saw the data block at different occasions during the approach. I continued to provide radar monitoring.

CHAIRMAN FRANCIS: Richard, we're -- we're having a little trouble with the interpretation here, so if we can just slow it down a little bit just so that they can keep up, and -- and Mr. Mayo, if you could as well. It's -- it's kind of tough for those folks.

MR. WENTWORTH: Sure. I understand. Thank you.

After being told by the local controller thatthe aircraft was down, why did you believe you needed to have a confirmation from another airborne aircraft if you monitored the progress of the aircraft?

THE WITNESS: Would you please restate that?

MR. WENTWORTH: After being advised by the local controller that he was no longer in contact with Korean Air 801, why did you believe you needed a confirmation from another airborne aircraft, specifically Ryan 789?

THE WITNESS: I was fairly certain in my mind that the aircraft had crashed, but I thought it would be best and -- to get a confirmation visually, and Ryan was in a perfect position to observe the area.

MR. WENTWORTH: So, at what point did you initiate either a crash response or get your associate in the control room? What -- what -- at what point did that occur?

THE WITNESS: When the pilot of the Ryan aircraft advised me that he saw a fire on the hillside I was certain. At that time I contacted my co-worker who began making the appropriate phone calls.

MR. WENTWORTH: Well, if you felt that the aircraft had crashed before getting the confirmation, would it have been incumbent upon you to initiate some type of crash response?

THE WITNESS: Yes, sir. It may have been. I just wanted to be -- I wanted to be 100 percent sure.

MR. WENTWORTH: I'd like you to refer to Exhibit 3G, please, Mr. Mayo.

(Pause)

MR. WENTWORTH: If you would look at the --this is the facility accident incident notification record that was developed by the CERAP for which you work. And if you'll notice the second block there, it says, "Government of Guam off-base crash." Do you have specific procedures for a crash that occurs off Guam International Airport?

THE WITNESS: Yes, we do.

MR. WENTWORTH: Can you explain what those would be?

THE WITNESS: We have a checklist book at the supervisor's desk that gives us a list of what parties to call.

MR. WENTWORTH: And what -- I noticed on the next line there it says, "U.S. Coast Guard Search and Rescue." Is the response to them initiated concurrent with an off-airport crash?

THE WITNESS: The Coast Guard is always notified.

(Pause)

THE WITNESS: They assist in on-shore as well as off-shore.

MR. WENTWORTH: Did you make any of these notifications on the sheet?

THE WITNESS: No, sir. I was working the radar, and my co-worker made the calls.

MR. WENTWORTH: You will notice the times that are listed on the sheet. There is a listing for the facility manager, Mr. Cornelison, and it shows a time of 16:02. Do your procedures require that he be the first person notified in the event of an accident?

THE WITNESS: First, we should notify the Coast Guard or the search-and-rescue parties.

MR. WENTWORTH: Mr. Mayo, did you observe any visual MSAW alerts for Korean Air 801?

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: Based on the record we know that one was indeed developed. If you had observed it, where would it have been displayed as it would have been generated by the Micro-EARTS radar -- automation?

MR. WENTWORTH: Only on the long-range radar system, and the letters MSAW would flash in the lower portion of the data block as well as being displayed in the alert tab list. The call sign would be -- the call sign would be displayed in the alert tab list on thescope.

MR. WENTWORTH: And where was that particular list located on your radar scope?

THE WITNESS: The alert tab list was located at the upper and center portion of my scope.

MR. WENTWORTH: To your knowledge, sir, is there an MSAW speaker in the control room?

THE WITNESS: Yes, sir. There is.

MR. WENTWORTH: And can you tell me where that's located?

THE WITNESS: To the right of the R4 position approximately 10 to 15 feet above one of the radar scopes. It's clearly audible throughout the room from that position.

MR. WENTWORTH: Prior to be notified by the tower that he was no longer in contact with Korean Air 801 did you hear any oral MSAW alerts?

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: Prior to the day of this accident were you aware that the alert system, the MSAW was virtually non-existent?

THE WITNESS: No, sir. I was not.

MR. WENTWORTH: Prior to the day of this accident were you aware that you would not receive an oral MSAW alert from the Micro-EARTS system?

THE WITNESS: No, sir. I was not.

MR. WENTWORTH: Do you provide approach control services to other airports?

THE WITNESS: Yes, we do.

MR. WENTWORTH: Other than Guam International?

THE WITNESS: Yes, sir. We do.

MR. WENTWORTH: For instance, which airports, sir?

THE WITNESS: Anderson Air Force Base, which is located on the island of Guam; Rhode International Airport; Tinion and Saipan International Airport.

MR. WENTWORTH: Can you tell me what a safety alert is, Mr. Mayo?

THE WITNESS: A safety alert is an --advisory to an aircraft to alert them of a situation which may be unsafe.

MR. WENTWORTH: In what response -- in what -- in what level of hierarchy of -- in your job does that particular function fall?

THE WITNESS: It along with separation is a first priority.

MR. WENTWORTH: Do you consider issuing --excuse me, sir. Do you consider MSAW in itself, this particular function, as a safety feature?

THE WITNESS: Yes, sir. I do.

MR. WENTWORTH: In your view as a controller, do you believe that MSAW provides protection for you in doing your job?

THE WITNESS: Protection for me?

MR. WENTWORTH: For yourself.

THE WITNESS: It assists me in doing my job.

MR. WENTWORTH: Can you amplify how it would assist you?

THE WITNESS: It alerts me to situations which may be unsafe so that I can alert the crew members or the controller who's in control of the aircraft.

MR. WENTWORTH: To your knowledge, is MSAW now working at Guam?

THE WITNESS: Yes, sir. It is.

MR. WENTWORTH: I don't believe I have any further questions. Thank you.

CHAIRMAN FRANCIS: All right. We'll now go to the party questioning of Mr. Mayo, and we'll start with the Korean accredited representative. It'll take us a second here so all of us can get our headsets on.

(Pause)

CHAIRMAN FRANCIS: You all right, Mr. Mayo? You okay?

THE WITNESS: Yes, sir.

CHAIRMAN FRANCIS: All right. Korean CAB?

MR. LEE: Mr. Chairman, thank you very much. And ladies and gentlemen, thank you very much. Mr. Kurt Mayo, thank you very much.

(The following is a verbatim transcript of the English translation of Mr. Lee's questions posed in Korean and Mr. Mayo's responses in English.)

MR. LEE: Are there seven positions at the Guam Control Tower, including CERAP coordinator approach control, oceanic, and domestic?

THE WITNESS: No, sir. There are six.

MR. LEE: If that is the case, then when approach clearance was issued for KAL 801, were you, Kurt Mayo, there on your own, by yourself?

THE WITNESS: There were two persons on duty.

MR. LEE: Okay. Then, you two started to work together. However, the other controller was on duty only an hour then went on break. Is that what happened?

THE WITNESS: I'm not certain of the amount of time that he worked prior to his break.

MR. LEE: Regarding the breaks at your control center, is there any formalized way of taking duties on a shift basis, such as a staggering fashion,or is it that you can take a break at any time of your choosing?

THE WITNESS: The breaks are based on the traffic load, the number of persons assigned to the shift, and it's normally controlled by the supervisors or the controller-in-charge.

MR. LEE: When the approach clearance was issued for KAL 801, were both radars used, one for en route and the other for approach control?

THE WITNESS: Yes, sir. I was scanning back and forth between both radar scopes, the long-range and the short-range.

MR. LEE: When approach clearance was issued, I understand there were eight aircraft which received approach clearance. Of the eight, how many were given clearance using the en route radar and how many using the approach control?

(End of translation)

CHAIRMAN FRANCIS: Could we -- excuse me. Could we stop for a minute, please? We've got two things. Number one, the court reporter is having a problem here, and let's get that clarified because that's the official record. So, what -- what do we need to do here, Carolyn?

(Pause)

CHAIRMAN FRANCIS: Please be back -- it's now 10:30 -- at 10:45. We'll make it a 15-minute break.

(Whereupon, a brief recess was taken.)

CHAIRMAN FRANCIS: We'll resume the -- the KCAB, still questioning Mr. Mayo. And go ahead, gentleman.

(The following is a verbatim transcription of the English translation of Mr. Lee's questions posed in Korean and Mr. Mayo's responses in English.)

MR. LEE: On the previous occasion in connection with your working system at your control tower following the accident, the work system that you had set up might have been changed. If the -- if that was the case, if there were any changes, can you tell us what actions you take following the accident?

THE WITNESS: The MSAW system was changed.

MR. LEE: FAA Order 7110.65K. According to the regulation of said FAA Order there are such provisions. Let me read. "If -- is this -- if altitude heading or other items are read -- are read back by the pilot ensure the read-back is correct. If incorrect or incomplete make corrections as appropriate."

However, with respect to the accident aircraft, Korean Air Aircraft, when you were issuingapproach clearance you -- Korean Air 801 -- Korean 801 cleared for ILS runway 6-left approach, glide slope unusable. When you said that the -- the Korean Air pilot read back just simply, quote, "Korean 801, roger. Cleared for ILS runway 6-left," quote. As the result, the glide scope -- "glide slope unusable" section was not read back. Did you notice that and correct that?

THE WITNESS: Yes, sir. I noticed that. I only need to correct the read-back if the pilot's read-back was incorrect. Nothing that he read in his read-back was incorrect. And the use of the term "Roger" in and of itself is sufficient. The word "Roger" according to the pilot controller glossary in our handbook means that the pilot has received and understands my last clearance in its entirety.

CHAIRMAN FRANCIS: And I would say again Mr. Mayo has already been asked this question and answered it to Mr. Wentworth.

MR. LEE: Okay. Let me then move on to one more question.

FAA Order 7110.65K 5-1-17, radar service termination. According to the said regulation radar service termination should be notified to the accident aircraft. That is my understanding. Did you actually do that to the accident aircraft?

THE WITNESS: Would you please restate the question?

MR. LEE: FAA Order -- according to FAA Order 7110.65K, air traffic control paragraph 51-13, radar service termination. According to the provisions of the regulation, CERAP power controller should notify radar service termination to the accident aircraft. And what I asked you just now is that whether you performed that obligation.

THE WITNESS: The section also reads that radar service is automatically terminated and the pilot not -- need -- need not be advised when the aircraft lands. Radar service is automatically terminated and the pilot need not be advised when the aircraft lands.

MR. LEE: Just bear with me. Let me have time to just ask two more questions.

Agana Tower D-BRITE increment was established as of January 1997. Were you aware of that?

THE WITNESS: I am aware that the Agana Tower has a D-BRITE.

MR. LEE: And then let me ask you the final question. At the time of the accident 15:32 hours there was official weather advisory. With respect to this official weather advisory measurement, did you receive any notification from the Agana Control Tower?

THE WITNESS: No, sir. I did not.

MR. LEE: Okay. Then let me follow up on that question to ask you whether you received any such weather advisory notification from any other organizations, including the Weather Bureau?

THE WITNESS: No, sir. I did not.

MR. LEE: At the CERAP are there any -- any receiving increment to receive meteorological information?

THE WITNESS: Yes, sir. There -- there is. There's a teletype printer and also a weather television monitor.

MR. LEE: FAA Order 7110.65K 4-7-8, weather information regulation. According to the provisions set forth in this particular regulation, the controller -- when there is official weather or meteorological advisory either the controller is supposed to issue instrument landing clearance or issue notification based on that. At that time did you notify the pilot of the accident aircraft, Korean Air aircraft such notice?

THE WITNESS: -- the questions.

MR. LEE: The controller, when he receives or recognize a special weather advisory prior to issuing instrument landing clearance, he should notify thepilot of the special weather advisory status or information or to include such information within such instrument landing clearance. That is the regulation. Did you ever notify the Korean Air pilot of any such special weather advisory information?

THE WITNESS: No, sir. I did not. I was not aware of any special weather or significant weather in the area.

MR. LEE: Thank you very much. That's all.

(End of translation)

CHAIRMAN FRANCIS: Thank you.

Boeing Company?

MR. DARCY: Thank you, Mr. -- excuse me, Mr. Chairman. We don't have any questions for the witness.

CHAIRMAN FRANCIS: Thank you.

Barton ATC?

MR. E. MONTGOMERY: No, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Yes, thank you, Mr. Chairman.

Mr. Mayo, in your almost 20 years experience as an air traffic controller in the Navy, Los Angeles approach, and now Guam CERAP, has it been a fairlycommon experience --

CHAIRMAN FRANCIS: Excuse me. Slower, please. Controllers -- we understand the controller's business is to speak fast, but here you've got to sort of work in reverse.

MR. MOTE: Yes, sir. Thank you, Mr. Chairman.

In your experience, is it a common daily occurrence for flight crews to read back clearances and acknowledge clearances, particularly with respect to approach clearances with terms such as "roger" and perhaps with partial acknowledgement of elements of that clearance?

THE WITNESS: Yes, sir. It is.

MR. MOTE: Thank you. And also, in your experience as a controller, do you operate with the daily anticipation -- in other words, is it your expectation that flight crews that are coming into your air space will comply with the FARs by familiarizing themselves with NOTAMs and equipment outages affecting their flight? Do you operate with that expectation?

THE WITNESS: Yes, sir. I do.

MR. MOTE: And based on the answer to that --

CHAIRMAN FRANCIS: Slowly. Slowly.

MR. MOTE: Sorry.

And based on that answer, given the fact that you expect the crews to be familiar with outages and other things affecting the condition of that flight and given the fact that you ensured that the flight crew had or was receiving the ATIS uniform in effect at the time, which broadcast the glide slope outage, and given the fact that you issued the handbook phraseology "glide slope unusable" in the approach clearance, was there any doubt in your mind that this crew should have been aware that the glide slope was not in service at the time the approach clearance was issued?

THE WITNESS: No, sir. There was not.

MR. MOTE: Okay. Thank you.

That's all, Mr. Chairman. Thank you very much.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: No questions, sir.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Thank you, Mr. Chairman.

Mr. Mayo, just two short questions. What would you characterize your workload as at the time of the accident?

THE WITNESS: Light to moderate.

MR. DONNER: And the complexity of the situation at that time?

THE WITNESS: I'd characterize the complexity as routine.

MR. DONNER: Thank you very much. Thank you, sir.

CHAIRMAN FRANCIS: All right. Thank you. That completes the parties.

Mr. Feith, you got anything further?

MR. FEITH: I just have a couple of questions, sir.

Mr. Mayo, with regard to the MSAW, have you received any formal training on the MSAW in your position?

THE WITNESS: I've received courses and I feel that I've been well-trained in MSAW. I know what it is, I know how to use it.

MR. FEITH: Can you just characterize for me the type of training that you would have received? Was it videos? Was it hands-on? Was it book work?

THE WITNESS: Written courses as well as videos.

MR. FEITH: How long a training period is that? A day? A month? A year? How much training?

THE WITNESS: Each session may last for 30 to 60 minutes.

MR. FEITH: And with regards to recurrenttraining, do you receive recurrent training?

THE WITNESS: Yes, we do.

MR. FEITH: Prior to the accident had you received training on MSAW?

THE WITNESS: Yes, I had.

MR. FEITH: And subsequent to the accident have you received training on MSAW?

THE WITNESS: No, sir. I have not.

MR. FEITH: I have no further questions, Mr. Chairman.

CHAIRMAN FRANCIS: Pat?

MR. CARISEO: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: I -- I'd -- I'd like to clarify one thing here. And this is something that's come up as -- during your testimony. This is the question of the difference between out of service and unusable, if there is a difference, in terms of the glide slope. When one reads the NOTAM, and you may not be the -- the person to answer this question, but the NOTAM says out of service. You said when you gave the clearance to the -- to the aircraft unusable. Is there, to your knowledge, a difference in these or is that effectively the same thing?

THE WITNESS: It's effectively the same thing.

CHAIRMAN FRANCIS: All right. Thank you. We appreciate your being here with us, and I understand you have to leave so that you will not be subject to perhaps coming back. We -- we do appreciate your coming and being with us.

THE WITNESS: Thank you.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: The next witness is Mr. Marty Theobald, local controller, Barton ATC.

Whereupon,

MARTY THEOBALD

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF MARTY THEOBALD LOCAL CONTROLLER BARTON ATC INTERNATIONAL, INC. AGANA CONTRACT AIR TRAFFIC CONTROL TOWER

CHAIRMAN FRANCIS: Mr. Wentworth?

(Pause)

CHAIRMAN FRANCIS: Oh, I'm sorry.

MR. SCHLEEDE: Mr. Theobald, please state your full name and business address for our record.

THE WITNESS: Marty Theobald. 202 --correction. 2024 Piper Avenue, Pocatello, Idaho.

MR. SCHLEEDE: And what is your present position? Work position?

THE WITNESS: I'm an air traffic control specialist for Barton ATC International, Incorporated, and I'm currently in training at that location.

MR. SCHLEEDE: Could you move just a little closer to the microphone, please?

THE WITNESS: Yes, sir.

MR. SCHLEEDE: Could you give us a brief description of your education and training and experience that -- qualifies you for your present position?

THE WITNESS: Yes, sir. I began my air traffic control experience with the United States Navy in 1983. I completed the air traffic control basic course in October of that year.

I was subsequently stationed in -- at an approach control facility in Texas. I was qualified as a ground controller and a flight data controller in the tower there as well as full facility rated in the radar facility.

I transferred from there in April of '89 and arrived in May in Guam at Naval Air Station, Agana, Guam. Subsequently, complete facility rated there both route -- and tower and radar. I also servedapproximately six months as the radar branch manager there.

April of '92 I was reassigned to the air traffic control facility officer as an administrative assistant until my separation from Navy in October of '92.

I was hired by Barton Air Traffic Control, Incorporated -- I'm sorry. Barton Air Traffic Control International, Incorporated in May of '95 as an air traffic control specialist in Guam International Control Tower, which was the former NAS Agana Tower.

January of this year we had a opening at another facility and I requested a transfer. And I did transfer in February, and I'm in training now.

MR. SCHLEEDE: Thank you very much. Mr. Wentworth will proceed.

MR. WENTWORTH: Thank you, Mr. Schleede.

Mr. Theobald, you said that currently you're in Pocatello, Idaho?

THE WITNESS: Yes, sir.

MR. WENTWORTH: When did you transfer from Guam?

THE WITNESS: In February of this year.

MR. WENTWORTH: Was this at your request?

THE WITNESS: Yes, sir. It was.

MR. WENTWORTH: Are you medically --certified as a controller, sir?

THE WITNESS: Yes, sir. I am.

MR. WENTWORTH: Do you have any waivers or limitations?

THE WITNESS: No, sir.

MR. WENTWORTH: And when was your last physical, please?

THE WITNESS: October of last year, sir.

MR. WENTWORTH: And at the time that you were working in the tower on the night of this -- accident you were a fully certified controller at that time?

THE WITNESS: Yes, sir. I was.

MR. WENTWORTH: To your knowledge, is it standard procedure to work that particular shift by yourself?

THE WITNESS: Yes, sir. It is.

MR. WENTWORTH: Can you explain what the procedures would have been for taking a break to go to the bathroom or something like that?

THE WITNESS: You would normally wait until the traffic permits. You would coordinate with Guam CERAP that you would be out of the tower momentarily. You would also coordinate with airport authority's ramp control to let them know you would be out of the towershould an aircraft call on either ground or tower frequency. And you would take a hand-held with you when you went down to the facilities.

MR. WENTWORTH: Having seen this coordination take place, is it fair to say that you remained in the tower while you were on duty prior to the time of the accident?

THE WITNESS: Yes.

MR. WENTWORTH: Teddy, can you put up 3E for us, please?

(Pause)

MR. WENTWORTH: Mr. Theobald, this is a layout of the control tower. Can you tell us where you were primarily located during the course of the shift?

THE WITNESS: Primarily in this location, sir. In front of the local control position.

MR. WENTWORTH: Okay, sir. And to orient us of the view of the tower cab in relation to the runways, could you tell us where those would generally be?

THE WITNESS: Yes, sir. The runways would be located on this side.

MR. WENTWORTH: So your scan would be from your left to your right?

THE WITNESS: Yes, sir. The approach end ofrunway 6 would be this direction.

MR. WENTWORTH: Okay. And from the tower cab, where is the crash/fire/rescue station located?

THE WITNESS: Sir, it would be located on this portion over in here.

MR. WENTWORTH: Off to the right.

THE WITNESS: Yes, sir. Off to the right in the local control position.

MR. WENTWORTH: Now, would you point out for us the D-BRITE radar displays?

THE WITNESS: Yes, sir. There's one located here and there's one located here as well.

MR. WENTWORTH: Would you point out where the crash/fire/rescue phone is?

THE WITNESS: The crash phone would be located right here, sir.

MR. WENTWORTH: Could you show us where the monitor panel for the ILS six-left is?

THE WITNESS: Be located right here.

MR. WENTWORTH: And where do you receive your weather? 1">

THE WITNESS: Comes in via a printer located right here, sir.

MR. WENTWORTH: Okay. Right --

THE WITNESS: I'm sorry. It would be righthere.

MR. WENTWORTH: And then the ATIS recording station is just above that, is that correct?

THE WITNESS: Yes, sir. That would be ATIS.

MR. WENTWORTH: And where is the phone for the search and rescue?

THE WITNESS: We have a line that is located over in this that is a coordination line with the Coast Guard.

MR. WENTWORTH: Thank you.

Thank you, Teddy.

(Pause)

MR. WENTWORTH: Can we bring up the lights? Thank you.

Would you pull out Exhibit 3H, hotel, please?

(Pause)

MR. WENTWORTH: My correction, Marty. That's 3 foxtrot.

THE WITNESS: I'm sorry?

MR. WENTWORTH: 3 foxtrot. 3F.

THE WITNESS: Foxtrot?

(Pause)

MR. WENTWORTH: Okay. Sir, on page -- the first page here we see two ATIS messages.

THE WITNESS: I'm -- I'm sorry. I can't hearyou, sir. I can't hear you.

MR. WENTWORTH: On the first page there are two ATIS -- there's two messages here, weather sequences which appear to be marked U and V.

THE WITNESS: Yes, sir. The U and the V would be the letter for the phonetic alphabet of that ATIS broadcast.

MR. WENTWORTH: So, were those annotations made by you?

THE WITNESS: Yes, sir. That is my writing.

MR. WENTWORTH: If you'd look on the last page we have the sequence from the National Weather Service, and it would appear there's a mark on about the fourth one down. That particular sequence seems to be the same as the ATIS broadcast Uniform that you developed.

And then at the next mark further down at 02:04 if you see that, Marty, on that last page?

THE WITNESS: Yes, sir.

MR. WENTWORTH: It appears that that sequence is the same as ATIS broadcast Victor.

THE WITNESS: Yes, sir.

MR. WENTWORTH: Okay. Now, it appears here in looking at the last page there are two specials, one issued at 01:32, 01:47, 0 -- the hourly at 01:50, andthen a -- an additional three specials there.

THE WITNESS: Yes, sir.

MR. WENTWORTH: Can you tell us why these particular broadcasts or this weather was not disseminated by you as the local controller?

THE WITNESS: Sir, the special observation with the time of 01:32, I was in the process of recording that broadcast when CERAP called me with an in-bound which stopped me in the middle of that -- that recording. I went back to the recording and was in the process of checking it for correctness when the Korean Air aircraft checked in with me.

The ones beyond that were during the period when I was attempting to locate the aircraft and I was performing higher priority duties than the weather at that point.

MR. WENTWORTH: Are you certified to determine the prevailing visibility?

THE WITNESS: Yes, sir. I am.

CHAIRMAN FRANCIS: And in Guam in particular on -- on this accident?

THE WITNESS: I'm sorry?

MR. WENTWORTH: At Guam in particular during the time of this accident?

THE WITNESS: Yes, I was.

MR. WENTWORTH: At what point does the tower assume responsibility for determining prevailing visibility?

THE WITNESS: If the visibility drops below five miles, sir.

MR. WENTWORTH: With the hourly weather sequence we see the visibility being reported as three statuate miles. And then it reduces down to one, back up to two, and then back to four. Did you make any of these determinations of prevailing visibility?

THE WITNESS: No, sir. At that point I was involved in coordination reference the air -- accident aircraft and was searching for the aircraft as well.

MR. WENTWORTH: So, these would have been visibility at the surface as determined by the weather -- National Weather Service?

THE WITNESS: Yes. Those would be their determinations on visibility, sir.

(Pause)

MR. WENTWORTH: And if you'd look on page two of these sequences.

THE WITNESS: F2?

MR. WENTWORTH: F2, yes. That's correct, Marty.

There is a time of receiving 15:25 and then atime apparently of the sequence 15:32. There appears to be a disparity there. Can you explain what was occurring?

THE WITNESS: I believe that that time in the -- the receiving time there is a time that's set in the system itself, the actual printer in the tower cab. It appears to be that the -- the clock on that was not correct.

MR. WENTWORTH: Is there a way that you had to set that or check that?

THE WITNESS: No, sir. We're not allowed to set any equipment or make any adjustments to any equipment in the control tower.

MR. WENTWORTH: Okay. Thank you.

(Pause)

MR. WENTWORTH: Go to 3 X-ray, page 12.

(Pause)

THE WITNESS: Yes, sir. I have that.

MR. WENTWORTH: Okay. This is the maintenance log for the glide slope at Guam. In the upper right-hand corner it's marked June 1997. However, in the middle of the page it's carried on to July of 1997. Do you see that?

THE WITNESS: Yes, sir. I do.

MR. WENTWORTH: I'd like to direct yourattention to the July entry of the 7th where it says that the glide slope is out of service, to replace the building coordination with ATCT, and then in parens (Marty), and then the MCC and in parens, (TC). The "Marty" that's being referred to on this particular log, was that you?

THE WITNESS: I would have -- correction. It appears to be, yes, sir. I'm the only Marty that works in the control tower.

MR. WENTWORTH: Okay, sir. So then you did have knowledge that the glide slope was out of service?

THE WITNESS: Not at that point, sir. I was on vacation then in the United States mainland on 7 July.

MR. WENTWORTH: So, then somebody had to be mistaken when they put your name down here, is that correct?

THE WITNESS: Yes, sir. It appears that way.

MR. WENTWORTH: All right. Does the tower issue NOTAMs?

THE WITNESS: I'm sorry?

MR. WENTWORTH: Does the tower issue NOTAMs?

THE WITNESS: No, sir. We do not.

MR. WENTWORTH: Do you know who does?

THE WITNESS: I believe it would be GuamAirport Authority or the FAA Airways Facilities people or Maintenance Coordination Center in Honolulu.

MR. WENTWORTH: Okay. You pointed out for us earlier the monitor panel for the ILS to runway 6-left.

THE WITNESS: Yes, sir.

MR. WENTWORTH: In the event of a failure of either the glide slope or the localizer -- that is the two components that you would monitor, is that correct?

THE WITNESS: Yes, sir.

MR. WENTWORTH: Would you receive any type of an alert?

THE WITNESS: Yes, sir. There would be a visual actual change from one color light to another as well as an audible tone.

MR. WENTWORTH: Now, did you receive any type of audible alerts or visual alerts for the glide slope or the localizer that morning?

THE WITNESS: When I arrived to work to the best of my knowledge the glide slope was already in a failed position. A red light in the localizer was in the green, which would be the operational position.

MR. WENTWORTH: However, you were aware at that particular point the glide slope was indeed out of service, is that correct?

THE WITNESS: Yes, I was.

MR. WENTWORTH: During the time that you were on shift did you receive any reports from pilots of any problems with NAV/AIDs that serve the airport?

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: When Korean Air 801 was in-bound to the airport did you observe the flight?

THE WITNESS: No, sir. I never did see the aircraft.

MR. WENTWORTH: Did you know why you were not able to see the airplane?

THE WITNESS: No, sir.

MR. WENTWORTH: Did there become a point at which you believed you should have been able to see the airplane?

THE WITNESS: Yes, sir.

MR. WENTWORTH: And can you tell us when that was?

THE WITNESS: It would have been approximately three to four minutes after I cleared the aircraft to land.

(Pause)

MR. WENTWORTH: If you would, Marty, go to 3 India, page 13.

(Pause)

THE WITNESS: Yes, sir.

MR. WENTWORTH: -- to the left on the page, paragraph 3-10-7. Landing clearance without visual --

THE WITNESS: I'm sorry. What -- what paragraph, sir?

MR. WENTWORTH: 3-10-7 on page 13.

(Pause)

THE WITNESS: Yes, sir.

MR. WENTWORTH: Okay. You see that to the left?

THE WITNESS: Yes, sir.

MR. WENTWORTH: Landing clearance without visual observation?

THE WITNESS: Yes, sir.

MR. WENTWORTH: We note that in the transcript that the flight was not told that they were not in sight. Can you tell us why they were not advised of this?

THE WITNESS: As this states, when an arriving aircraft reports a position where he should be seen but has not been visually observed, and I don't believe he was in a position where I should have visually seen him when he checked in with me.

MR. WENTWORTH: And based on what, sir?

THE WITNESS: The distance of the aircraft from the airport on the initial call from CERAP withthe in-bound and his position distance from the airport being to the west to 12 miles.

MR. WENTWORTH: You heard the earlier testimony of Mr. Mayo that there was weather along the final approach course between the flight and the airport?

THE WITNESS: Yes, sir. I have.

MR. WENTWORTH: Had you known that weather was out there would you have done anything differently?

THE WITNESS: Yes, sir. I would have.

MR. WENTWORTH: Could you amplify?

THE WITNESS: I would have immediately on initial contact with the aircraft I would have read him the weather observation that I was attempting to record at the time. And I -- if I had known that cell was there I would have issued that information to the aircraft as well to be sure that he had the information.

MR. WENTWORTH: And another point that I'd like to make, when you said that the monitor panel had a red light for the glide slope, what was being shown on the localizer? What did you receive on that?

THE WITNESS: On the status panel, sir?

MR. WENTWORTH: Yes, sir. On the status panel.

THE WITNESS: Yes, the glide slope was in the red, which would be the alarm position, and the localizer was in the green, which would be the go indicator, operational.

MR. WENTWORTH: Thank you. At what point did you become concerned about Korean Air 801?

THE WITNESS: As I said before, approximately three to four minutes after I issued him his landing clearance he was not visible and not over the approach into the runway.

MR. WENTWORTH: And so, then what did you do?

THE WITNESS: I commenced a communication search for the aircraft.

MR. WENTWORTH: Which included calling the ramp?

THE WITNESS: Yes, sir. It did.

MR. WENTWORTH: From the tower cab how far are the runway out in front of you?

THE WITNESS: Approximately one-quarter mile, sir.

MR. WENTWORTH: Can you normally hear aircraft landing in the -- and taking off?

THE WITNESS: Yes, sir. You can.

MR. WENTWORTH: After you called the CERAP and was told by them that the aircraft was no longer onradar, why did you call Anderson Air Force Base?

THE WITNESS: To ascertain whether or not the aircraft had possibly landed there, sir.

MR. WENTWORTH: Have you ever had a commercial air carrier land at Anderson inadvertently?

THE WITNESS: No, sir. It has not happened to me personally.

MR. WENTWORTH: Has it ever happened to your knowledge?

THE WITNESS: When I got to Guam it was one of the things in my training that they cautioned me on, that it had happened prior.

MR. WENTWORTH: Do you know whether this occurred during the day or -- or during -- at night?

THE WITNESS: I'm not sure if that was a day -- during the day or at night.

MR. WENTWORTH: In your view, was there a reluctance on your part to initiate a crash response?

THE WITNESS: No, sir. Not once I had some actual evidence and -- and a position and a location to send someone to.

MR. WENTWORTH: So you felt like you had to have a location before you could send vehicles out to nowhere?

THE WITNESS: Yes, sir.

MR. WENTWORTH: I see. And you pointed out for us earlier there's a crash -- a search-and-rescue phone on the tower cab. Did you use that in any manner?

THE WITNESS: No, sir. I did not.

MR. WENTWORTH: And why not?

THE WITNESS: We don't have an established procedure for using that for search-and-rescue type information. That's normally a line that's used for coordination between the Coast Guard and us, normally in-bound calls to the tower.

MR. WENTWORTH: And that's how you've seen it used?

THE WITNESS: Yes, sir.

MR. WENTWORTH: For an off-airport crash, do you still retain responsibility to initiate the crash/fire/rescue response?

THE WITNESS: Yes, sir. I would make the notification as soon as I become aware of it to ramp control, which would then make the notifications to the appropriate Government of Guam agencies.

MR. WENTWORTH: And now I'd like you to go to 3H, please, Marty. This is the facility accident incident notification record.

(Pause)

THE WITNESS: I'm sorry. I don't have that.

(Pause)

THE WITNESS: Thank you. Yes, sir.

MR. WENTWORTH: At the first entry there at the top of the page it shows a time, and would you tell us what time that is?

THE WITNESS: 15:58 --

MR. WENTWORTH: And then there's initials. Who is that -- those initials?

THE WITNESS: Those are my initials behind that.

MR. WENTWORTH: T.O. is your initials?

THE WITNESS: Yes, sir. Those are my operating initials.

MR. WENTWORTH: And the recipient was Juan --does it appear?

THE WITNESS: Yes, sir.

MR. WENTWORTH: So, is this handwriting yours?

THE WITNESS: Yes, sir. That is.

MR. WENTWORTH: And when this entry was made, from where did you derive the time?

THE WITNESS: From my directory digital clocks in the tower on the local control position.

MR. WENTWORTH: Was it marked or annotatedconcurrent with the time you made the call?

THE WITNESS: I'm sorry?

MR. WENTWORTH: Was it marked concurrent with the time that you made the call?

THE WITNESS: Yes, sir.

MR. WENTWORTH: You showed us earlier that from the tower you were able to see the crash/fire/rescue -- the crash/fire station?

THE WITNESS: Yes, sir.

MR. WENTWORTH: After you made the notification did you see any of those trucks leave?

THE WITNESS: Not to my knowledge.

MR. WENTWORTH: During the duration of the time you were in tower?

THE WITNESS: No, sir.

MR. WENTWORTH: Do you know whether they have a requirement to leave the station for off-airport crash?

THE WITNESS: That would be based on the Airport Authority's releasing them, to my knowledge.

MR. WENTWORTH: Mr. Theobald, what -- what is a safety alert?

THE WITNESS: A safety alert would be a -- an alert that you would issue to an aircraft if you were aware that he is too close to terrain, obstructions, oranother aircraft.

MR. WENTWORTH: Have you received any formal training on MSAW?

THE WITNESS: During wash -- which portion of my career, sir?

MR. WENTWORTH: While you've been with Barton.

THE WITNESS: No, sir.

MR. WENTWORTH: During what portion have you received training?

THE WITNESS: When I was an approach controller in -- when I was stationed in Texas we had an MSAW system there and I had some training there for it, sir.

MR. WENTWORTH: So you basically know what it is?

THE WITNESS: Yes, I understand what the system is.

MR. WENTWORTH: Okay. Had you been told by the CERAP controller to issue a safety alert to Korean Air 801, what would you have done?

THE WITNESS: I would have issued the low altitude alert, check your altitude immediately, to the aircraft.

MR. WENTWORTH: I believe I have no furtherquestions. Thank you.

CHAIRMAN FRANCIS: KCBA -- does KCAB?

(The following is a verbatim transcript of the English translation of Mr. Lee's questions posed in Korean and Mr. Theobald's responses in English.)

MR. LEE: You have pretty much covered all the questions that we originally intended to, so let me just touch up on several simple issues.

(Disruption in recording)

THE WITNESS: -- pilot report or notification from the FAA -- personnel -- was not operational.

MR. LEE: Let me just confirm one more thing. On January 16, 1997, at Agana Tower there were two D-BRITEs installed at the Agana Control Tower. Up until -- up to the moment of accident, for about six months, for 24 hours around the clock the two D-BRITEs were turned on. Did you ever actually use the increment -- D-BRITE increment? If you ever did, then please let me know, particularly with respect to the accident? Have you ever utilized D-BRITE system in connection with this accident?

THE WITNESS: No -- no, I did not use --utilize that system as it is not a certified system and it is not an operational piece of equipment.

(End of translation)

CHAIRMAN FRANCIS: Barton ATC?

MR. E. MONTGOMERY: I have no questions, Mr. Chairman.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Yes, sir. I just have a couple questions. And the first one's by way of clarification. I'm sorry I missed your answer, Marty.

At 01:58 you notified who?

THE WITNESS: Ramp Control, I'm sorry.

MR. DERVISH: Is there a notification list that you have for notification or do you just call Ramp Control?

THE WITNESS: Yes, sir. We do have a notification list. That would be the exhibit that I was looking at at the time, 3 Hotel.

MR. DERVISH: And who else did you notify?

THE WITNESS: My next call was to the facility and the air traffic manager, and then we commenced with the -- I commenced with my portion of this as I was able to with other things that were going on with coordination.

MR. DERVISH: So you -- you did contact 911 and those --

THE WITNESS: I'm sorry?

MR. DERVISH: Who contacted 911?

THE WITNESS: It was not I. I don't know.

MR. DERVISH: And just by way of clarification again, and I might have missed it, did you say the clock might have been wrong in the tower? Or did I miss that?

THE WITNESS: That would be the printout clock for the weather --

MR. DERVISH: Oh.

THE WITNESS: -- received time.

MR. DERVISH: Okay. But you have a clock there that would have the accurate times for these notifications?

THE WITNESS: Yes, sir.

MR. DERVISH: Okay. Thank you.

THE WITNESS: You're welcome.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman.

You stated in your answers to Mr. Wentworth a few moments ago that had the approach controller advised you of weather off -- on the final with regard to Korean Air you would advised the pilot of the -- of the special ATIS observation that you had, is that correct?

THE WITNESS: Yes.

MR. MOTE: The special weather at 01:32 --let me refer, by the way, to Exhibit 3 Foxtrot or the 01:32 special observation page, that form.

(Pause)

THE WITNESS: Which page?

MR. MOTE: It's page F4.

THE WITNESS: Yes.

MR. MOTE: Do you see the approximately four lines down -- five lines down from the top, the special Guam observation, 01:32?

THE WITNESS: Yes.

MR. MOTE: There are rain showers or showers depicted on that special weather observation. Do you see that?

THE WITNESS: Yes, sir. I do.

MR. MOTE: I'm curious to know why you would advise the flight crew of showers on the final if the approach controller told you that but why you would not advise them when you have a hard copy showing showers in the vicinity of the airport. What -- what's the difference?

THE WITNESS: The showers that are located here are not on the final approach course, sir.

MR. WENTWORTH: So, you're -- so you're specifically relating it to the final, is that correct?

THE WITNESS: No, sir. What I -- the reasonI would have passed that information would have been the ceiling information.

MR. MOTE: Okay. Thank you, Mr. Chair.

CHAIRMAN FRANCIS: Korean Air?

(The following is a verbatim transcript of the English translation of Captain Kim's questions posed in Korean and Mr. Theobald's responses in English.)

CAPTAIN KIM: Yes, let me ask one question. I'm with the Korean Airlines.

Of the questions that are asked by ATC chairman special weather conditions, why it was not notified to the aircraft -- pilot, the witness said the reason was called --

(Pause)

CHAIRMAN FRANCIS: I think we've got a problem -- hang on just a second.

(Pause)

CHAIRMAN FRANCIS: Go ahead.

CAPTAIN KIM: Among the questions asked by the chairman, the special weather conditions advisory which is not notified of the pilot and the -- why such notification was not done. The witness answer was that it was because of radar recording matters. Was it also -- would it be interpreted as -- would it be reasonableto interpret your answer as the -- the tasks that you were performing -- you alone were performing were too demanding on any one person?

THE WITNESS: I'm not sure I understand the question as it was stated.

CAPTAIN KIM: Okay. Then, my assistant will ask the question in English.

FIRST OFFICER CHUNG: You -- one of your answers implied that the -- the reason the special observation was not transmitted to the pilot was because you were interrupted in the process, and we're asking if that -- if your answer implies in any way that at particular times during your shift your tasks might be too much for one person. Is that question clear, sir?

THE WITNESS: Yes, it is. And the answer would be no, I don't believe it's too -- too much for one person.

FIRST OFFICER CHUNG: Thank you.

CHAIRMAN FRANCIS: Do you have another question?

CAPTAIN KIM: No. Thank you very much.

(End of translation)

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: Thank you, sir. We have noquestions.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Thank you, Mr. Chairman. We have no questions.

CHAIRMAN FRANCIS: Greg?

MR. FEITH: I just have one question regarding the weather, and that is in reading the transcript when Ryan was turning onto the localizer coming in-bound and was asked whether they had seen 801 and they were describing or in the process of looking for the aircraft, they stated that they went -- they just went IMC. And they -- they lost the airport. Did you do anything to get them to provide you a prep of some sort or any update to the weather given the fact that they just went IMC, which apparently wasn't the same condition at the airport? Was there any attempt to update the weather out there that you could provide to following aircraft?

THE WITNESS: I wasn't aware that they went IMC. They were not on my frequency when they were searching for the aircraft.

MR. FEITH: Okay. Thank you.

CHAIRMAN FRANCIS: Pat?

MR. CARISEO: No question.

CHAIRMAN FRANCIS: Ben?

MR. BERMAN: Mr. Theobald, you testified that you didn't make the crash call until you knew a position and location for the crash to send the units to. From whom did you ascertain the position and location and how did that go?

THE WITNESS: That was information that was passed to me by Guam CERAP from Ryan 789.

MR. BERMAN: Thank you.

THE WITNESS: You're welcome.

CHAIRMAN FRANCIS: Monty?

MR. M. MONTGOMERY: Thank you -- thank you, Mr. Chairman. I do have one question.

In your tour of duty there at Guam, Mr. Theobald, have you ever received an MSAW alert of any kind?

THE WITNESS: No, sir. I've never worked in that tower when there was a functional MSAW capability in that control tower.

MR. M. MONTGOMERY: Did you ever get a call from approach control with such a message?

THE WITNESS: No, sir.

MR. M. MONTGOMERY: Thank you.

CHAIRMAN FRANCIS: Were you aware that the MSAW was not functional in the approach control?

THE WITNESS: No, sir. I was not.

CHAIRMAN FRANCIS: And could you -- could you just clarify for us a little bit the status of the D-BRITE in your -- in your facility?

THE WITNESS: The D-BRITE was an uncommissioned, unserviceable, non-certified piece of equipment at the time.

CHAIRMAN FRANCIS: So you basically were not using it at all for your ATC duties?

THE WITNESS: No, sir.

CHAIRMAN FRANCIS: Thank you very much.

THE WITNESS: You're welcome.

CHAIRMAN FRANCIS: That's good. Appreciate it.

(Pause)

CHAIRMAN FRANCIS: Mr. Theobald, the same thing applies to you. You're -- you're released now. I understand you want to leave as well.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: All right. Our next witness will be Ms. Sherrie Ewert, air traffic manager, Barton ATC.

Whereupon,

SHERRIE EWERT

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF SHERRIE EWERT AIR TRAFFIC MANAGER BARTON ATC INTERNATIONAL, INC. AGANA CONTRACT TRAFFIC CONTROL TOWER

MR. SCHLEEDE: Ms. Ewert, please state your full name and business address for the record.

THE WITNESS: My name is Sherrie Lynn Ewert. My business address is 1775 Adamborough Boulevard, Tgin, Guam.

MR. SCHLEEDE: And what is your present occupation?

THE WITNESS: Air traffic manager, Agana, Guam, and air traffic control specialist.

MR. SCHLEEDE: And how long have you held that position?

THE WITNESS: I've been a manager for approximately two years and I've been a specialist with Agana FCT for almost three years.

MR. SCHLEEDE: Would you give us a brief description of your education, training, and experience that brings you to your present position?

THE WITNESS: I went to Navy Air Traffic Control School, a school, from June of '76 to October '76. And then October '79 through November '79 I wentto Navy Radar Air Traffic Control Facility school. June '86 to July '86 I went to Navy Facility Management Terminal En Route Procedure school.

I've been stationed at Naval Air Station Fallon; Naval Air Station Siganella, Sicily; again at Naval Air Station Fallon; Naval Air Station Agana, Guam; and then Agana FCT.

And I've been qualifications in flight planning, flight data, clearance delivery, tower visibility, ground control, local control, tower supervisor, radar final control, IFR data, desert data, IFR coordinator, arrival control, approach control, desert control, radar supervisor, facility watch supervisor, on-the-job training instructor, team leader, flight planning chief, tower chief, radar chief, training and standardization, ATCS examiner, control tower examiner, operations duty officer, command training team, facilitator, CPR instructor, air field driving instructor, carrier air group in-briefer, controller-in-charge, air traffic manager.

MR. SCHLEEDE: Thank you very much. Mr. Wentworth will proceed. Please pause between some of the sentences so that the interpreters can keep up.

MR. WENTWORTH: Thank you. Good morning, Ms. Ewert.

THE WITNESS: Good morning.

MR. WENTWORTH: Based on your qualifications -- I heard you say both manager and controller, so you work as a controller at Guam International in addition to being manager of the facility?

THE WITNESS: Yes, sir.

MR. WENTWORTH: You maintain currency work on a daily basis?

THE WITNESS: Yes, sir.

MR. WENTWORTH: So you're considered a full performance level controller also?

THE WITNESS: Yes, sir.

MR. WENTWORTH: Would you provide for us an overview of your training program and how it's administered?

THE WITNESS: We have a person come into the facility and they have to complete all the courses and take graded tests prior to getting on position. They do on-the-job training. At the completion or what we hope to be the completion FAA will send over a CTO examiner. They'll be observed and then certified by the FAA.

We continue periodic training, proficiency training as part of the program, which will includerefresher training, supplemental training that might come along.

MR. WENTWORTH: Are emergencies and procedures for those emergencies covered as part of your remedial or supplemental training?

THE WITNESS: It's covered under the refresher training.

MR. WENTWORTH: Under refresher. Can you tell me what the average experience or level of experience within the tower is?

THE WITNESS: Approximately 15 years average experience.

MR. WENTWORTH: And out of the -- what --what is the full staffing complement of the tower, please?

THE WITNESS: The full staffing now?

MR. WENTWORTH: Yes.

THE WITNESS: Seven.

MR. WENTWORTH: And out of that complement, how many have previous experience at Guam International or Agana when it was under the Navy?

THE WITNESS: The number of people that are there now?

MR. WENTWORTH: Yes.

THE WITNESS: Two.

MR. WENTWORTH: And -- but yet, at the time of the accident Mr. Theobald had previous experience at that facility?

THE WITNESS: Yes.

MR. WENTWORTH: Okay.

THE WITNESS: That would have made it three at the time.

MR. WENTWORTH: Did the staffing or the midnight shift on August 6th, did it conform to the contractual requirements of Barton ATC, the FAA, or both?

THE WITNESS: Both.

MR. WENTWORTH: Both. As a contract facility, to what standards do you provide service to what level?

THE WITNESS: We provide 'em in accordance with FAA and company policy.

MR. WENTWORTH: So, those regulations that are applicable to the FAA controllers also applicable to -- to you?

THE WITNESS: Yes, sir.

MR. WENTWORTH: As a VFR facility, how is D-BRITE radar display used?

THE WITNESS: How is it normally used out of the --

MR. WENTWORTH: Yes. How is it used --

THE WITNESS: -- tower?

MR. WENTWORTH: -- not at the tower itself, but how would it be used?

THE WITNESS: It would be used as an aid to the -- the VFR tower controller. A term that's commonly used is an extension of the eye so you can get a geographical idea of where, like, the aircraft might be.

MR. WENTWORTH: But you do not separate aircraft through the use of the D-BRITE, is that correct?

THE WITNESS: We still don't separate with them the D-BRITE. We -- it would still just be used as an advisory.

MR. WENTWORTH: The two displays that we've been talking about that are currently in the tower, are they commissioned today as we speak?

THE WITNESS: No, sir.

MR. WENTWORTH: If the system is not commissioned, why does the facility log the system in and out of service? I -- I know I had to conduct a review of your facility logs. I noticed that.

THE WITNESS: We log them in the facility to help the FAA AF maintain a history of the status of theequipment.

MR. WENTWORTH: Can you provide us a history during your tenure at least of -- of the D-BRITE, please?

THE WITNESS: At the time that my company started working in the tower, there was a Navy brands in the tower, which is similar to the D-BRITE system. In October of '95 the Navy brands and all associated equipment was removed.

In January of '96 a remote display was installed. That is a display that is displayed up to the Anderson Air Force Control Tower.

In October of '96 there was a group of gentlemen that came out to do an overview for revamping of the control tower. I was told at that time that the D-BRITE system was going to be installed in Guam and that they even knew at that time already where they were going to be getting a system from.

In -- in February of '97 the D-BRITE system was transferred to the FAA.

In between November of '97 and January of '98 digital maps were delivered and it's installed at Agana FTC.

In December of '97 some testing and more software was installed.

In December of '97 the Agana FCT or traffic control personnel received training on the D-BRITE.

And at present FAA AF is continuing to evaluate and optimize the system. The D-BRITE is currently not commissioned or certified.

MR. WENTWORTH: In your view as a manager, does this seem to be an -- extraordinarily long time in getting the system commissioned?

THE WITNESS: Well, this is the first time that I've been a manager and been associated with the FAA, and it's -- it's been an educational time for me to learn how things work.

The duration, I'm not really sure on that. I don't -- I don't have experience with them within this system to say how long it's been.

MR. WENTWORTH: Have you been told when the system is expected to be commissioned?

THE WITNESS: The latest word I have is the end of March, April time frame of this year.

MR. WENTWORTH: Of '98?

THE WITNESS: Yes, sir.

MR. WENTWORTH: Okay. Have you started training your people on the system at this point?

THE WITNESS: We've already received our training and we've already taken our test and we'vealready received the results back from the test.

MR. WENTWORTH: Has -- have you learned what the status of the D-BRITE was on the morning of the accident?

THE WITNESS: It was not a usable piece of equipment.

MR. WENTWORTH: Okay. When this new system, this D-BRITE system is commissioned, will it have MSAW capability?

THE WITNESS: Would you please ask that question again?

MR. WENTWORTH: When the -- when the D-BRITE system is indeed commissioned, will it have MSAW capability? That is, the ability to provide both oral and visual alerts to the controller?

THE WITNESS: My understanding is it will not.

MR. WENTWORTH: Will the components that would allow these warnings to be issued, will they be present in the system?

THE WITNESS: My understanding is they will.

MR. WENTWORTH: But in essence, inhibited?

THE WITNESS: Yes, sir.

MR. WENTWORTH: Now, is that just the oral or the visual portion?

THE WITNESS: I'm not --

MR. WENTWORTH: Or in total?

THE WITNESS: I'm -- I don't remember about the visual, but I -- the oral is what I remember for sure as being inhibited. I don't recall if the visual will be there or not.

MR. WENTWORTH: As the manager, do you believe that you should have that capability to receive both oral and visual?

THE WITNESS: I'm sorry. I missed the first part of your question.

MR. WENTWORTH: As the manager of the facility, do you believe that you should have the capability of receiving both oral and visual MSAW alerts?

THE WITNESS: My understanding is that FAA policy is that we will not receive oral.

MR. WENTWORTH: Earlier from Mr. Theobald we heard about the search-and-rescue line in the tower cab. And did Barton ATC or the Navy or if you can identify who requested that it be installed?

THE WITNESS: Barton did not request it. We had a similar line that was a Navy line when the Navy was there. That line was removed. I believe the line now is -- was installed by Guam Airport Authority, butI don't know as to what discussion or, you know, how that line came about, who decided to put the line in. I don't have that information.

MR. WENTWORTH: Therefore, you as a facility have no procedures for its use, formal procedures?

THE WITNESS: No, sir.

MR. WENTWORTH: With what frequency at the facility do power outages occur?

THE WITNESS: They happen quite often. Power outages or power hits. It's very common.

MR. WENTWORTH: And when you lose commercial power, what happens? Do you have back-up capability?

THE WITNESS: We have several different backup capabilities. Different components that we have has battery pack. We have a UPS system connected to several items in the tower. And the whole tower is on a generator back-up that is automatic. As soon as it -- we lose power that starts up.

MR. WENTWORTH: Within the facility who checks the tower clocks, the digital clocks?

THE WITNESS: The FAA AF.

MR. WENTWORTH: And how often is that conducted?

THE WITNESS: My understanding is it's done weekly.

MR. WENTWORTH: Is there a log to that effect?

THE WITNESS: Ask me that again?

MR. WENTWORTH: Is there a log kept to that effect that -- that -- that the check is made?

THE WITNESS: I don't know.

MR. WENTWORTH: Do you know from where the time source is derived?

THE WITNESS: Yes, sir.

MR. WENTWORTH: Can you tell me what that is?

THE WITNESS: It would either be from WWVH in Hawaii or the GPS clock from Guam Center.

MR. WENTWORTH: Who owns the equipment in the tower cab?

THE WITNESS: The FAA.

MR. WENTWORTH: And they're responsible for making sure that it operates correctly?

THE WITNESS: Yes, sir.

MR. WENTWORTH: About what time were you notified of this accident? Do you recall?

THE WITNESS: Ask me that again?

MR. WENTWORTH: About what time were you notified of the accident?

THE WITNESS: Approximately 2:00 in the morning.

MR. WENTWORTH: And who were you notified by?

THE WITNESS: Mr. Theobald.

MR. WENTWORTH: And approximately how long did it take you to get to the facility?

THE WITNESS: Approximately 25 minutes.

MR. WENTWORTH: And what was going on at the tower cab when you arrived?

THE WITNESS: Mr. Theobald was busy working traffic. I can't recall exactly what type of traffic, but I know he was active at the time.

MR. WENTWORTH: Did you assist with any of the notifications?

THE WITNESS: I called -- yes, I verified that some people had been notified. I called CERAP to see if there was anything that they needed me to do, and then I went on from there and notified my company.

MR. WENTWORTH: Have any changes to procedures been made or are anticipated?

THE WITNESS: We've made an additional to our tape. When we change our tapes in the morning we do tape checks. With that we've added where we would tell the time that it is when we do it. That is with the crash phone, and that's at the request of the ramp control supervisor and airport rescue and fire-fighting -- fire chief to help them until they can come up withfurther procedures for times.

MR. WENTWORTH: Is there any procedure for the controller to call an entity other than the Airport Authority or the crash/fire/rescue station on the airport in the event of an off-base or off-airport accident?

THE WITNESS: No, sir. The procedure is the same.

MR. WENTWORTH: I have no further questions. Thank you.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman.

(The following is a verbatim transcript of the English translation of Mr. Lee's questions posed in Korean and Ms. Ewert's responses in English.)

MR. LEE: Let me just ascertain two things. As of now do you -- staff size at your control center, Agana Control Tower -- to think it's appropriate staff size the contract between FAA and the Barton Company. If we have a chance to review the contract, would we be able to find out the staff size of the controller?

THE WITNESS: I -- that question. Can you please restate it?

MR. LEE: Yes, with respect to the operation of the control tower at the Guam Airport, I believethere is a contract with the FAA. What I'm wondering is the way there the size of the controller staff is also included under the provisions of the contract.

THE WITNESS: My understanding that it is.

MR. LEE: My understanding is that judging by reading of the report, it says that the staff size is supposed to be seven, including the witness and the six others. One is -- I believe one is missing. So, currently, five people are staffing the duty around the clock. Don't you think you don't have a sufficient manpower?

THE WITNESS: I'm not sure I understand the statement. The question was do I have sufficient manpower. Yes, I do. The statement before that I'm not understanding completely.

MR. LEE: I'm looking at the report, the Barton Company as of January 1997. It was taken over by Circor Company. I believe it is in the process of being taken over. Is there still an ongoing process, the company -- Barton Company taken over by this Circor or has it been completed?

THE WITNESS: It's been completed.

MR. LEE: Let me ask you just one more question. Just now you mentioned or Mr. Theobald the controller said that whether the outer mark -- markswere working or not can be done through report from a pilot or FAA notification. Like, in this -- in this fashion, whether certain increment at the control tower navigation aids are not under continuous monitoring it cannot be confirmed on a constant basis. Would you think that it is normal?

THE WITNESS: I don't completely understand your question. The outer marker is not monitored from the tower.

MR. LEE: That the outer marks are in such a state as not to be monitored by the tower, considering the outer marker may not be working at any moment until you receive a report from the pilot, do you think it's normal to resort to ILS landing clearance?

THE WITNESS: I'm sorry, sir. I'm still not understanding the question.

(Pause)

MR. LEE: Outer marks whether they are working or not, the way it can be done is that when it is not working then you have to receive reports from the pilot or you can depend upon regular feedback from the FAA. I believe those are only the two methods, two ways of confirming whether outer marks are working or not. Under such a circumstances at the control tower when you have to clear the aircraft to land, let's saywhen the outer marks are not working but you would still clear ILS approach or a localizer approach? In other words, I believe you should have at your control tower something you can use to confirm whether outer marks are working or not. That's the point of my question.

THE WITNESS: Sir, we don't clear 'em for ILS approaches. That's done by Guam CERAP. We only clear them to land after they have their clearance for the approach.

MR. LEE: Okay. Thank you very much. That's all.

(End of translation)

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Yes, thank you.

Just one quick question regarding notification. There was a airport crash exercise in April of '97, I believe the last one they had. Are the controllers normally part of those exercises, especially in relationship to notification?

THE WITNESS: Yes.

MR. DERVISH: Okay. Thank you, Sherrie.

CHAIRMAN FRANCIS: Korean Air?

(The following is a verbatim transcript of the English translation of Captain Kim's response in Korean.)

CAPTAIN KIM: No questions from Korean Air.

(End translation)

CHAIRMAN FRANCIS: NATCA?

(Pause)

MR. MOTE: -- you asked NATCA, Mr. Chairman. I didn't hear that. We have no questions. Thank you.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: We have no questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: Mr. Chairman, no questions.

CHAIRMAN FRANCIS: Barton ATC?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Thank you very much for your help.

(Pause)

CHAIRMAN FRANCIS: Oh, I'm sorry. I missed this group of people that is surrounding me up here. I -- I could tell that you were enjoying yourselves so much that -- okay.

Greg, I'm sorry.

MR. FEITH: Just one question. Sherrie, can you tell me since the accident, is there now any procedures in place for the controllers if they believe an accident to have occurred off the airport to go down the notification list like they have for on-airport accidents getting off-airport emergency services involved?

THE WITNESS: The procedure is the same that we have.

MR. FEITH: Would you just run through it real quick for me, please?

THE WITNESS: The procedure is to activate the crash phone. On the crash phone is Guam International Airport Ramp Control. They have the list of people that they notify. Also on the crash phone is the Airport Rescue and Fire-fighting. In addition to activating the crash phone we would also notify Center and weather personnel, and then we would go on from there with our -- our notification list that we have. But the procedures are the same on and off.

MR. FEITH: But if you notified the on-airport crash/fire/rescue personnel and it's an off-airport accident, how are you -- how is it ensured that the notification is being made to off-airport emergency response units?

THE WITNESS: We don't ensure that. The procedure is set up with the ramp control and then CERAP.

MR. FEITH: Okay. Thank you.

CHAIRMAN FRANCIS: Monty?

MR. M. MONTGOMERY: I have no questions. Thank you.

CHAIRMAN FRANCIS: Ron?

MR. SCHLEEDE: Yes, thank you. I have a couple regarding the D-BRITE.

I'm not sure we asked you what -- for a fully certified, fully operational D-BRITE what does the local controller use it for. How is it used?

THE WITNESS: Yes, sir. That was asked --asked, and it was basically the extension of the eyes, an aid to the aircraft -- I mean to the controller.

MR. SCHLEEDE: Okay. If I could ask you then, under the circumstances of Flight 801, a dark night with instrument conditions on the final approach, could you tell us how a controller would -- when he would look at it, when a controller would use the D-BRITE during an approach like that?

THE WITNESS: He would use it when he got the information initially with the in-bound -- with the --when he was passed the information. Like, on thisparticular instance, 12-west, there -- the controller would look on the scope for 12-west -- 12-west, correlate it, look out the window, and see if he could see him at that point, and then follow him generally in, look in the win -- out the window, and if he can't see it look back to the scope to try to have -- to correlate it back and forth.

MR. SCHLEEDE: And when the controller looks at the D-BRITE on the scope, what in general is he looking for? A position or altitude?

THE WITNESS: Position, generally.

MR. SCHLEEDE: Do they look at the altitude block? Is it a procedure to look at the altitude block?

THE WITNESS: They could.

MR. SCHLEEDE: They -- I'm sorry?

THE WITNESS: They could.

MR. SCHLEEDE: Okay. But is it a standard practice that they would not only look at the -- the general position but the aircraft's altitude in relation to the approach path?

THE WITNESS: They would look at the position. Then, if they couldn't see the aircraft then I would imagine they would look at the altitude to see if he was, like, higher or lower than what he expectedhim to be.

MR. SCHLEEDE: Okay. Thank you very much.

CHAIRMAN FRANCIS: Ben?

MR. BERMAN: Ms. Ewert, the Safety Board issued a recommendation to the FAA in December of 1996 that was on a slightly different subject but covered the issue of notification -- post-accident notification, and in -- in March of 1997 the FAA wrote to us and said that it would direct regional air traffic division managers to ensure that actions were taken to ensure that Order 7210.4 was reviewed and managers would review reference materials, procedures, and letters of agreement to ensure that all emergency notification telephone numbers are available and current, including those for crash, fire, and rescue operations.

Facility managers should notify -- should --correction. Facility managers should forward the date of completion of the above actions to headquarters air traffic service through division managers no later than March 26th of 1997.

Was the contract control tower at Guam included in this program?

THE WITNESS: I don't recall that.

MR. BERMAN: You have no -- no word of thisat all?

THE WITNESS: Not that I remember.

MR. BERMAN: Okay. Thank you.

MR. CARISEO: One quick question. You had mentioned that D-BRITE was expected to be commissioned the end of this month or early April. What was the original schedule for that to happen, or was there one?

THE WITNESS: The original I'm not sure. We've had several dates throughout the time frame.

MR. CARISEO: And what was the earliest date that you recall?

THE WITNESS: The earliest I can remember is December of '97.

MR. CARISEO: Okay. Thank you.

CHAIRMAN FRANCIS: I think now you can leave. Thanks very much. And with you, as the others, if --if you have to leave --

THE WITNESS: Thank you.

CHAIRMAN FRANCIS: -- you may. And we appreciate what you've contributed.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: I think we'll have --we've got one more witness, I think, before lunch. It's 12:15, 12:20. Maybe we'll ask Mr. Thomas Howell, acting manager, National Field Support Division, FAATechnical Center, please.

Whereupon,

THOMAS HOWELL

was called as a witness, and first having been duly sworn, was examined and testified as follows:

CHAIRMAN FRANCIS: I think that we'll change here. Apparently this is going to be considerably longer than -- than the other witnesses have been. And given that it's -- it's after 12, I think we'll have lunch now. And why don't we reconvene here at 1:30. It's 12:25 now, so please everybody be back promptly at 1:30.

(Whereupon, at 12:25 p.m., the proceedings were adjourned for lunch, to reconvene at 1:30 p.m., the same day.)

P R O C E E D I N G S

1:30 p.m.

CHAIRMAN FRANCIS: All right. We're going to start again. And Mr. Schleede has the floor.

Whereupon,

THOMAS HOWELL

having previously been duly sworn, was recalled as a witness and was examined and testified as follows:

TESTIMONY OF THOMAS HOWELL ACTING MANAGER NATIONAL FIELD SUPPORT DIVISION, AOS-600 FAA TECHNICAL CENTER ATLANTIC CITY, NEW JERSEY

MR. SCHLEEDE: Mr. Howell, please give us your full name and business address for our record?

THE WITNESS: My name is Thomas B. Howell. My address is FAA, Operational Support Service, AOS-600, in care of the William J. Hughes Technical Center, Atlantic City International Airport, Atlantic City, New Jersey.

MR. SCHLEEDE: And what is your present position with the FAA?

THE WITNESS: My present position is manager of the National Field Support Division, AOS-600.

MR. SCHLEEDE: Please give us a brief summary of your training, education, and experience that brings you to your present position? And please try to pause slightly between the sentences.

THE WITNESS: I've been with the FAA since 1967. In 1973 I was trained as an en route automation specialist. And the next 20 years I spent either in en route automation specialty functions or management functions and operational -- functions in the air traffic environment.

My last air traffic position in 1993 was manager of the Cleveland Air Route Traffic Control Center.

I spent one year detail as a deputy director in the Operational Support Service in Washington, D.C.

Since then I've been in the Engineering Services Division, AOS-600. Our mission as it regards to this hearing is to provide centralized software support for the automated radar terminal systems that have the automated radar tracking system, the ARTS system. We receive requirements from those field facilities, interpret those requirements into software language that we call adaptation, deliver the product back to the field for implementation.

MR. SCHLEEDE: Thank you. Mr. Dunham willbegin the questioning, and Mr. Pereira will also have questions from this witness.

Oh, I'm sorry. The reverse.

MR. PEREIRA: Good afternoon, Mr. Howell.

THE WITNESS: Good afternoon.

MR. PEREIRA: Would you please describe the FAA's Minimum Safe Altitude Warning program, also known as the MSAW program, including information about when and why MSAW was developed?

THE WITNESS: Yes. I -- well, I have prepared a presentation. If I can begin now?

MR. PEREIRA: Please.

MR. SCHLEEDE: This is coming from what exhibit? 13?

MR. PEREIRA: 13 D, Delta.

MR. SCHLEEDE: Thank you.

MR. PEREIRA: Actually, this is 3FF, Foxtrot Foxtrot.

THE WITNESS: What I intend to talk about this afternoon is an overview of the Minimum Safe Altitude Warning system, the purpose that it was designed for, an overview of the history as to why it was developed, a brief description of how it functions, and steps that we have taken to optimize its performance and maintenance.

The Minimum Safe Altitude Warning is a function designed solely as a controller aid in detecting potentially unsafe aircraft proximity to terrain or obstructions. It generates an alert to the controller when a pilot is below or is predicted to be low -- below a specified altitude.

These alerts are generated in two forms: a visual alert that will be displayed to the controller as a -- a L -- flashing LA in the data block or -- I should say and an oral alert. The oral alert is much like a smoke detector type of alert.

It must be specifically adapted at each one of our 193 Automated Radar Terminal Systems. Each site around the country and in the Pacific and -- and Caribbean that use the Automated Radar Tracking System has special site tripography that has to be included in the adaptation, a local database. Each one of these systems has various amounts and different types of runways, different approaches, different NAV/AIDs, different location of those NAV/AIDs, different numbers and types of airports as well as unique air space requirements that causes each site to be adapted uniquely.

MSAW came about as a result of National Transportation Safety recommendation A73-46. Thisresulted from an accident December 12th, 1972, Eastern Airlines 1011 in Miami, Florida. Specifically, the NTSB requested the FAA to review ARTS III program for the possible development of procedures to aid flight crews when marked deviations in altitude are noticed by ATC, air traffic control.

In December of 1973 the FAA contracted with Univac to develop hardware and software modifications necessary to implement this recommendation.

In 1977 MSAW was implemented into the ARTS III program, and in 1990 into the ARTS IIA program. Additionally, we have installed this function into the EARTS system and the en route environment.

Though there are several different types of MSAW processing, today we're going to focus -- this briefing or presentation will focus primarily on the terminal processing. In the terminal environment there are two different types of processing that we'll talk about. One is general terrain warning and the other is approach path monitoring.

However, both of these types of processing require certain things to be present before the aircraft will be eligible for MSAW processing. It must be a tracked target. That is, a flight plan must be entered into the system. It must have a valid mode Cor altitude reporting. It must be within the adapted eligibility area. It must be outside any inhibit zones. It also must be in a proper flight status, and by that it's to be -- to receive arrival processing it has to be listed as an arrival in the flight plan.

It also has to have a proper beacon code assignment because there are some areas where we would intentionally inhibit flights from receiving or being eligible to receive MSAW processing. Those might be cases of military operations, helicopter operations, special VFR operations.

In the area of general terrain monitoring we've got three different types of alerts or alarms that may be presented to the controller. The first one would be the current alarm. Any time an aircraft is presently less than 500 feet above the digital terrain map it will automatically generate an alarm.

We also have prediction alarms. When the pilot would be less than 500 feet above the digital terrain map within 30 seconds -- in advance of the flight course within 30 seconds of the flight trajectory.

We also provide a third type of alarm called a projection alarm. If the pilot will be unable to clear all obstacles within eight minutes flying time onpresent course at a five degree climb angle.

Before I explain more about those particular alarms, I'd like to briefly mention about what digital terrain maps are. The -- to MSAW processing. The graph that's up on the -- screen is a -- a small sample of a digital terrain map, and each one of our radar sensors that is used in the automated -- in the ARTS system will have a digital terrain map built for it. So, each sensor -- and we have some of our systems that have multiple -- multiple sensors, but the important thing is that each sensor will have one of these individually built for it.

And each one of these maps consist of 4096 two-nautical-mile bins. And the bin altitudes are expressed in feet. This data is provided and certified by NOAA. NOAA gets this data and builds these maps with data from the National Imagery and Mapping Agency and the coast -- the U.S. Geological Survey. They build the terrain maps.

To these terrain maps NOAA adds the obstacle obstruction layer which will determine the highest obstruction within that two-mile bin.

And I'll just point to one of the bins here. Hopefully you can see that. This bin says 333. Well, that means that that bin -- highest obstruction in thatbin is 333 feet mean -- sea level.

Now, our software will add 500 feet to that bin for processing purposes. So, if the aircraft is projected to be within 833 feet we'll generate an alert to the controller.

Each one of these -- I -- I need to back up and correct that statement. We -- we actually round off these bins to the nearest hundred feet, the nearest highest 100 feet. So, in that case that bin would go up to 400 feet. That's an important point to notice. We round those bins up to 100 feet and then we add the 500-foot buffer to that in the software.

Now, back -- back to the -- the different types of alarms. Remember, we had three different types of alarm. We have the current alarm which will generate an immediate alert, all right.

On Point A as used to -- to show a projection, all our aircraft are continually projected 30 -- 30 seconds in advance of its trajectory. If in that -- anywhere along that 30-second route if it's projected to be in a bin below that altitude, the projected trajectory of the aircraft, the alert will be sounded.

Now, there are some exceptions to that. Generally, it will take two consecutive predictions togenerate the alert to the controller. Two consecutive projections 30 seconds in advance will generate a alert to the controller. In the MSAW -- terminal MSAW environment we're dealing with 4.75-second radar, so the scan rate is every 4.75 seconds. The projection 30 seconds. Any two consecutive hits will generate an alert to the controller.

Now, we have a -- I'm sorry. That's a --prediction.

We also from that Point A on the screen we have another -- this is almost a separate type of projection. From that point we are constantly projecting eight minutes in the future at a five degree climb angle to make sure that the aircraft can clear any obstacles in its path.

So, we've got two things going on here. The projection point is continually updated every 4.75 seconds, and from that Projection Point A we're continually projecting 480 seconds into the future at a five degree climb angle to make sure the aircraft can clear any obstacles within its path. If any two scans detect an altitude bin encroachment, we will generate an alert to the controller.

The next area of MSAW alert processing is the approach path monitor. Again, any current violationsof the air space will provide an alert to the controller. On the prediction the pilot is projected to be 100 feet below the calculated approach path alarm slope altitude within the next 15 seconds.

Approach path monitors are used to transition aircraft from general terrain monitoring to the airport. These approach path monitor boxes are generally one mile either side of runway center line. They initiate generally five miles from the end of the runway. They generally will terminate within one mile of the runway. The initiate altitude for the slope will be based upon the D -- the -- the DTM at the initiate point plus 500 feet. The cut-off altitude will be based on any obstructions or the MDA. And we're -- for this purposes, if there's obstructions we will use the MDA minus 100 feet for the lowest non-precision approach for that runway.

It comes into the airport inhibit area, which is normally within one mile of the airport. At some point you have to stop this processing 'cause eventually everybody, we hope, is going to land successfully. So, anything within one mile we find generates a tremendous amount of nuisance alerts.

Also, that's generally the point where we stop tracking and we have our -- our drop trackparameter for the -- the system. And we also terminate any alert processing.

Now, I'd like to show you a picture of the Guam adaptation prior to the accident. You will notice the outside ring is a 60-mile ring around the radar antenna. Inside that -- that ring -- there's actually a double line -- a double ring there, and it may be difficult for you to see that, but there's actually a double ring there. That's only one mile apart.

Processing in this case was enabled between 54 and 55 miles from the radar antenna, effectively inhibited processing within 54 miles of the airport. It also inhibited any approach path monitoring processing. In this situation there were no oral or visual alarms generated within that circle. This resulted from a facility request and has been operational in that condition, as far as we can determine, since February of 1995.

After the accident we had some -- we were on the phone with the folks at -- in Guam two days later to go over what was in the system and we had dispatched some people out there the following Monday. I -- I don't have the exact date, but I think it was in a couple days they had readapted the system. We had removed that double line, enabled the processing within55 miles, optimized the approach capture boxes, reduced the size of the departure inhibit areas, expanded the airport eligibility, and we are still presently working on trying to eliminate nuisance alerts.

We've learned a lot from this. As a result of -- of this and several other accidents, on October the 3rd, 1990 --

MR. PEREIRA: Mr. Howell?

THE WITNESS: Yes?

MR. PEREIRA: Can I stop you there before we get into the -- the changes after the fact and the review process? Could we go over some questions first, if you don't mind?

THE WITNESS: Yes, sir.

MR. PEREIRA: Okay. Thank you.

(Pause)

MR. PEREIRA: What kind of MSAW systems were in place at the Guam ATC facility at the time of the accident? You had mentioned we had ARTS and EARTS. You mentioned a couple different types of MSAWs. What -- what was in place at Guam at the time of the accident?

THE WITNESS: At the time of the -- the accident the ARTS IIA system was being used for the terminal approach services and the micro-EARTS wasbeing used for the en route environment.

Micro -- I'm sorry.

MR. PEREIRA: It's okay. Could you -- you mentioned the fact that we had a eligibility area problem on the ARTS MSAW. Was the EARTS functioning properly or was it configured properly?

THE WITNESS: Yes, as far as I can tell it was.

MR. PEREIRA: Okay. And did we get any EARTS MSAW alarms for the Korean 801 accident airplane?

THE WITNESS: Yes, we did. We received one -- one alert that was displayed.

MR. PEREIRA: Okay. Teddy, could you put up Exhibit 3EE, page two?

(Pause)

MR. PEREIRA: And at the bottom of this page here we have the EARTS output?

THE WITNESS: Yes, that's correct.

MR. PEREIRA: Would you explain the date on this page and what they show regarding the EARTS MSAW processing and the radar scope warnings for KA 801?

THE WITNESS: Yes. At time 15:41:08 there was a projection alert, a software projection calculated for Korean 801. It was a general terrain warning prediction. As I've also mentioned in the --the prediction for the ARTS IIA program, this is the same thing that it's going to take two predictions to generate an alert to the controller. We had one predicted alert at 15:41:08. Since there was not another alert it did not display to the controller.

However, on 15:42:20 there was a -- an actual alarm in the approach path monitor area. Now, as I --as I stated before, any actual penetrations will generate an immediate alert. So, the one alert that was generated was 15:42:20 on the Korean 801. I know that there was some confusion around this earlier.

Now, that -- the alert itself is the next --the last two lines. The MA stands for the MSAW alert that was generated, as you can see, at 15:42:20 for the KAL 802. And that was for the approach path warning.

MR. PEREIRA: Okay. Thank you very much.

You mentioned the ARTS II MSAW eligibility area had been set to a ring, and you showed a graphic of that. When was that -- actually, I think you already answered that. That was the February '95 date of that change, is that correct?

THE WITNESS: Yes, it had the two -- the one-mile ring that was enabled from 54 miles to 55 miles and then as far as we can tell was in operation since February of '95.

MR. PEREIRA: Can you explain why the eligibility area was set as it was and who requested and approved these changes relative to the prior status?

THE WITNESS: I -- I cannot speak to why it was set that way or what the thought processes were. However, it -- up -- at that time local facilities had -- there was no -- no -- national policy in place that would prohibit a facility from doing that. So it was left to the discretion of the local facilities.

MR. PEREIRA: Did they physically make that change in the software there or was it made back at the tech center?

THE WITNESS: That was part of a -- some data that was sent to us the previous fall for -- it was called a site adaptation kit where they fill out a form to describe what their local site environment should be, and we translate that and build a new program and send it out to them. And I think we received the data some time in the fall of '94 and that software package was installed -- it was a new upgrade -- was installed in February of '95.

MR. PEREIRA: Okay. So that process was in place -- that was in place at the time, at this point do you feel that that was appropriate to maintain aproper configuration of the MSAW system? The process that was in place for requesting and -- and -- and carrying out the changes to the MSAW. What's your opinion on the adequacy of that at the time?

THE WITNESS: I really can't speak for the appropriateness of it, but what I can tell you now in this environment, we have taken steps to see that we're going to do business in a different manner and that we're not going to do that anymore. And we've actually designated these type of parameters to be the responsibility of one organization, the AOS organization, that organization that I work for.

MR. PEREIRA: After this accident the FAA performed a simulation of the Guam ARTS IIA MSAW performance, the one that had the eligibility ring. With the eligibility ring removed and in its proper configuration using the Korean Air 801 radar data, would you please describe the simulation further and the results of that simulation?

THE WITNESS: Yes. We do not have the ability to record the ARTS IIA data. We do have the ability to record the Micro-EARTS data. And the Micro-EARTS uses a 12-second radar versus the -- the terminal radar using 4.75. So, we took the data from the 12-second radar and we -- put it into a test targetgenerator and extrapolated the 12-second returns on the flight that we had -- the information that we had for the Korean 801 and fed it into the ARTS IIA program through the simulator.

And it did show that approximately at 1700 feet it would have generated an alarm and it went on for approximately 60 seconds prior to impact -- or prior -- prior to coasting.

MR. PEREIRA: Okay. So, the simulation showed approximately 60 seconds of continual message on the radar scope, is that correct?

THE WITNESS: Yes, being -- through the simulation it did show that.

MR. PEREIRA: Okay. Thank you.

THE WITNESS: Any other questions on the displays before or after?

MR. PEREIRA: No, I think that does it for me. Mr. Dunham has some questions for you now.

MR. DUNHAM: You can go ahead and resume your briefing, and then I will -- I may ask you a question after each slide.

THE WITNESS: Okay.

October 3rd, 1997, FAA established a method for strict configuration management of MSAW. All modifications are now centrally maintained. We'vedescribed -- established strict management oversight of these parameters. We've developed guidelines and a review process of quality assurance of how we're going to manage this.

As I mentioned before, each site prior to the -- that date had the authority to make changes to MSAW. Unfortunately, they had limited guidance on how to make those changes. AOS is now the only organization authorized to make changes to this program, the MSAW program.

We have developed common MSAW adaptation standards for all terminal systems. Additionally, those facilities that we find cannot fit into these standards go through a comprehensive waiver review process at the national or Washington level.

I'd like to spend a little bit more talk about this optimization process and steps that we've taken since October the 3rd. We've assembled or we did assemble an interdisciplinary team, chose -- recognize AT and AF experts to develop standards for clear guidance on how to adapt this MSAW.

Prior to that time, the local facilities were left with just a guidance of -- of adapting it. An --an example might be there -- when they're told how to adapt an eligibility area it could be zero to 60 miles. Now we have developed a standard and said that it's got to be a minimum of five miles beyond your approach air space. It can't be any -- and it's got to -- it can't -- it's got to start at the airport. So, we've really nailed down the standards and we've -- we've testified some nominal values, and if they deviate from those nominal values it's going to require a waiver.

The initial optimization, we set up a review process to gather all the data. We actually went out and copied all the operational programs in the system and put a team together to review what was actually in the -- the data and the systems. And we developed some tools that would allow us to -- to graphically or -- or -- or put this data -- software data into a picture. So, we go by -- to it and review it and prioritize what need to be done. And then set up a work process to start the review.

And each -- each review process was done by two people and then checked by another two people and then sent to a different organization for a quality review process. And if any errors were found it would stop -- back -- start back in the beginning of the --the review process.

We also, as I mentioned previously, developed tools to take the program listings and develop it intopictures. That's a real quick way to see what's going on. Unfortunately, had these kind of tools been in the field at the time it would have been probably a different story.

However, technology has just recently allowed us to do this kind of stuff. We've applied new standards to each site. Additionally, we've --developed and tested site-specific test scenarios for each site for functional verification. So now our technicians, when they do certify these systems, they've got a test scenario to run that would produce hard copy results.

MR. DUNHAM: Okay. Can you talk a little bit about those tools? The two slides previously that showed the illustration of the Guam adaptation, those were created with those tools?

THE WITNESS: That's correct.

MR. DUNHAM: Okay. So that's -- that's the actual data from Guam? That's not a simulation?

THE WITNESS: This is the actual data that's in -- adapted in the Guam system.

MR. DUNHAM: Okay.

THE WITNESS: Now, I said this was the actual data as of a couple weeks ago. All right. Now, we've since -- I'd have to check as to whether this is theoptimized program or not, but it's -- it's definitely after the accident. And also we're -- as I said, we're continuing the optimization process of nuisance alerts.

MR. DUNHAM: Okay. And was that re-adaptation, was that flight-checked?

THE WITNESS: I don't have that information.

MR. DUNHAM: Okay. And which -- what sites are included in the 193? What types of facilities?

THE WITNESS: We have 130 ARTS II sites, ARTS IIA sites. We've got 60 ARTS IIIA sites, and three ARTS IIIE sites.

MR. DUNHAM: Can you explain the differences between those facilities?

THE WITNESS: Generally, the -- the -- the IIA system is -- is a basic program. The IIIA system is a little more sophisticated. It has a little more functionality. And the IIIE system is -- is kind of a state-of-the-art solid state advanced system, which would be more of a -- a land type network system distributed -- type processing.

MR. DUNHAM: Okay.

THE WITNESS: Okay.

MR. DUNHAM: Thank you.

THE WITNESS: Again, the one thing I need to mention here is that we -- we actually have re-adaptedall of the 193 sites, and that work has been completed. At least half those sites are operational with the --the new -- new functionality.

MR. DUNHAM: And what does the -- the site-specific functionality tests actually test?

THE WITNESS: It -- it tests the -- it --it's a random test to see that the software is generating alerts where it's supposed to, that we're getting general terrain warning alerts and we're getting approach path monitor -- alerts. It also tests conflict alert.

MR. DUNHAM: Okay. So that testing is done on every site before the adaptation is sent out?

THE WITNESS: Yes. We test -- we're testing it at the tech center. But we also send out this --this scenario and this tape along with the new program so that the local people can do their own testing, and they're required to do it on a monthly basis.

MR. DUNHAM: All right.

THE WITNESS: I'd like to talk about just a -- a couple of nation wine -- nationwide findings and fixes that we've uncovered through our investigation of 193 sites.

We reduced a significant amount of inhibited air space. Again, we -- we did not have any specificstandards and we've since developed standards which require the rebuild of basically all of our sites to make sure that everybody was in the same conformance and that we can now configuration manage all of these systems.

An example of some new inhibit standards, in the departure inhibit area we had a range of zero to 50 miles. Now the new standard is two miles from the airport, maybe up to six depending on local conditions. Anything beyond that would require a waiver.

General terrain monitoring didn't have a standard before. New standard: not to exceed five miles from the airport.

Fly-in inhibit areas didn't have a standard before. New standard: on defined airports not to exceed five miles.

We redesigned all the approach capture boxes, -- redefined the initiate and termination points on the digital terrain maps. Previously it was a manual effort to update all these altitude bins -- whenever new obstructions would come in.

On alarm -- approach path monitor slope alarm we've developed guidelines and procedures for what the initiate altitude should be, also what the cut-off altitude should be. Before it was left to local --discretion. Now we've got strict standards.

MR. DUNHAM: On the approach slope adaptation, was that also added to the EARTS system?

THE WITNESS: The EARTS system does not have approach slope adaptation capability. We have generated a National Transit proposal to incorporate that. Until that -- that case file is approved, we're adapting what we call pseudo-capture boxes, all right, that allow us to, actually like a step-down approach, step down the approach like a stair -- like a ladder stair.

MR. DUNHAM: Okay. And why would you add that adaptation to a system that didn't have it previously?

THE WITNESS: Okay. What we found -- our team in -- in reviewing MSAW and trying to make this as -- as best as it can be that we -- in the ARTS II environment there was two methods of adapting approach box monitors. One was you could adapt a flat plane at -- at the -- the MDA of the lowest non-precision approach minus 100 feet below that approach as -- as a method of adapting approach capture box. Or you could adapt an approach path monitor slope alarm.

Well, we found that it provided much more accuracy to adapt the slope, and we've incorporatedthat as our standard.

Now, when we first started this process we --we did not -- we weren't aware that you could put it in all the systems, and we've since decided to go ahead and put it in all those systems. And we've developed some -- some coding modifications and some change proposals to take action to do that and improve the performance of the system. So -- and our -- our standards, I -- I couldn't tell you exactly how many airports were adapted at the flat plane, but our new standard is to have the -- the approach path monitor slope alarm. And we're in the process of incorporating that nationwide.

MR. DUNHAM: And what's the practical effect of implementing that slope?

THE WITNESS: It'll generate alarms sooner. It'll generate alerts soon -- sooner.

MR. DUNHAM: Okay. And just to clarify, the ARTS IIA system has had that capability longer than the other systems?

THE WITNESS: Yes. ARTS IIA came along in 1990, and if you remember, the IIIA system was 1977. This was kind of the prototype.

MR. DUNHAM: And the -- the IIIA did or did not have that capability?

THE WITNESS: The IIIA -- the IIIA was not released with that capability. We found that there were some coding in there that -- that we can modify and give it that capability, and we have since rebuilt all the IIIA programs with that new capability.

MR. DUNHAM: Okay. So, your intention at the completion of this will be that all the ARTS systems of any type will have that slope available?

THE WITNESS: They will have that slope available, that's correct. And most of the approaches will have that slope unless there's a step-down approach.

MR. DUNHAM: Okay. Thank you.

(Pause)

THE WITNESS: I'd like to spend just a few minutes to talk about how we're going to maintain this. We have spent a lot of resources and a lot of time getting -- gathering all this data and -- and getting it up to date.

CHAIRMAN FRANCIS: Excuse me. Could -- you talk really fast.

THE WITNESS: Okay. I'm sorry.

CHAIRMAN FRANCIS: I mean I don't know whether you're a former controller or not, but I -- I suspect that these folks in the back of the room are --having some trouble translating. So, I know it's hard to sort of think about what you're saying and think about speaking slowly, but if you can try to keep that --

THE WITNESS: Okay.

CHAIRMAN FRANCIS: -- help that.

THE WITNESS: Thank you. I'll slow down.

We've spent a lot -- lot of time and resources and efforts in -- in getting this program up-to-date and -- and optimizing it to make it everything that we -- we think that it can be. So, we certainly don't want to let it fall back in any -- any form of disrepair.

We're going to establish a process where we can by automation tools build new digital terrain maps every 28 days. We've already contracted with -- with NOAA to put a piece of equipment on line that can generate these digital terrain maps for us. And we can just pull 'em down and -- and compare for any changes, and if there are any changes we'll just build a whole new map and send it out to the facility each month.

Every year we -- we plan to review every site -- excuse me. We also are going to be reviewing every new and amended standard intimate approach procedure to check for any obstacles. Since we've adapted the glidepath concept we have to -- check any changes to those runways.

We're going to conduct yearly site adaptation review with -- specifically to review these parameters and make sure these systems are adapted properly. We'll divide up all 193 sites by 12 and do so many per month on a review basis annually.

Resources and processes are available 24 hours a day. We've got a 24-hour help -- help line. We're going to establish a team at the tech center. Their sole function will be to take care of MSAW. We're going to get experienced field people that work well in a team environment that are technically competent and conceptually understand ATC procedures. We also intend to use modern software technology practices as much as possible and our requirements --management project tracking configuration management and we're going to use peer reviews for a defect prevention process.

MR. DUNHAM: Okay. By your use of the digital terrain maps from NOAA you've effectively out-sourced the basis of your adaptation. Have you satisfied yourself that their processes are suitable to base your MSAW processing on?

THE WITNESS: Yes, we have. I've had acouple of specialists over there talking with NOAA, and they're satisfied with the -- the quality control that they're using.

MR. DUNHAM: And will you be looking into that periodically yourself to make sure that it doesn't deteriorate over time?

THE WITNESS: Sounds like a good idea. We'll put that on the list.

MR. DUNHAM: Okay.

(Pause)

THE WITNESS: In summary, we -- we feel this is very important to our organization. We've taken action to centralize the oversight and management of this program. We've developed standards and guidelines. We've developed new tools. We've streamlined the process. And we're going to continually look for ways to improve this program.

And that concludes my presentation.

MR. DUNHAM: Okay. Can you back up to the slide that shows the approach path monitor boxes?

(Pause)

MR. DUNHAM: That one. Could you just go through that slide and discuss which of those elements would be considered a user-defined site variable as MSAW was being managed at the time of the accident?

THE WITNESS: Everything that's on that slide would be a user-defined variable. As far as the initiate point of the boxes, the width of the boxes, the altitudes, whether it was a slope or whether it was a flat plane, the general terrain maps. The general terrain maps were originally sent from NOAA but they required updating. That was also a -- a locally generated task to update those maps and those bins. Anytime a bin would change they'd have to calculate what the new altitude was and then patch it into the program.

The inhibit areas around the airport was locally generated. Everything on that slide was locally generated and controlled.

MR. DUNHAM: Okay. Thank you.

After the accident AOS sent a team to Guam and you explained what they -- the work they did after they got there. When was the MSAW system on the ARTS IIA returned to service after the team had arrived? Just roughly.

THE WITNESS: I don't have the exact date, but I -- I think it was within five days of their arrival.

MR. DUNHAM: Okay. And how long had the MSAW been out of service prior to that? That was all theway back to the February of '95 date?

THE WITNESS: Well, technically, I mean it was processing that one-mile gap, okay, since February of '95. And until our team arrived there it was just -- it was still processing that one-mile gap.

MR. DUNHAM: Okay.

THE WITNESS: Then when they left that --that first week, then it was processing normally.

MR. DUNHAM: Okay. Are you aware of any problems they may have had with acquiring a digital terrain map between 1995 and the time of the accident?

THE WITNESS: No.

MR. DUNHAM: Okay. When the team put in the revised adaptation, did they have to make any program changes to the ARTS IIA system?

THE WITNESS: Not that I'm aware of.

MR. DUNHAM: Okay. So, there was no technical reason that the adaptation they put in after the accident could not have been used prior to the accident?

THE WITNESS: Not that I'm aware of.

MR. DUNHAM: Are there any inhibited areas in the current effective latest version of the Guam adaptation?

THE WITNESS: No volume inhibit areas. There's some departure inhibit areas that are a couple miles from the airport, which is a routine thing.

MR. DUNHAM: Okay. But effectively, areas that are analogous to the 54-mile radius area are no longer used?

THE WITNESS: That's correct.

MR. DUNHAM: Okay. Has the CERAP reported any false alarm problems with the new adaptation?

THE WITNESS: Yes, they have.

MR. DUNHAM: Okay. What's the process for analyzing and minimizing the problems from those?

THE WITNESS: Along with the -- the release of the new program tape we've also put in a program modification that prints out a copy -- hard copy of all the -- the alerts so that when a site does complain about false alerts they can -- they can fax the hard copy to us and we can quickly look at it and find out where these alerts are being generated.

Right now it's my understanding there's a --a major portion of these alerts at Guam are when the aircraft are being turned on visual approach and turning on base lag. We've analyzed that and we think that we can improve that situation.

MR. DUNHAM: So the technical means for eliminating false alarms have been in the software allalong?

THE WITNESS: Could you please repeat that?

MR. DUNHAM: The technical means for eliminating false alarms, the tools you'd use, the --the functions of the software that you're planning to use are not new? They've been available since ARTS IIA was put in?

THE WITNESS: Yes and no. The -- some of these tools have just developed so that we can easily look at it. Prior to that it was a very cumbersome process to try and analyze those results.

MR. DUNHAM: Okay. But they -- the program itself has had the capability?

THE WITNESS: Yes.

MR. DUNHAM: Okay. Given that that alternative process exists, is there any reason that --any technical reason that the 54-mile radius inhibit area was the only alternative available before that?

THE WITNESS: Could you restate that question?

MR. DUNHAM: Yeah. At the time of the accident we had a 54-mile circle of inhibited area at Guam because of false alarms. There are alternatives available to that approach, are there not?

THE WITNESS: Yes.

MR. DUNHAM: Okay.

Okay. Teddy, could we have O1 please?

For the record, Exhibit O is a briefing that was presented to NTSB on January 29th, 1998, regarding the progress of the MSAW review team.

(Pause)

MR. DUNHAM: And Mr. Howell, is this -- is this slide inaccurate in any way?

(Pause)

THE WITNESS: That's correct.

MR. DUNHAM: Okay. Thank you very much.

Do you feel that adequate resources have been allocated to the MSAW review to ensure that it's thorough and complete?

THE WITNESS: Yes, I do.

MR. DUNHAM: Okay. Have you had any problems getting support for the effort from FAA?

THE WITNESS: No, I haven't.

MR. DUNHAM: Okay. What is the level of MSAW training and expertise required for proper understanding and management of the software?

THE WITNESS: I believe each one of the automation specialists had received a minimum of eight hours worth of training in this area along with several other hours about adaptation. So, it doesn't really --they're receiving adequate training right now.

MR. DUNHAM: Okay. How about at the time of the accident?

THE WITNESS: It's also my opinion that they received adequate training.

MR. DUNHAM: All right. What were the most serious problems identified in the -- the review that your people have found?

THE WITNESS: The -- probably the most serious were the amount of inhibit areas and how some of the inhibit areas were adapted.

MR. DUNHAM: And how many sites had that sort of problem?

THE WITNESS: There was -- was four.

MR. DUNHAM: Okay. And when will a -- a final report on the outcome of the review be available?

THE WITNESS: Within 60 days.

MR. DUNHAM: How confident are you that upon completion of the review MSAW will be properly configured and managed at all FAA facilities?

THE WITNESS: Very confident. We plan to use software engineering institute capability maturity model processing for the maintenance of this system.

MR. DUNHAM: Okay. And that's a formal software management process?

THE WITNESS: That's correct.

MR. DUNHAM: Okay. Have there been any changes to the ARTS IIA documentation as a result of the review?

THE WITNESS: Yes, there have. We've developed new standards.

MR. DUNHAM: Okay. Prior to that what level of detailed guidance was available to the ARTS II automation specialist? You described it as -- as sort of general. Can you expand on that?

THE WITNESS: No, I -- probably the -- the best example would be, you know, just how to adapt it, not what the standard would be. Maybe it would be like a speed -- knowing that the car can go zero to 100 where are the optimum value, perfect driving range would be should be 55.

So, we've -- in, like, the general terrain monitor inhibits, it could be any value. It just said you could adapt from zero to 50 miles. Now we've said it can't go any farther than five miles away from the airport. And it must include the air space five miles outside the approach air space.

So, what we're trying to do is -- is to really have a hard and fast standard.

MR. DUNHAM: Okay. And what was the -- themajor difference between the ARTS IIA documentation and the ARTS IIIA documentation prior to the accident?

THE WITNESS: The ARTS IIIA had a little bit more -- specificity and had some nominal values suggested in some of their parameters.

MR. DUNHAM: Was there any use of the ARTS IIIA documentation to obtain proper values for ARTS IIA systems prior to the -- the accident?

THE WITNESS: I -- I would say probably because some of the -- the technicians that developed the IIA documentation and standards were also trained in IIIA, so they had experience with IIIA systems.

MR. DUNHAM: Is there any technical difference in the way that inhibit areas are adapted under ARTS IIIA and under ARTS IIA?

THE WITNESS: No. We're applying the same standard for all airports regardless of the system.

MR. DUNHAM: Okay. How about prior to the accident?

THE WITNESS: Yes, there was.

MR. DUNHAM: There was a difference between the two?

THE WITNESS: Yes. In -- the main difference being one system had a standard and the other didn't.

MR. DUNHAM: Okay. But as far as the -- theprogram operation itself, was the adaptation essentially identical or were there differences?

THE WITNESS: It was very similar.

MR. DUNHAM: Okay. So, if a -- an ARTS IIA technician was looking at the IIIA documentation for inhibit areas would he be able to follow that and achieve it under an ARTS IIA system?

THE WITNESS: Probably.

MR. DUNHAM: Okay. Take a look at Exhibit 3R.

(Pause)

MR. DUNHAM: Okay. This is a recommendation from the Safety Board for November 21st, 1994, regarding the crash of a Lear jet at Dulles Airport. Could you refer to that and explain to us the MSAW adaptation problems that were identified in that recommendation?

THE WITNESS: Yes, I believe this is -- was the wrong MDA used for the calculation approach on runway -- runway 1-right where they used the MDA altitude of the precision approach instead of using the MDA of the non -- the lowest non-precision approach. Resulted in a -- an error in that adaptation.

MR. DUNHAM: Okay. And was there a specific standard applicable to that -- to the Dulles system atthe time of that accident?

THE WITNESS: Yes, there was.

MR. DUNHAM: Okay. And it -- this was not in compliance with that standard?

THE WITNESS: That's correct.

MR. DUNHAM: Okay. At that time the Safety Board asked the FAA to "conduct a complete national review of all radar environments using MSAW systems. This review should address all user-defined site variables for the MSAW programs that control general terrain warnings as well as runway capture boxes to ensure compliance with prescribed procedures."

As someone familiar with MSAW systems, is the meaning and intent of this recommendation clear to you?

THE WITNESS: It is to me.

MR. DUNHAM: Okay. Did the FAA conduct a review in response to that safety recommendation?

THE WITNESS: Yes, they did.

MR. DUNHAM: What guidance was available reference that review to the local facilities to assist them in ensuring that their MSAW settings were correct?

THE WITNESS: One of our organizations in February of '95 put out a -- a memo to the regional division managers with that exact same verbiage to check the parameters -- site variable parameters onMSAW. And it appears that there was a diligent effort by the Washington office that had that responsibility to track and report the progress. And there was some indication that each facility reported back.

We have since learned that that's probably not the best way to do that type of thing. And unless we have to go out and do what we just did as far as getting a copy of all the program tapes and have an independent assessment is the only way that we can accurately assure ourselves what's in those systems at that time.

MR. DUNHAM: Okay. So it's your opinion that that review was not in fact effective in identifying the existing problems?

THE WITNESS: Not effective.

MR. DUNHAM: Okay. On -- if you could look at Exhibit 3Q.

(Pause)

THE WITNESS: Got it.

MR. DUNHAM: Okay. This is a report from AOS on a -- their analysis of an accident that occurred on January 13th, 1998. It was another Lear jet crash on approach to runway 2-6 at Houston Intercontinental Airport. Mr. Howell, are you familiar with this accident?

THE WITNESS: Yes, I am.

MR. DUNHAM: Okay. AOS examined the adaptation for Houston in use on that date. Can you explain what was found?

THE WITNESS: Used the wrong MDA. Used the wrong approach MDA.

MR. DUNHAM: Okay. So how do those problems relate to the problems found at Dulles in 1994?

THE WITNESS: Same problem.

MR. DUNHAM: Okay. Do you know how long the Houston MSAW parameters had been set in that way?

THE WITNESS: No, I don't.

MR. DUNHAM: Is the -- there any evidence at all when it might have been put in or has it been lost to -- lost in the records?

THE WITNESS: I don't have any information about that.

MR. DUNHAM: Okay. Were there clear standards for ARTS IIIA MSAW adaptation available prior to that accident?

THE WITNESS: Yes, there were.

MR. DUNHAM: Were those standards followed?

THE WITNESS: No, they weren't.

MR. DUNHAM: Okay. Should this problem have been detected in the 1994 review?

THE WITNESS: Yes, it had -- yes, it should.

MR. DUNHAM: Okay. How important is the proper functioning of MSAW to AOS?

THE WITNESS: Very important.

MR. DUNHAM: And why is that?

THE WITNESS: Safety critical item.

MR. DUNHAM: Okay. So it provides a safety critical function to the system?

(No response)

MR. DUNHAM: Okay. I have no further questions.

(Pause)

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Mr. Chairman, -- no questions, thank you.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: No.

CHAIRMAN FRANCIS: Barton ATC?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Just a very minor question, Mr. Howell. You'll have to excuse me. I need more clarification than most.

When you said prior to October of '97 thelocal facility had the option of installing or modifying the software, what do you mean by local facility? Is that the CERAP or is that --

THE WITNESS: Yes.

MR. DERVISH: So it was the FAA CERAP that modified the Guam --

THE WITNESS: They had the --

MR. DERVISH: -- software?

THE WITNESS: -- the -- they could modify the -- the ARTS IIA program.

MR. DERVISH: Yeah. 'Cause you said in '95 it was modified, new software.

THE WITNESS: Could you repeat this question? I'm not sure that I understand what you're --

MR. DERVISH: Yeah. You -- you keep referring to the local facility, and you said prior to October of '97 the local facility had the option of modifying the software for the MSAW and that -- you also said that in 1995 it was modified at Guam. Who is the local facility that modified that software that created that double inner ring?

THE WITNESS: Okay. The -- the adaptation.

MR. DERVISH: The adaptation, okay.

THE WITNESS: The requirements come from the facility.

MR. DERVISH: Okay. And who's --

THE WITNESS: To the -- to the tech center.

MR. DERVISH: Are we talking about the Guam Airport Authority? Are we talking about the --

THE WITNESS: FAA facility.

MR. DERVISH: Okay. So it is an FAA decision?

THE WITNESS: FAA facility, yes.

MR. DERVISH: Okay. Thank you.

THE WITNESS: You're welcome.

CHAIRMAN FRANCIS: Just -- just to pursue that for a second. How would that work within the facility? I mean would that come to -- to the tech center via AF because of an AT requirement in terms of false alarms or how would that have worked internal to -- to the CERAP?

THE WITNESS: That would come from AT to the tech center.

CHAIRMAN FRANCIS: From AT?

THE WITNESS: From AT.

CHAIRMAN FRANCIS: With AF not involved in it then?

THE WITNESS: No.

CHAIRMAN FRANCIS: Okay. Thank you.

Boeing Company?

MR. DARCY: Mr. Francis, we have two questions.

The first one is can you explain, Mr. Howell, why there was a visual but not an oral alert on the Micro-EARTS implementation?

THE WITNESS: Yes. The oral alert on the Micro-EARTS has a -- parameter value of zero to 200-some seconds to display or sound the alarm for that many seconds. The alarm was -- value was set to zero.

MR. DARCY: Do you -- oh, okay. I think I understand.

And the second question I guess is, is it correct to assume there was a -- different adaptation for the Micro-EARTS and the ARTS IIA? And if so, why were they done differently?

THE WITNESS: The concept is the same. They're just adapted differently. The ARTS -- the Micro-EARTS does not have a digital terrain map capability to use the -- the digital terrain maps, the bins, the two-mile bins. But they do have the ability to adapt approach capture boxes.

MR. DARCY: Okay. Would that -- would that result in -- or the -- the Micro-EARTS not being adapted the same way, would that result in nuisance alerts on that system that -- that didn't occur on theARTS IIA?

THE WITNESS: Not necessarily.

MR. DARCY: Can you explain why that would be for -- for me? Sorry, I don't quite get it.

THE WITNESS: Well, one system uses digital terrain maps for -- for general terrain warning, and the other system would develop its -- its base altitude off of minima of our altitude charts in the form of polygons.

MR. DARCY: Okay. I see. Thank you. That's all the questions.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: I have one question by my assistant.

FIRST OFFICER CHUNG: Thank you for allowing us to ask you some questions.

The first one is a -- a point of clarification. When you just answered to our Boeing party about the setting being zero, is that in -- in essence saying that the setting was turned off?

THE WITNESS: It was functioning for zero seconds so there was no alert -- there was no oral alarm generated.

FIRST OFFICER CHUNG: But you would not say that this is exactly the same as saying that it wasturned off?

THE WITNESS: That's correct.

FIRST OFFICER CHUNG: Thank you.

And follow-on to that question would be if that is the case, can you give us a reason for that? Why it was set at zero?

THE WITNESS: Yes, because that system in Guam, the Micro-EARTS is predominantly used for en route operations. And there is no requirement or no policy for an oral alarm in the en route environment. They use the IIA system for the route -- approach processing.

FIRST OFFICER CHUNG: Thank you. You'll pardon us asking one more uneducated question. Most of us are not familiar with the system, and regarding something you mentioned. I believe it was during optimization you said the technology to achieve this --and it was -- seems to be done -- had been done rather quickly -- that the technology only recently became available. Were you referring to that -- with adaptation or -- I'm sorry, or with optimization?

THE WITNESS: Well, the tools that we have used to optimize the systems when -- when Micro -- when MSAW was developed back in the '70s and early '80s we didn't have flight PCs, and now we're using PCs toquickly analyze this data and paint -- or develop pictures that somebody can visually look at. Before they were just looking at software coding. Very hard to analyze.

FIRST OFFICER CHUNG: So you were referring to adaptation and not optimization when you said recently?

THE WITNESS: Optimization of the adaptation.

FIRST OFFICER CHUNG: And a date of around 1990 was mentioned. What was that in reference to? Optimization of adaptation was -- technology became as early as 1990, is that our understanding or --

THE WITNESS: No, in 1990 MSAW was put into the ARTS IIA program.

FIRST OFFICER CHUNG: Okay. When you said recently, then could you put a date or a year on the recent technology that makes the optimization process available today?

THE WITNESS: We used PC technology in the fall of this year to develop the -- the tools necessary to optimize the programs. Of -- we could have done it other ways, but now we've got tools that we can do it quickly.

FIRST OFFICER CHUNG: Did you say fall of last year was really the first time this optimizationprocess could have taken place?

THE WITNESS: That's hard to answer. I guess it could have taken place a little bit sooner.

FIRST OFFICER CHUNG: Okay. Thank you very much.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Yes, Mr. Chairman, I have just one question for Mr. Howell.

Sir, earlier you mentioned that the alert at 15:42 and 20 seconds was displayed on the radar but I don't believe you said whether or not that was the only time that there was an alert displayed on the radar. Was it?

THE WITNESS: That was the only time the alert was displayed on the radar.

MR. DONNER: Thank you.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: Just a couple of follow-up questions, one regarding the EARTS MSAW.

Had the EARTS MSAW had an approach slope warning capability like the -- the ARTS II did, is it likely that we would have gotten a warning much earlier than the six-second time period that we did have?

THE WITNESS: No.

MR. FEITH: Can you tell me why?

THE WITNESS: The distance from the airport would not have changed. So, it was -- the penetration point at the distance from the airport that triggered that alarm more so than the altitude of the slope.

MR. FEITH: You had answered a question. I think it was for Mr. Dunham regarding the rehab --readaptation and -- and if the readaptation site at Guam when it was -- or I should the readaptation that occurred at Guam hadn't been flight checked. First off, why not? And second off, how do you validate the -- the -- the new software change if it isn't flight checked?

THE WITNESS: Well, let me correct this. Not -- I -- I have no knowledge of whether it was flight checked or not.

MR. FEITH: Okay.

THE WITNESS: So, I -- I can't say no, it wasn't flight checked. I have no knowledge of whether it was or not. Maybe somebody else can answer that question.

MR. FEITH: Do you know if any of the other readapted sites had been flight checked?

THE WITNESS: Yes, I do.

MR. FEITH: Is that a typical practice to validate the new software changes?

THE WITNESS: Yes, it is.

MR. FEITH: You had mentioned something about a waiver that had -- had been issued or is issued when a site wants to change the parameters for the -- the MSAW. Do you -- Guam was issued a waiver?

THE WITNESS: I don't know.

MR. FEITH: Okay. Very good. Thank you. That's all I have.

CHAIRMAN FRANCIS: Pat?

MR. CARISEO: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Ben?

MR. BERMAN: Mr. Howell, you mentioned that the -- the false alarm problem at Guam is -- is -- is fixable, is that correct?

THE WITNESS: I think we can improve it.

MR. BERMAN: When will -- when will that be completed?

THE WITNESS: Should be a patch on the way out there this week.

MR. BERMAN: Okay. One more thing. I wanted to just get some clarification on an answer you gave to Mr. Feith a minute ago about the -- the difference between the EARTS MSAW approach slope warning and not having that feature. If -- if the approach slope warning wouldn't have provided additional assistancehere in the case of EARTS, why would the ARTS II have provided 60 seconds of warning if it had been working correctly?

THE WITNESS: I believe the aircraft penetrated the side of the box. It didn't descend into the box. It penetrated the side of the box.

MR. BERMAN: Okay. I think I understand.

(Pause)

MR. M. MONTGOMERY: Thank you, Mr. Chairman.

Mr. Howell, let me ask you what I hope is a rhetorical question. In the development of the replacement systems for the ARTS programs, the common ARTS, which is now under way, and soon to be the STARS system, we hope, is your office working with these programs to make sure that all these improvements that you've made in the ARTS II and ARTS III systems will be maintained and promulgated?

THE WITNESS: Yes, definitely. We are very closely related and working with them on these -- this issue.

MR. M. MONTGOMERY: Okay. Thank you. No more questions.

CHAIRMAN FRANCIS: Let me -- I don't have any questions. Let me make a little editorial personal comment here.

I think that this exchange that we just had is -- is exactly what I was talking about this morning in terms of people cooperating together to try to make the system safer. Mr. Howell has been professional, candid, forthcoming, and constructive, and I think that our questioners Charlie and Scott with the assistance of Richard Wentworth have -- have also handled this very well. And I -- I appreciate it. I think that's in everyone's interest that -- that something that is as sensitive as this and could have been as difficult has been as productive for -- for all of us. Thank you very much.

THE WITNESS: You're welcome.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: Our next witness -- you're free to -- our next witness, David Canoles, manager, Evaluations Investigations Staff, AAT-20.

(Pause)

CHAIRMAN FRANCIS: Oh, I'm sorry. I'm on the wrong -- missed one here. Sabra Kaulia, deputy director, Air Traffic Operations Programs, FAA in Washington.

Whereupon,

SABRA KAULIA

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF SABRA KAULIA AIR TRAFFIC OPERATIONS PROGRAM, ATO-2 FEDERAL AVIATION ADMINISTRATION WASHINGTON, D.C.

MR. SCHLEEDE: Please state your full name and business address for our record?

THE WITNESS: My name is Sabra Kaulia. Business address is 800 Independence Avenue, Southwest; Washington, D.C.

MR. SCHLEEDE: And you work for the FAA?

THE WITNESS: Yes, I do.

MR. SCHLEEDE: In what position?

THE WITNESS: I'm the deputy program director for Air Traffic Operations.

MR. SCHLEEDE: Okay. Could you give us a brief summary of your training, education, experience that brings you to your present position? And again, please try to speak slowly and pause between the sentences.

THE WITNESS: I have 27 years of experienceair traffic control, including six operational air traffic control facilities both in the en route and the terminal environment, positions as a supervisor, staff support specialist, Washington headquarters and regional. Facility management, both assistant management and manager time. Regional air traffic assistant division manager and now deputy program director.

MR. SCHLEEDE: Thank you very much.

Mr. Dunham?

MR. DUNHAM: Good afternoon. Could you please -- sorry. Could you please explain from a operational perspective the reasons for having MSAW functions in air traffic control software?

THE WITNESS: The MSAW system is a function of our Automated Radar Processing System. That is a tool to assist the controller by providing information so they can help the pilot avoid terrain and/or obstructions.

MR. DUNHAM: Okay. And what's the role of MSAW in the prevention of CFIT accidents?

THE WITNESS: To provide the controller with an additional alert, an automated alert through that processing regarding aircraft proximity, potential proximity to terrain or obstructions.

MR. DUNHAM: Okay. And this software is in use in both en route and terminal facilities?

THE WITNESS: Yes, it is.

MR. DUNHAM: Okay. If a radar controller inadvertently cleared an aircraft to operate below the minimum IFR altitude for the area it was in in close proximity to either terrain or obstructions, please describe the various ways that error might be brought to their attention.

THE WITNESS: The read-back from the pilot could bring that altitude to their attention. The observance of the aircraft proceeding into an area below their depicted altitudes on their radar scope could do that. And also, the MSAW system could do that.

MR. DUNHAM: Okay. Number two and three are actually the same thing, are they not?

THE WITNESS: Not necessarily. I believe number two, what I was referring to is the observance of the target of the aircraft and its altitude reference the altitude that you either thought you had issued or would have issued, not the alert itself, the low altitude flashing in the tag.

MR. DUNHAM: Okay.

THE WITNESS: The third was that one.

MR. DUNHAM: Okay. Could you look at Exhibit 3I3? I'm sorry. Page three.

THE WITNESS: Yes.

MR. DUNHAM: And just read us the part there about safety alerts. We've had a couple of paraphrases of it today, but I thought we should get the exact words.

THE WITNESS: You want me to read the paragraph for safety alert?

MR. DUNHAM: Yeah, and just explain what --what safety alerts are.

THE WITNESS: Paragraph 2- -- 1-6, safety alert. "Issue a safety alert to an aircraft if you are aware the aircraft is in a position slant altitude which in your judgment places it in unsafe proximity to terrain, obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Do not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued. Inform the appropriate controller."

MR. DUNHAM: Okay. And -- and what priority does that fall under in the controller's overall workload?

THE WITNESS: This is a first priority.

MR. DUNHAM: And it's equivalent to what?

THE WITNESS: Control instructions.

MR. DUNHAM: Separation of aircraft?

THE WITNESS: Yes.

MR. DUNHAM: Yes. So -- so, separation and safety alerts are equal priority?

THE WITNESS: First priority.

MR. DUNHAM: Okay.

THE WITNESS: Yes.

MR. DUNHAM: Is an MSAW activation an event that could cause a controller to issue a safety alert?

THE WITNESS: Yes.

MR. DUNHAM: Okay. So then, responding to an MSAW alert under some circumstances could be a first priority duty?

THE WITNESS: If in the controller's judgment there was an unsafe situation, yes.

MR. DUNHAM: Okay. And what of the possible consequences of MSAW misconfiguration or malfunction?

THE WITNESS: In the absence of processing we would not have this additional alert system and/or automated process available.

MR. DUNHAM: Okay. So do you believe that MSAW makes an important contribution to the overalllevel of safety in NAS operations?

THE WITNESS: Yes, I do.

MR. DUNHAM: Okay. Could you look at Exhibit Z 32? Z like zebra.

(Pause)

THE WITNESS: 3Z?

MR. DUNHAM: That's correct. 3Z 32.

(Pause)

MR. DUNHAM: Sorry. I'm a little slow dredging it up myself.

(Pause)

MR. DUNHAM: Okay. Paragraph 5-2-2, item classification?

THE WITNESS: Yes.

MR. DUNHAM: Number D says problem. Now, this is an explanation of how items are classified on a facility evaluation report. Could you explain to us what the definition of a problem is as shown here in this order?

THE WITNESS: I could read that to you, but I believe that really is outside my expertise. This is --

MR. DUNHAM: Well, we could --

THE WITNESS: -- the evaluations.

MR. DUNHAM: Go ahead and read this and thenwe'll -- we'll talk about that.

THE WITNESS: Okay. And specific under D you wanted to hear which part?

MR. DUNHAM: The definitions of problem items.

THE WITNESS: "Problem items are those (A) items identified that are in contradiction to national, regional, hub, or facility directives. The specific refer -- reference shall be noted at the end of each problem description. (B) Items not governed by specific references but which clearly and negatively affect performance programs, quality of service, or efficiency. (C) Items identified as hub, regional, or national in scope, the resolution of which requires action above the facility level."

MR. DUNHAM: Okay. That's fine.

Do you feel that loss of MSAW functionality meets the Section B, there the -- that it clearly and negatively affects quality of service?

THE WITNESS: Again, I'm not sure -- that is outside of my area of expertise. I'm not sure I could respond to that.

MR. DUNHAM: You've been an operational facility manager, correct?

THE WITNESS: Yes, sir.

MR. DUNHAM: And you're responsible for the quality of service of the facility you're running?

THE WITNESS: Yes, sir.

MR. DUNHAM: Okay. So, in that case, if you -- your facility lost MSAW functionality, would you consider that clearly a negatively affecting the quality of the service?

THE WITNESS: Depending on the facility I was in and the guidelines and national requirements I was given it would determine whether it would fit under that evaluation category.

MR. DUNHAM: I'm -- I'm not --

THE WITNESS: It's a broad scope. I'm sorry.

MR. DUNHAM: I'm not asking you to evaluate it. I'm just saying as a -- as an operational manager, would you feel that was a problem for your facility?

THE WITNESS: I would not use that word. I would consider it serious.

MR. DUNHAM: Okay. Is the overall level of safety in AT system related to the quality of service it provides?

THE WITNESS: I'm sorry. Could you repeat that?

MR. DUNHAM: Is the overall level of safety in the ATC system related to the quality of servicethat it provides?

THE WITNESS: Yes.

MR. DUNHAM: Okay. Could you explain how loss of ATC terrain warnings for both pilots and controllers affects quality of service?

THE WITNESS: Specifically meaning the MSAW service?

MR. DUNHAM: Yes.

THE WITNESS: It is a secondary activity, a secondary piece of information that would be missing. So, the additional service of MSAW would be missing. That would be the impact.

MR. DUNHAM: Does that have any effect on safety?

THE WITNESS: I think the -- it would be an absence of an additional system. I'm not sure I understand your question. I'm sorry.

MR. DUNHAM: Does MSAW have any effect on the safety of the system?

THE WITNESS: It assists the controller. It enhances the safety.

MR. DUNHAM: Okay. So, if it's absent what does it do to the level of safety?

THE WITNESS: It's an additional piece of information that's not there.

MR. DUNHAM: Okay. Could you please explain the obligations at the time of the accident of FAA facility managers regarding the maintenance and configuration of MSAW systems?

THE WITNESS: The -- the facility management -- you specifically require -- requesting regarding Guam or the system in general?

MR. DUNHAM: In general.

THE WITNESS: The facility management handbook provides some guidance for that. The 7210.3. And it's very broad. It read -- it allows facility management to inhibit systems. It requires oversight of the digital terrain maps of other mapping parts of that system. I'd have to refer to that particular handbook to give you more specific.

MR. DUNHAM: Okay. That -- that's probably clear enough.

Was the ARTS IIA MSAW system at Guam CERAP operating in accordance with established standards and policies at the time of the accident?

THE WITNESS: Yes, it was.

MR. DUNHAM: Was MSAW providing any operationally meaningful services as configured at the time?

THE WITNESS: Not outside that one-mile ring,no.

MR. DUNHAM: Okay. Do you know what the terrain is under that one-mile ring?

THE WITNESS: I'm -- I'm not personally familiar with the 54-miles all the way around, but I don't think there was much terrain there.

MR. DUNHAM: Okay. Was there in fact any operationally significant distinction between the Guam MSAW performing as configured at the time of the accident and MSAW being completely shut off?

THE WITNESS: I'm -- any significant difference? Could you repeat that? Thank you.

MR. DUNHAM: That was -- that was essentially the point. Do you --

THE WITNESS: Okay.

MR. DUNHAM: -- was there in fact any operationally significant distinction between the Guam MSAW performing as configured at the time of the accident and MSAW being completely shut off?

THE WITNESS: No, I would believe there isn't.

MR. DUNHAM: Okay. Do you use as part of your job full facility evaluation reports for exercising your ATC management responsibilities?

THE WITNESS: In my current position we doreview reports that are sent to us.

MR. DUNHAM: Okay. And from time to time you might use those reports to identify problems in the system?

THE WITNESS: No. We -- we would not identify problems. The report would identify things that they have found, that the evaluations people have found. We would review that to see if there was impact on the procedures and day-to-day operation as we manage it.

MR. DUNHAM: Okay.

(Pause)

MR. DUNHAM: Okay. Could you look at Exhibit 3P, like puppet?

(Pause)

THE WITNESS: Yes. AME="E7E1">

MR. DUNHAM: Okay. This is the 1997 Guam CERAP full facility evaluation report. Based on the information contained in this report, what was the apparent status of the MSAW system at that time?

THE WITNESS: In the 1997 report?

MR. DUNHAM: Yes.

THE WITNESS: The 1997 report I believe did not mention the MSAW system.

MR. DUNHAM: And what does that tell youabout it under normal circumstances?

THE WITNESS: There would be no problems identified.

MR. DUNHAM: Okay.

(Pause)

MR. DUNHAM: Mr. Howell has described the visual and oral alarms which are provided by ARTS and EARTS in response to conflict alert and MSAW activations and has noted that the EARTS oral alarm was disabled at the time of the accident. What effect would this have on the ability of CERAP controllers to detect an MSAW alarm activation?

THE WITNESS: On the EARTS system they would not receive the oral alarm but they would still be able to see and -- and visually notice the visual attached alarm.

MR. DUNHAM: Okay. The Guam CERAP controllers on the midnight shift are using multiple radar scopes so their attention is sometimes distracted from one to the other. Would having an oral alarm contribute to bringing the alarm to their attention?

THE WITNESS: Conceivably.

MR. DUNHAM: Is disabling the oral alarm a common practice within the ATC facilities?

THE WITNESS: Within all ATC facilities?

MR. DUNHAM: Terminal and CERAPs.

THE WITNESS: That's outside my knowledge area. To my knowledge within the terminal ATC facilities it is not normal.

MR. DUNHAM: Okay. How about within the CERAPs?

THE WITNESS: CERAPs and en route, to my knowledge, it is normal.

MR. DUNHAM: Okay.

(Pause)

MR. DUNHAM: Would you look at Exhibit 3S, like Sam, 1, please?

THE WITNESS: Yes.

MR. DUNHAM: This is a Safety Board recommendation number 95-120 asking FAA to install oral MSAW warning equipment in VFR towers that receive radar information from a host radar control facility and would otherwise receive only a visual MSAW alert. The last response received from FAA seems to indicate that the recommendation has been accepted but only discusses ARTS III facilities. Is the oral alarm feature being extended to VFR towers currently covered by ARTS IIA systems?

THE WITNESS: Yes. The new automated system being delivered called Common ARTS contains thatcapability. It will have it for all of them. And that will be installed at all ARTS II -- current ARTS II facilities. I believe the projected date is April of 2000 to complete that waterfall.

MR. DUNHAM: Okay. When will -- in particular, when will Agana Tower receive an oral alarm capability?

THE WITNESS: I don't personally know the date of the waterfall for them. It will be sometime between now and April of 2000.

MR. DUNHAM: Okay. Could -- could you provide that for the record after your testimony?

THE WITNESS: Yes.

MR. DUNHAM: Okay. Is there any intention of providing the oral alarm capability through their currents ARTS IIA system prior to the installation of the IIE?

THE WITNESS: Technically, again, this is outside of my area of expertise. As I understand the way the system is built, the technical capabilities of the system, it cannot provide that oral alarm directly to two different airports as a primary, only to one primary. And Agana is the secondary airport in that system, so it cannot be adapted to do that. That's why Common ARTS is necessary to provide that to all of themin the ARTS II environment.

MR. DUNHAM: So, under the current capabilities of ARTS IIA as you understand it, the alarm will continue to be sent only to the CERAP?

THE WITNESS: As I understand it, yes.

MR. DUNHAM: At the time of the accident what was the staffing level of Guam CERAP?

THE WITNESS: The reports indicated two controllers on duty.

MR. DUNHAM: And is that normal and acceptable for midnight shift operations?

THE WITNESS: Yes.

(Pause)

MR. DUNHAM: Which facility was responsible for providing IFR services to the Korean aircraft at the time of the crash, the actual impact?

THE WITNESS: IFR services would be provided by the approach control or the CERAP facility.

MR. DUNHAM: Okay. So, as far as actual ATC responsibility for the aircraft, that remained with the CERAP?

THE WITNESS: For the IFR in-flight services, yes.

MR. DUNHAM: Okay. If CERAP is responsible for providing all the IFR services to Korean Air 801,why did it not initiate the search-and-rescue response when informed by Agana Tower that the aircraft couldn't be located?

THE WITNESS: I do not know that answer.

MR. DUNHAM: Okay.

(Pause)

MR. DUNHAM: Okay. No further questions.

(Pause)

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman. Just one question. Did FAA head office evaluate Guam CERAP personnel levels and working shift and MSAW training, training status, etc., after the Korean Airlines 801 accident? If there are some improvements to be made, could you please explain them briefly?

THE WITNESS: I'm sorry. I'm getting a lot of feedback. Could you repeat that?

MR. LEE: Okay. If there are some improvements to be made could you please explain them?

CHAIRMAN FRANCIS: He's -- he's asking the question in English.

MR. LEE: Did the FAA --

(Pause)

THE WITNESS: I'm getting feedback.

I -- I understand the --

CHAIRMAN FRANCIS: Why don't you just take --

THE WITNESS: -- there are improvements --

CHAIRMAN FRANCIS: -- take the headset off.

THE WITNESS: All right. That may help.

MR. LEE: One more? Okay. Did the FAA head office evaluate Guam CERAP's personnel levels, working shift, MSAW training status, etc. after the Korean Airlines 5801 accident? If there are some improvements to be made, could you please explain them?

THE WITNESS: I'm sorry. I still don't believe I understand the nature of your question. Is it reference search-and-rescue efforts after the accident?

MR. LEE: Not -- no, not search-and-rescue. Just in CERAP's personnel levels and qualification and working shifts and training -- etc.

THE WITNESS: Okay. Staffing and training --

MR. LEE: Just the evaluate -- the evaluate to them -- just controller. Just evaluated on the investigation staff for the CERAP -- CERAP's office.

THE WITNESS: Okay. I'm -- my office does not oversee the training and personnel activities. I am not aware of any issues in that area.

MR. LEE: Okay.

Okay. That's it. Thank you.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: No questions.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPT. KIM: No questions, sir.

CHAIRMAN FRANCIS: Barton ATC?

MR. E. MONTGOMERY: No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: No questions, Mr. Chairman. Thank you.

CHAIRMAN FRANCIS: We'll have to rely on Mr. Donner to ask a question.

MR. DONNER: Gee, I'm sorry, Mr. Chairman. I don't have any.

CHAIRMAN FRANCIS: Thank you.

Monty?

MR. M. MONTGOMERY: Thank you. No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Thank you very much.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: The next witness will be Mr. David Canoles, Manager, Evaluations and Investigations Staff, FAA.

Whereupon,

DAVID CANOLES

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF DAVID CANOLES MANAGER EVALUATIONS AND INVESTIGATIONS STAFF, AAT-20 FEDERAL AVIATION ADMINISTRATION WASHINGTON, D.C.

MR. SCHLEEDE: Mr. Canoles, please give us your full name and business address for the record?

THE WITNESS: My name is John David Canoles. My business address is Federal Aviation Administration, AAT-20; 800 Independence Avenue, Southwest; Washington, D.C., 20591.

MR. SCHLEEDE: And what is your current position at the FAA?

THE WITNESS: Current position is manager of the Air Traffic Evaluations and Investigations Staff, AAT-20.

MR. SCHLEEDE: Would you give us a brief summary of your training and education experience that qualifies you for your present position?

THE WITNESS: Yes, sir. I will.

I've been employed by the Federal Aviation Administration --

MR. SCHLEEDE: Slowly, please.

THE WITNESS: I've been employed by the Federal Aviation Administration in air traffic control for 27 years. I held journeyman air traffic control positions in three FAA terminals, held later post of training specialist, first-line supervisor, was manager of two air traffic facilities, including the tower in Newark, New Jersey.

In 1980 I became manager -- I'm sorry. In 1987 I became manager of the air traffic division for the eastern region therefore providing oversight over all facilities in that region. Subsequently was manager of the air traffic procedures division until two years ago when I accepted the position I have now.

MR. SCHLEEDE: Thank you very much. Mr. Dunham will begin the questioning slowly.

MR. DUNHAM: I'm really trying.

Mr. Canoles, good afternoon. What is the purpose of the FAA National Facility Evaluation Program?

THE WITNESS: Basically, the Evaluation Program measures the effectiveness and compliance of all field facilities with national standards,directives, and orders.

MR. DUNHAM: And how are evaluations conducted?

THE WITNESS: Evaluations are conducted on a regularly scheduled basis by teams of air traffic experts who are employed within my organization. These teams will range in size and duration of visit based on the size of the facility they are evaluating. They will travel on-site, collect data. They operate in accordance with a published checklist which can range to several hundred items for -- for our more complex facilities, consist of evaluations and other measurements during their period of time in the facility, and the culmination of these visits is a written report which is given to facility management as well as management of the air traffic division having operational control over that facility.

MR. DUNHAM: How long does a typical evaluation take to complete of, say, a CERAP?

THE WITNESS: I'm guessing -- it's --typically our evaluations range from three days to two weeks. I would say that an evaluation of a CERAP would probably involve four to five of my specialists for a duration of approximately one week.

MR. DUNHAM: And what is the composition of atypical facility evaluation team?

THE WITNESS: Again, the -- the range of numbers varies depending upon the size of the facility and the commensurate levels of work to be accomplished. Evaluators themselves are selected into this organization from among active air traffic control specialists. Typically, only those who have attained at least the rank of first-line supervisor. So in fact we're -- we're selecting individuals who have already distinguished themselves as -- as excellent controllers in the first place. We try to maintain a mix of those who specialize in the en route terminal and flight service options.

MR. DUNHAM: Are the evaluators required to be experts in the area they are assigned to evaluate?

THE WITNESS: Not in all cases. For example, one of the areas that an evaluation would look at would be training. An air -- an air traffic controller proficient in training in a terminal facility could transfer those skills and knowledges and successfully evaluate an en route or a flight service facility. Therefore, we transfer that. Operational oversight is restricted to -- to people with experience in that particular option.

MR. DUNHAM: So, when the Guam CERAPautomation functions were evaluated, would that have been done by an automation-trained specialist?

THE WITNESS: No. We did not evaluate the Guam CERAP automation functions nor do we evaluate the automation functions of any air traffic facility. Our evaluation focuses simply on operational effectiveness and compliance.

MR. DUNHAM: So, the automation section of the checklist that they use to do an evaluation actually accomplishes what?

THE WITNESS: No, the items contained in the evaluations portion of the checklist -- and incidentally, that has been modified just as a clerical point since -- since this accident -- are rudimentary at best. For example, in the area of MSAW at the time of this accident basically all we were doing was checking to make sure that the audible portion of the alarm was workable and had not been modified in the facilities. But as far as any in-depth evaluation of software, that is not accomplished by my teams.

MR. DUNHAM: You said that evaluations are conducted on a regularly scheduled basis. Do you believe that providing advance notice of an upcoming evaluation leads to a true picture of the facility's day-to-day quality of operation and compliance withdirectives?

THE WITNESS: I believe that it does by and large. And frankly, there's a trade-off involved. Surprise evaluations would probably give us more of a true picture, but our method of evaluation is one of teaching and coaching improvement in facilities rather than surprise inspections to -- to -- that could prove disruptive to the day-to-day operation. We do have latitude within our directive and I'm empowered by the director of air traffic to conduct surprise audits, if you will, or surprise visits. We try to use them very, very sparingly, only in cases where we feel they're absolutely necessary.

MR. DUNHAM: And what would be one sort of typical situation that might provoke that?

THE WITNESS: The last one I recall was a non-Federal facility that we'd received complaints from the user community that they were providing services apparently using a radar that wasn't certified. We conducted a rather clandestine observation of that operation and indeed found that non-certificated equipment was in use and the controllers had not received training on it.

MR. DUNHAM: Have any no-notice evaluations been performed on an FAA facility?

THE WITNESS: Not in the past three or four years, no.

MR. DUNHAM: Could you please describe in general the functional areas examined in a typical evaluation?

THE WITNESS: Yes, there are four areas that are -- that are scrutinized. They are training, administration, quality assurance, and operations.

MR. DUNHAM: And then how are those -- the checklist items under those areas classified?

THE WITNESS: I'm sorry. I don't understand the question.

MR. DUNHAM: I'm looking for the -- the rating of each individual checklist item as commendable, etc.

THE WITNESS: Oh, I beg your pardon. The --each item is -- is either rated as satisfactory, commendable if -- if a particular degree of excellence is witnessed in that particular checklist item, or as a problem, a problem being denoted only in instances where an FAA handbook or regulation is -- is violated or in cases where we feel that -- that an extreme safety factor is -- is at risk.

MR. DUNHAM: And is there a fourth classification?

THE WITNESS: I'm sorry?

MR. DUNHAM: Is there another classification besides those?

THE WITNESS: I believe we covered informational, satisfactory, commendable, and problem.

MR. DUNHAM: Okay.

(Pause)

MR. DUNHAM: So, what standard was the MSAW item on the CERAP checklist being compared to when the evaluation team was looking at it?

THE WITNESS: There were two evaluations. The two most current evaluations accomplished at Guam were in 1995 and '97. The 1995 evaluation contained an informational item that the Guam MSAW had been disabled to the 54-55 mile ring that we've seen earlier. And that was based on non-delivery of a digital terrain map. We were advised by the facility that that was anticipated to arrive some months late and would rectify the problem that they were encountering with MSAW.

MR. DUNHAM: Okay. And in 1997 was the MSAW referred to at all?

THE WITNESS: The -- in 1997 there was no reference to the MSAW. It was not brought to our attention in the facility as a difficulty. Therefore,we did not identify it.

MR. DUNHAM: And the 1995 evaluation, which was Exhibit P like Papa, pages seven through 17 --excuse me, 16.

THE WITNESS: Say again the pages, please?

MR. DUNHAM: It's P seven through 16.

And in what -- what section is MSAW mentioned?

(Pause)

MR. DUNHAM: Page P14.

THE WITNESS: Thank you.

(Pause)

THE WITNESS: You're right. I didn't see it. It's at the bottom of the page. It -- the item does begin on page P14.

MR. DUNHAM: And what section of the report was that classified in?

(Pause)

THE WITNESS: It appears to be listed under the administrative segment of the report.

MR. DUNHAM: And then it was put in as an informational item?

THE WITNESS: Yes, it was.

MR. DUNHAM: And what -- what is the other item in that area that was classified as informational?

THE WITNESS: The other one has to do with FAA housing and difficulties regarding the FAA's ability to furnish Government-sponsored housing on Guam.

(Pause)

MR. DUNHAM: Can you describe the corrective actions and follow-up processes applied to informational items?

THE WITNESS: Informational items do not always require corrective action. By definition informational items are those that the evaluators feel need to be brought to the attention or could be of special interest to higher management.

MR. DUNHAM: So the inhibition of the MSAW functions at the Guam CERAP did not qualify as a problem under the FAA's evaluation standards?

THE WITNESS: No, sir. As stated earlier, there was no criteria by which it could be measured. Therefore, basically, it was in accordance with national standards.

MR. DUNHAM: Okay. Could you look at Exhibit 3J, page 16?

THE WITNESS: I'm sorry?

MR. DUNHAM: That's 3J, page 16.

THE WITNESS: Oh. Thank you. Yes, I haveit.

MR. DUNHAM: Okay. Paragraph 13-2-7E. Could you read the guidance for the facility managers in section three of that paragraph, please?

THE WITNESS: Yes. 13-2-7B says the facility air traffic managers --

MR. DUNHAM: Sorry. It's E.

THE WITNESS: I'm sorry.

MR. DUNHAM: -- sorry.

(Pause)

THE WITNESS: That's the paragraph that begins "Facility air traffic managers shall ensure that"?

MR. DUNHAM: Yes. And then section three of that.

THE WITNESS: "Three, MSAW parameters are modified as appropriate to minimize the extent of inhibit areas as specified in the NAS configuration management documents, NAS MD 633, NAS MD 643 for MSAW and site adaptation."

MR. DUNHAM: Okay. Did the 54-mile radius inhibited area found at Guam in 1995 meet that standard?

THE WITNESS: It did not. However, it did meet other criteria contained in this same handbookwhich allows facility managers to otherwise modify MSAW temporarily if it's disruptive to the operation. We were advised that was the action that had taken place.

MR. DUNHAM: And is there any standard for how many years temporary could be?

THE WITNESS: No, I can't define that.

MR. DUNHAM: Could you please look at Exhibit P, Papa, one through six, which is the 1997 Guam evaluation report.

(Pause)

THE WITNESS: Okay.

MR. DUNHAM: In this 1997 report there is no mention of MSAW. As we've discussed that generally would indicate that it was satisfactory?

THE WITNESS: That's correct.

MR. DUNHAM: Was it in fact functional at that time?

THE WITNESS: Based on what I've seen, no, it was not. It was --

MR. DUNHAM: It --

THE WITNESS: -- it -- excuse me. I stand corrected and say that yes, it was functional but for all intents and purposes it was useless being only functional for a one-mile radius.

MR. DUNHAM: Would the evaluation team havebeen aware of that having reviewed the '95 report?

THE WITNESS: We would not have been unless we were alerted by facility personnel. Software in --in the automation systems used by air traffic controllers, quality assurance is assured through configuration management, and I have no -- neither the expertise nor the methodology to go in and check those systems.

MR. DUNHAM: Okay. In the '95 report the team was aware that the function was inhibited, correct?

THE WITNESS: Right.

MR. DUNHAM: The '97 team would have reviewed that report?

THE WITNESS: In all certainty, yes, they would have reviewed that report.

MR. DUNHAM: Would they have asked the simple question at that time of whether MSAW was functioning as intended?

THE WITNESS: I suspect that they either asked that question or they asked if the new digital terrain map had been installed, either one, which would have indicated to them that -- that this informational item no longer existed.

MR. DUNHAM: And so, the fact that the MSAWwas not in fact working was of no particular concern to the evaluation?

THE WITNESS: No, sir, I would not say that. I would say that they were not made aware of it or they had reason to believe that that situation had been corrected.

MR. DUNHAM: So you're saying that it was noted as inhibited in the '95 report and the '97 team wouldn't be aware of it?

THE WITNESS: I'm sorry. Say that again?

MR. DUNHAM: You're saying that in the '95 evaluation where it was noted as inhibited the '97 team would not be aware that it had continued to be inhibited?

THE WITNESS: That is -- that's apparently what has happened, yes.

MR. DUNHAM: Okay.

(Pause)

MR. DUNHAM: In Exhibit R, take a look at that one, please. R like Robert.

(Pause)

MR. DUNHAM: Yeah, it's 3R.

THE WITNESS: Okay. Say again the number, please?

MR. DUNHAM: It's 3R like Robert. It's asafety recommendation.

(Pause)

THE WITNESS: R3?

MR. DUNHAM: Yeah, it's Exhibit R. It says 1994 -- I believe it's November 21st, 1994, is the date on that.

THE WITNESS: Okay. Yeah, '94, 186 through 188?

MR. DUNHAM: That's correct.

As Mr. Howell explained, that recommendation referred to some configuration problems with MSAW adaptations at Dulles Airport. It would -- would it be a function of the evaluation teams to go to a level where those problems would be detected or is that, as you said, only detectable through configuration management?

THE WITNESS: This sort of audit would be the initial responsibility of the office of primary interest, in this case either the air traffic requirements or the air traffic operations organizations. In cases where compliance is questioned my unit has been asked to go out specifically and --and check various features. But routinely, no, we would not have been involved in this response.

MR. DUNHAM: Okay. Wouldn't thatrecommendation -- whereas accepted by FAA, they replied to the Safety Board that they would be conducting a review in order to check the parameters as specified in that recommendation. As we've seen, that recommendation was apparently attempted but the review process did not actually succeed in locating those problems. Does the FAA have any evaluation process that would track responses to safety recommendations to ensure that they've been completed properly?

THE WITNESS: Yes, and -- and in my organization these are referred to as special emphasis items. For example, subsequent to the -- to the Guam accident Air Traffic Operations and AOS jointly asked us to go out and as a special emphasis item interview automation specialists in facilities to ascertain their level of compliance with national directives. This is something that will run for a year or two years based upon their request and then will expire.

MR. DUNHAM: Okay. That -- we'll talk about that more in a minute.

Do you know if, in reference to the 1994 review, was there any sort of follow-up evaluation performed?

THE WITNESS: I don't know.

MR. DUNHAM: Does the Air Traffic Servicehave any quality assurance program in place other than facility evaluations that should have detected these chronic MSAW problems?

THE WITNESS: There are basically three evaluations-type processes in effect in Air Traffic Service. One is the one that I manage, which looks at air traffic operational issues. Airways Facilities has a similar effort underway for compliance to national standards for hardware and so on and so forth. And then AOS maintains a separate quality assurance role in assuring the quality of the -- of the software that they develop.

MR. DUNHAM: But at the time of the Guam accident that software was actually the responsibility of Air Traffic Service as far as its functionality, correct?

THE WITNESS: I -- I believe it was in transit, so I would hesitate to say precisely whose responsibility it was on that given day.

MR. DUNHAM: Was your office responsible for that item before the transition?

THE WITNESS: For what item?

MR. DUNHAM: The MSAW quality.

THE WITNESS: No. As -- as far as the software?

MR. DUNHAM: Well, if it belonged -- I'm trying to establish that you're saying that we're not sure whether it belonged to Air Traffic or Airway Facilities.

THE WITNESS: No, the organization I head has never had responsibility for -- for auditing MSAW or any other operational software. We -- we will, if made known by the -- by the people who use it, certainly identify it to the organization that has primary interest over it. But again, quality assurance is assured mainly through -- through configuration management.

MR. DUNHAM: Okay. So on the -- at the time of the Guam accident, who was the office of primary responsibility for MSAW configuration?

THE WITNESS: It was somewhere between the ATO, the ATR, and the AOS organization. And I -- I can't tell you with precision.

MR. DUNHAM: All right. So do you know --are you aware of who would have been responsibility --or who would have been responsible for oversight of the work of local automation specialists?

THE WITNESS: Again, because the transition between Air Traffic and AOS was taking place I'd be guessing.

MR. DUNHAM: Well, the automation specialists are and remain Air Traffic employees, correct?

THE WITNESS: They are, yes.

MR. DUNHAM: Okay. So wouldn't that put the responsibility for their work with Air Traffic?

THE WITNESS: It -- it should but again, because of the transition I'm not sure. There were various responsibilities being transitioned over from AT to AOS. I was not intimately familiar with -- with that transition or how it was taking place so I can't speak to it with any authority.

MR. DUNHAM: All right. I think we'll skip that one.

The evaluational order that the teams use when they go to the field provides standards references for various checklist items. How are those standards selected?

THE WITNESS: They're designed first and foremost based on requirements contained in the controller's handbook 7110.65. Also, facility operations and administration and other air traffic documents. The checklist is -- is updated frequently because of the number of manuals that references, they change on different cycles. Therefore, maintaining the references for each and every item is -- is somewhat ofa difficult chore.

We also accept input from both air traffic users and air traffic providers and the services who --who direct and develop air traffic policy for special emphasis items and areas of current concern that we look at.

MR. DUNHAM: So, is the objective in selecting the standards to ensure that that checklist item is functionally acceptable or simply meets some administrative standards or operationally useful standards?

THE WITNESS: Could you repeat that, please?

MR. DUNHAM: Let me rephrase it. The -- the standard, for example, on the checklist for MSAW as you've stated refers to the facility operation and administration guide, and the guidance in that manual is very general. For some example, the EARTS III systems, there are specific configuration management documents which ensure the performance of MSAW is according to standard. Those references are not part of the standards that are used on the checklist.

THE WITNESS: I still didn't understand the last sentence you said.

MR. DUNHAM: The -- the standard on the checklist item for compliance --

THE WITNESS: Mm-hmm.

MR. DUNHAM: -- is not the technical reference for MSAW. It's instead a general management reference --

THE WITNESS: Right.

MR. DUNHAM: -- which doesn't necessarily ensure that the configuration meets performance standards for MSAW. Is that normal?

THE WITNESS: Yeah. Again -- again, considering that -- that this evaluation is aimed only at -- at operational compliance with national standards, the technical standards under which MSAW is written and governed would -- would be a matter for those developing the software to monitor. Again, I don't have the expertise with me along on evaluation trips to go into that level of detail in the automation software programs.

MR. DUNHAM: Okay. Does your office have any responsibility for developing the FAA response to the 1994 safety recommendation we spoke of a minute ago?

THE WITNESS: My office today did not exist in 1994 when that response was crafted.

MR. DUNHAM: Mm-hmm.

THE WITNESS: I was affiliated with -- with the -- as a matter of fact, I was the director of theprior organization, the Office of Air Traffic System Effectiveness. We would have been involved in fielding the question. However, the actual response would have been written probably by the Air Traffic Requirements Organization at that time.

MR. DUNHAM: Okay. Have you made any changes to the evaluation process in response to the Korean Air accident or any issues arising from it?

THE WITNESS: Yes, we have. As Mr. Howell described to you, our plans for -- for future configuration management of software built for MSAW as an interim measure, we've -- my office has sat down jointly with Air Traffic Operations. We've come up with a list of -- of questions which we now pose to automation specialists within a facility to try to measure compliance. I'll be candid and tell you it's -- it's not a perfect system and that's why we're working towards one of -- of tighter configuration management because it's going to be the only -- the only solid cure to what we're trying to achieve.

MR. DUNHAM: All right. No further questions.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman. Chairman, I have no questions. Thank you.

CHAIRMAN FRANCIS: Thank you.

Boeing Company?

MR. DARCY: We have no questions, Mr. Chairman.

CHAIRMAN FRANCIS: Barton ATC?

MR. E. MONTGOMERY: No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPT. KIM: I have one question. My official assistant ask you.

FIRST OFFICER CHUNG: Our question involves -- and thank you, Mr. Canoles. If the Guam Tower controller theoretically had used the D-BRITE facility in your judgment -- I'm not sure if we're asking the right person -- but would this have been a breach of FAA regulations since it was not commissioned? And if that's not a fair question, you don't have to answer it.

THE WITNESS: I -- I would respond and say that -- that we do not allow the use of non-certified air traffic equipment as -- as we wouldn't allow someone to fly a non-certified aircraft. Until it was certified to meet certain stringent safety and accuracy requirements we would -- we would not allow it nor we would encourage it or allow it.

FIRST OFFICER CHUNG: So in essence you wouldnot allow -- they would not be authorized to use D-BRITE equipment as it was?

THE WITNESS: That's correct. They would be told not to use it.

FIRST OFFICER CHUNG: Thank you.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Thank you, sir. No questions.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: No questions.

CHAIRMAN FRANCIS: I just -- I guess I'd ask one question, and it refers back to some of the things that Scott was talking about. This is the issue of --of where an evaluation office, quality assurance office reports within an organization. Has the FAA ever considered that your office reporting somewhere other than to -- to the AT 1 or who -- to whom do you report, I guess is --

THE WITNESS: Mr. -- Mr. Chairman, I do report to AT 1. Air Traffic --

CHAIRMAN FRANCIS: I'm not trying to -- totake a piece out of my friend Mr. Morgan's hide here. I --

THE WITNESS: Thank you.

CHAIRMAN FRANCIS: -- I think it's an important question.

THE WITNESS: Thank you, sir, and I'll tell him you said that.

We have -- we have never moved to do it. We -- we once had a direction from the secretary of Transportation which caused us to take it out of Air Traffic. The head of Air Traffic at that time, Bill Pollard, was successful and prevailed with the next secretary to bring it back. We realized that there is -- there is the potential for being too close to topics being employed in the same organization. However, we feel that that is more than adequately balanced by the fact that we can maintain a work force of fresh, current people who are -- are capable of evaluating today's current issues in air traffic.

CHAIRMAN FRANCIS: I guess I'd say that, you know, we -- we spend a lot of time in this industry --again, and this is not just with the FAA, but we talk a lot, to -- to airlines particularly, about the importance of their safety departments not reporting through operations because there is a potentialconflict but rather reporting directly to the CEO of the organization, so I -- I would like to -- to I guess suggest to the FAA that they might want to at least take a look at this. I'm not sure that Jane Garvey needs any more people reporting to it either, but --but it's a -- it's an extraordinarily important question and I think that the questioning here indicates that we do have some concerns in this area.

THE WITNESS: Again, sir, I think Mr. Morgan has moved to that. He -- he has established me as an officer reporting directly to him. Prior to that we were a service in competition for resources with other air traffic services. So, as -- as a peer to the directors who set policy in air traffic, I certainly have a free voice and can get to him with -- with any degree of urgency I demand to -- to bring issues to his -- to his office.

CHAIRMAN FRANCIS: Thanks very much for your testimony.

THE WITNESS: Yes, sir.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: Now we will -- I'm sure that there's nobody here that's at all interested in taking a break, but I'm going to dictate it anyway. We'll take a break. It's -- until 4:00.

(Whereupon, a brief recess was taken.)

CHAIRMAN FRANCIS: All right. Our -- our next witness is Mr. Carl Schellenberg, the director of Potomac Tracon Development, FAA in Washington.

Whereupon,

CARL SCHELLENBERG

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF CARL SCHELLENBERG DIRECTOR POTOMAC TRACON DEVELOPMENT, ATS-20 FEDERAL AVIATION ADMINISTRATION WASHINGTON, D.C.

MR. SCHLEEDE: Mr. Schellenberg, please give us your full name and business address for the record?

THE WITNESS: My full name is Carl B. Schellenberg. My business address is FAA Headquarters, 800 Independence Avenue, Washington, D.C.

MR. SCHLEEDE: And what is your present position with the FAA?

THE WITNESS: I'm sorry. I couldn't hear you.

MR. SCHLEEDE: What is your present position with the FAA?

THE WITNESS: My present position is director of the Potomac Program.

MR. SCHLEEDE: Would you give us a brief description of your education, training, and experience that brings you to your present position?

THE WITNESS: Yes. I have a Bachelor of Arts degree, Juris Doctor degree, and Master of Management degree. I've been employed by the Federal Aviation Administration for 29 years. I have served in capacities within the legal organization as regional counsel, chief of regulations and enforcement. I have served as deputy regional administrators in two regions. I was regional administrator in FAA's Western Pacific region. I have been director of System Capacity and Requirements. And in the immediate time of this accident and the aftermath I was acting as deputy associate administrator for Air Traffic Services.

CHAIRMAN FRANCIS: We -- we appreciate your only mentioning half of the positions that you've held in the FAA.

THE WITNESS: Thank you, Mr. Francis.

MR. SCHLEEDE: Thank you. Mr. Dunham will continue the questioning.

MR. DUNHAM: So, at the time of the accidentyou were deputy director for Air Traffic?

THE WITNESS: Deputy associate administrator for Air Traffic Services.

MR. DUNHAM: All right. Deputy associate administrator, okay.

To -- to start off kind of a follow-up from the -- the previous witness. Can you tell me who the automation specialists work for?

THE WITNESS: At what time?

MR. DUNHAM: At the time of the Korean Air accident.

THE WITNESS: At the time of the Korean Air accident the automation specialists were part of the Air Traffic Organization.

MR. DUNHAM: And who was responsible for overseeing their work?

THE WITNESS: Under those circumstances the Air Traffic Organization, the director of Air Traffic was responsible for that and the associate administrator for Air Traffic Services -- was responsible for direction above that.

MR. DUNHAM: So, at a -- let's go to a lower level. Were they reporting to the facility manager? You know, I'm trying to figure out who -- who would have been responsible for their quality assurance oftheir work.

THE WITNESS: Well, you -- let's talk two things. You talked about the reporting relationship of the automation specialists. That was a reporting relationship to the air traffic facility manager within that facility.

At the time of this accident, however, there was because of the policy that existed at that time some lack of clarity in who had the overall quality assurance requirements for assuring that the integrity of programs such as MSAW.

MR. DUNHAM: So, does that mean they weren't working for anyone who was actually responsible for the quality of their work?

THE WITNESS: That means that -- that there was no single entity at that point clearly responsible for the quality of programs and the total service delivery of -- of the MSAW program. That has since been changed.

MR. DUNHAM: Okay. Thank you.

To your knowledge, were there any concerns within FAA about MSAW performance before the Korean Air accident?

THE WITNESS: While there were, of course, continuing concerns about the program, major concernsabout MSAW started with the investigation following this accident.

MR. DUNHAM: How about before the accident?

THE WITNESS: Well, as I said, there were continuing concerns. There were items that you've mentioned previously in testimony with regard to the recommendations of the Board, and we were, of course, concerned with the program at that point. That concern escalated dramatically following this instance.

MR. DUNHAM: Okay. What -- what remedial efforts were in progress before the accident, if any?

THE WITNESS: Well, the efforts that we had talked about, some of the things that you have mentioned on some of the safety recommendations, those kinds of efforts were the continuing remedial efforts with regard to MSAW.

MR. DUNHAM: Okay. So, after the -- the 1994 review, for example, was there any management oversight to see if that review had been effective?

THE WITNESS: Was there any management oversight? Yes, there was.

MR. DUNHAM: And what was the assessment of the management as far as the quality of that review?

THE WITNESS: Well, I -- you -- I have to --I have to answer as of a point in time. If you ask mewas there management oversight, yes, I will tell you. If you ask me as of today am I satisfied with the extent of the management oversight that was exercised at that time, I am not. That's why we have changed it and -- and improved it.

MR. DUNHAM: All right. And what will FAA be doing to ensure that MSAW performance does not deteriorate?

THE WITNESS: Well, there are variety of things that we have done. First of all, we've established clear responsibility in a single organization for all of the aspects relating to MSAW, its performance, and its continued performance. That organization has established a number of very important pieces -- Mr. Howell testified to them earlier -- such as the establishment of a -- of criteria and standards against which MSAW performance will continue to be gauged and implemented. He's mentioned to you standards by which he will go back and do periodic updates against those standards to ensure that that performance continues. He's developed a variety of automated techniques and tools to quickly, promptly, and accurately determine the performance of all the M-site -- MSAW facilities.

In addition, we've developed flightinspection protocols and criteria to supplement that effort so that with the clear-cut responsibility, the tools, and the standards we feel we have at this point a far better policy, guidance, and direction of the MSAW system.

MR. DUNHAM: Okay. So, does FAA plan to continue to provide AOS with the level of support required to maintain the quality of that program?

THE WITNESS: Yes.

MR. DUNHAM: Okay. After this reorganization, do you still plan to continue to have automation specialists in the field facilities?

THE WITNESS: There will be a -- a change in the role of the specialists in the facilities to a multi-function approach and -- and responsibility. We have transitioned and increased the level of support in the AOS organization for accomplishing what previously was work done by the automation specialists. So there will be some decrease in the -- of the level and numbers of people within the air traffic organization. That now will be covered and accomplished by the AOS organization to replace that and improve that effort.

MR. DUNHAM: So there will still be people in the field with responsibility for some automation issues?

THE WITNESS: That is correct.

MR. DUNHAM: Will those people have access to sufficient training to ensure they're competent at that?

THE WITNESS: Yes.

(Pause)

MR. DUNHAM: And a more general question. In response to the earlier recommendation we discussed that provoked the 1994 review, the Safety Board received a letter from the FAA in response to that saying that this review had been completed. As that's been testified to today it was something less than effective. What policy changes do you anticipate to ensure that the Board can have confidence in responses from the FAA to a safety recommendation?

THE WITNESS: Let me answer that this way, Mr. Dunham. What we did following the '94 request I think was a good faith attempt to try to get a -- an accurate and complete response back to the Board. What we have learned since then and as a product of -- of our efforts following this particular accident that in the case of -- of issues involving complex systems such as MSAW and its adaptation to simply pull each of the offices and ask them if in fact they meet all the established criteria is not a satisfactory means toreally test whether that system is doing what it needs to do. That's why we have made the change, particularly the ones Mr. Howell testified to, so that in the future where we have to -- to respond and -- and describe the -- the state of the system in such complex systems we will use a similar process to that which we have described here where necessary.

There are some circumstances with less complex issues where such a polling can get a rapid, quick response of the status of individual items. In those cases we will continue to use that kind of process. What we will do is -- is exercise better judgment as to which of the tools works well under the particular circumstance we're trying to respond to. We learned a lot as a result of this.

MR. DUNHAM: And the FAA runs a -- a fairly, you know, decentralized organization. There are lots of facilities out there responsible for different functions. Even after receiving such a response from a facility will there be any formal follow-up efforts as part of the facility evaluation process or some other evaluation process to verify that that item has in fact been complied with?

THE WITNESS: Yes. We will use a combination of -- of the means that are most effective. In thisparticular case we're talking about MSAW. The -- the -- the use of -- of an evaluation program is probably not the most effective means to ensure the continued integrity of that system. The responsibility assigned to a specific focal point as we have, the techniques and tools Mr. Howell testified is a superior way, really, to keep the status of that system up-to-date and current and -- and known rather than using an evaluation process.

There are -- there are pieces of the evaluation process that will work well with that new system. What we will do is try to have the optimum mix of those two to stay on top of the issues. So there will be some pieces on an emphasis basis that Mr. Canoles and -- and his organization will continue to do, but the real driver in keeping track of the performance of MSAW will lie with the AOS organization.

MR. DUNHAM: All right. Can you describe FAA's future plans for management of air traffic-related software?

THE WITNESS: Our future plans for the management of air traffic-related software?

MR. DUNHAM: Yes.

THE WITNESS: As I indicated to you before, we are -- we have transitioned and moved most of thatresponsibility for air traffic-related software into the AOS organization to administer and maintain it with some support left within the Air Traffic Organization to provide the necessary field connectivity to make that happen. That's the general structure of the way we're going to proceed for the other systems, if I understood your question.

MR. DUNHAM: All right. I'm looking at the -- the more general issue of not just MSAW but are you -- your intention is to effectively place AOS in charge of all air traffic-related software management?

THE WITNESS: That is the -- that is the transitional step that we are referring to, yes.

MR. DUNHAM: Okay. And that'll continue with the STARS program and anything else that comes in later on?

THE WITNESS: It will occur in -- in the optimum blend with all those programs, yes.

MR. DUNHAM: Okay. No further questions.

THE WITNESS: Thank you.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman. No questions. Thank you.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. Noquestions.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPT. KIM: No, thank you, sir.

CHAIRMAN FRANCIS: Barton ATC?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: We have no questions, Mr. Chairman.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: No.

CHAIRMAN FRANCIS: Carl, we shouldn't let you off this easily.

THE WITNESS: Why not?

(Laughter)

CHAIRMAN FRANCIS: Oh, sorry. Mr. Donner. You've been so -- you've been so non-responsive all day long I forgot all about you.

MR. DONNER: Thank you for finally recognizing the FAA, sir. We have no questions either.

(Laughter)

CHAIRMAN FRANCIS: Why does that not surprise me?

I guess I'd just say, Carl, and we talked a little bit about this at the break, the question of the evaluation and quality assurance function that I mentioned to Mr. Canoles. I think that this is something that's interested and interesting, important, and I hope you folks will be looking at.

THE WITNESS: Yes, Mr. Francis. We continue to -- to examine that. As -- as you and I chatted, the reporting relationship has been in a variety of places when -- within the FAA. That location of the reporting relationship does not necessarily ensure success of the program. It's terribly critical we have the right people administering the program regardless of where the reporting relationship, and that's the really most important base.

CHAIRMAN FRANCIS: Thanks very much.

THE WITNESS: Thank you.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: Next witness will be Lewis Zeigler, who is the principal operations inspector for KAL, the Flight Standards District Office in San Francisco. Mr. Zeigler will be the last witness today.

Whereupon,

LEWIS ZEIGLER

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF LEWIS ZEIGLER KOREAN AIR GEOGRAPHIC OPERATIONS INSPECTOR FAA FLIGHT STANDARDS DISTRICT OFFICE SAN FRANCISCO, CALIFORNIA

MR. SCHLEEDE: Mr. Zeigler, please give us your full name and business address for the record?

THE WITNESS: Lewis I. Zeigler. The business address is 831 Nitten Road, Burlingame, California, 94010.

MR. SCHLEEDE: And you work for the FAA?

THE WITNESS: Yes, sir. I do.

MR. SCHLEEDE: In what position?

THE WITNESS: I'm a international geographic inspector at the San Francisco International Field Office.

MR. SCHLEEDE: Could you give us a brief description of your training, education, and experience that brings you to that present position?

THE WITNESS: I have a bachelor of arts degree. I'm a retired Marine Corps aviator. I flewcommercially for 10 years. I've been with the FAA for a little more than 12 years. And I've been an international geographic inspector for the last 10 years and five months.

MR. SCHLEEDE: Thank you. Captain Misencik?

CAPTAIN MISENCIK: Hello, Mr. Zeigler.

Prior to working in the western area you were a geographic inspector in Europe, I believe, weren't you?

THE WITNESS: Yes, sir. I was.

CAPTAIN MISENCIK: How long were you over there?

THE WITNESS: Seven years.

CAPTAIN MISENCIK: And how long have you been now in -- working out of California?

THE WITNESS: Since the first of October of 1994.

CAPTAIN MISENCIK: Okay. At the time of the accident last July what international carriers were you responsible for for providing oversight?

THE WITNESS: I had Air Nehru, Korean Airlines, Asiana Airlines, Garuda, Malaysia, Japan Air Charter, and Japan Air System.

CAPTAIN MISENCIK: Are you still providing oversight for Korean Airlines?

THE WITNESS: No, sir. I am not.

CAPTAIN MISENCIK: What airlines do you oversee at this time?

THE WITNESS: I have Air China, China Eastern, China Southern, All Nipon, Nipon Cargo, and I have the geographic responsibility for one of the Mexican airlines who we don't hold the op specs for 'em, Allegro.

CAPTAIN MISENCIK: When did you cease providing oversight for Korean Air?

THE WITNESS: In October '97.

CAPTAIN MISENCIK: Was that a scheduled transition or --

THE WITNESS: No, sir. We -- usually once a year or every two years we kind of rotate the airlines around to the different inspectors, but in this case we had an inspector that retired so we had to redivide all the airlines up. And then after that we had another new inspector came in the office some years later, so we ended up having to divvy 'em up again.

CAPTAIN MISENCIK: Concerning Part 129 oversight, how is Part 129 authority granted to foreign airlines?

THE WITNESS: It's through the IKO and the FAA grants the -- well, IKO grants the U.S. Governmentthe authority to inspect foreign airlines.

CAPTAIN MISENCIK: But who grants the -- the certificate? Is that the -- the FAA?

THE WITNESS: The FAA.

CAPTAIN MISENCIK: I understand. Does any other agency have any authority in granting Part 129 authority?

THE WITNESS: Only the Economic Authority, which is invested with the Department of Transportation.

CAPTAIN MISENCIK: How is being responsible for Part 129 oversight similar and different from Part 129 oversight?

THE WITNESS: You mean Part 121?

CAPTAIN MISENCIK: I'm sorry. How does Part 120 -- how is it different from Part 121, being a Part 121 --

THE WITNESS: Well, there are some similarities in that we do some of the same types of inspections, such as ramp inspections, station facility inspections, trip records inspections. We issue op specs. But in the case with the 121 carrier, you have the responsibility of approving all their training programs, all their manuals, lots of things that we do not have the authority to do under 129.

CAPTAIN MISENCIK: Who approves the -- who handles the oversight that normally would be provided for under Part 121 that -- that you don't do under Part 129?

THE WITNESS: The foreign government civil aviation authorities of whatever country we're talking of.

CAPTAIN MISENCIK: Just backtracking a little, when you were providing oversight at the time of the accident for Korean Air and all of the other carriers, how many airplanes normally were -- would you estimate that that included at that time?

THE WITNESS: You mean how many aircraft? That's -- my airlines have?

CAPTAIN MISENCIK: Yes.

THE WITNESS: I have no idea. It's quite a few.

CAPTAIN MISENCIK: Okay. Do you have any oversight responsibility regarding ground and flight training at all with foreign carriers?

THE WITNESS: No, sir. We do not.

CAPTAIN MISENCIK: Do you have any basic fundamental knowledge or any requirement to have basic or fundamental knowledge of the general operations manual or any of the -- the flight operationsprocedures for the foreign carriers?

THE WITNESS: No, sir. We don't.

CAPTAIN MISENCIK: Do you do en route inspections on the foreign carriers you oversee?

THE WITNESS: No, sir. We do not.

(Pause)

CAPTAIN MISENCIK: The -- the responsibility that you have under Part 129 or -- or actually, the --the responsibilities that you share with the foreign governments, what -- what defines those responsibilities? Is there a document or the sharing of responsibilities, the --

THE WITNESS: I --

CAPTAIN MISENCIK: -- 129.

THE WITNESS: The IKO articles and the annexes grant us the authority to inspect aircraft within the United States, and our FAA handbooks and other orders tell us how we do our job.

CAPTAIN MISENCIK: What incentive is there for Part 129 air carriers to comply with Federal Aviation regulations?

THE WITNESS: I'm sorry, sir. Would you --

CAPTAIN MISENCIK: I said what incentive is there for foreign airlines to comply with our regulations? What --

THE WITNESS: Well, they -- the incentive is if they want to operate in the United States then they must comply with the IKO rules and Air FAR 129.

CAPTAIN MISENCIK: Okay. What procedure --by which procedure are concerns, letters of investigation, or violations handled concerning foreign carriers that are operating under Part 129?

THE WITNESS: You mean how we go about doing a violation?

CAPTAIN MISENCIK: Yes.

THE WITNESS: Well, if we were to uncover something wrong we would initiate a violation or enforcement package. It would then go to the regional counsel's office, and it's handled by the regional counsel. They then forward it to Washington. I think from Washington it goes to the State Department and thence to the foreign government.

CAPTAIN MISENCIK: How does the -- how is the airline itself notified of this letter of investigation or -- or violation?

THE WITNESS: Well, at the time we initiate the investigation we do send a letter of investigation to the airline or to the individual pilot if it was a -- a violation against the pilot himself. And generally speaking, we would also send a copy of that to theforeign civil aviation authorities so that they would at least be informed that it was -- what was going on.

CAPTAIN MISENCIK: In your experience, how have the foreign carriers that you oversee responded to LOIs or enforcement actions or other discrepancies that you have brought to their attention?

THE WITNESS: Well, if you're asking do they ever respond, yes, they do. I've always gotten an answer back from the airline.

CAPTAIN MISENCIK: Well, have they responded in a manner consistent with, say, the way U.S. carriers would respond to LOIs or other enforcement action?

THE WITNESS: Yes, sir.

CAPTAIN MISENCIK: Do you do ramp checks also on foreign carriers?

THE WITNESS: Yes, sir. We do.

CAPTAIN MISENCIK: Have you ever been refused admittance to an aircraft or -- or a facility by foreign -- a foreign airline?

THE WITNESS: No, sir. I have not.

CAPTAIN MISENCIK: If you would be refused admittance to an aircraft, how would that be -- what would be your marching orders?

THE WITNESS: Well, I -- first thing I would do, inform the captain, remind him of the fact that IKOregulations give us the authority to inspect his aircraft and his crew and recommend that he maybe change his mind about allowing me to inspect him. Should he not do so, I would inform him that the first action I would take would be to inform the civil aviation authorities of his government that I'm being denied access. I would also open an investigation for filing a violation against him. And hopefully they would change their minds. If they didn't, then that's what I would do.

CAPTAIN MISENCIK: Do you normally -- or how do you interact with the KCAB in oversight of Korean Airlines or when you were overseeing Korean Airlines? Was there a -- a flow of information between the two government agencies?

THE WITNESS: Not generally speaking, but on a couple occasions where we discovered a problem are there I did send a -- a letter to the KCAB to inform 'em of what we had found.

CAPTAIN MISENCIK: Uh huh. Do you receive reports of KCAB concerns or -- with -- or did you receive reports of KCAB concerns with Korean Airlines?

THE WITNESS: No, sir.

CAPTAIN MISENCIK: Do you receive -- or were you furnished copies of Korean Air manuals, operationalprocedures, or -- or any other materials from the airline?

THE WITNESS: No, sir. We do not.

CAPTAIN MISENCIK: Are they required or why didn't you receive them --

THE WITNESS: No, sir. They -- we're --we're -- they're not required to submit copies of their manuals to us. The only exception to that would be if the airline was operating a U.S.-registered aircraft. Then the FAA has to improve the maintenance program and the MEL for that aircraft.

CAPTAIN MISENCIK: The -- is it required or -- that you send reports of your inspection activities concerning Korean Air to the KCAB?

THE WITNESS: No, sir. There is no requirement.

CAPTAIN MISENCIK: So essentially, there is no requirement for an exchange of information between the -- the two overseeing agencies?

THE WITNESS: No, sir.

(Pause)

CAPTAIN MISENCIK: With the airlines that you were overseeing at the time that you were providing oversight to Korean Air, how did Korean Air compare with the other airlines you were overseeing as far asdiscrepancies, concerns, LOIs?

THE WITNESS: Average.

CAPTAIN MISENCIK: Uh huh.

THE WITNESS: No better, no worse, you know.

CAPTAIN MISENCIK: There -- the discrepancies that manifested themselves at Korean Air, did they differ either in quantity or nature from any of the other airlines?

THE WITNESS: No, sir.

CAPTAIN MISENCIK: During the time period you were overseeing Korean Air, how many letters of investigation, violations, or enforcement actions did you initiate against them?

THE WITNESS: I initiated one violation, a second one was to one of their pilots, and that one was settled with a warning letter.

CAPTAIN MISENCIK: Okay. You -- and one was settled and one wasn't?

THE WITNESS: Well, one is still open, sir.

CAPTAIN MISENCIK: I understand. Has Korean Air ever failed to respond to a letter of investigation initiated by your office?

THE WITNESS: No, sir. Not to my knowledge.

CAPTAIN MISENCIK: Does the State Department or any other government agency other than the FAA haveany jurisdiction in enforcement actions against foreign carriers?

THE WITNESS: No, sir.

CAPTAIN MISENCIK: Has any government agency suggested leniency or that you take it easy in providing oversight to any of the foreign carriers?

THE WITNESS: To me, sir?

CAPTAIN MISENCIK: Yes.

THE WITNESS: No, sir.

CAPTAIN MISENCIK: Are you aware of -- of that situation happening to any other POI?

THE WITNESS: No, sir. I'm not aware of any such thing.

CAPTAIN MISENCIK: Uh huh. Well, I was just curious about your comment to me that indicated maybe there was something else, but --

THE WITNESS: Well, I'm -- I'm sure there's political pressure being applied to the top echelons of the FAA, but what goes on up there I'm not aware of. But personally, nobody's tried to put any pressure on me.

CAPTAIN MISENCIK: Uh huh. How are you sure of that, Mr. Zeigler?

THE WITNESS: Well, I'm -- I'm assuming just a fact of life, politics being politics.

CAPTAIN MISENCIK: I understand. What were some of the examples of your findings with Korean Air in ramp inspections or other -- other oversight -- some of the discrepancies that you had uncovered?

THE WITNESS: Well, one of the problems that we find probably with every one of the foreign carriers is with the floor path escape lighting system. On arrival we'll usually find the whole series, maybe a whole section of the cabin where the lights are inoperative. And in generally speaking, they fix 'em before they leave because the MEL says that they cannot have more than two in a row out at any one time. That's one of the more common things that we find.

The other thing is occasionally we'll find pilots that either don't have their license or they don't have their medical certificates with them. Those are probably the three most common things that we find.

CAPTAIN MISENCIK: Is that pretty common among the -- the carriers you -- you oversee or was that --

THE WITNESS: Everybody.

CAPTAIN MISENCIK: So, was there anything that stood out in your mind about Korean Air as far as oversight -- your oversight of the airline compared to the other carriers you oversaw?

THE WITNESS: No, not that I can think of offhand.

CAPTAIN MISENCIK: As a result of the accident in -- in Guam, are you aware of any changes that have occurred in -- in their operations, Korean Air operations?

THE WITNESS: I'm not aware of any.

CAPTAIN MISENCIK: Are you aware of any changes or proposed changes that have occurred at the FAA as a result of -- in Part 129 operations a result of the Guam accident?

THE WITNESS: I'm not aware of any, sir.

CAPTAIN MISENCIK: Okay. As a -- an international geographic or -- I know it's not a correct term, but POI, what changes would you like to see that would make your job of oversight more efficient or --

THE WITNESS: Well, I would like --

CAPTAIN MISENCIK: -- more safety-directed?

THE WITNESS: I would like to see FAR 129 rewritten in a more thorough and complete manner at least similar to the way 121 is written.

I would like to see the new automated 129 op specs produced so we can start using 'em.

And I would like to see more thoroughguidance in our handbooks and our orders for geographic international inspectors.

And one other thing that I would like to see corrected would be the addition of in -- in FAR 91 the addition of all of the articles of IKO and the annexes rather than the one place that it quotes in 91703 A2 where it only refers to Annex 2. The other annexes, particularly Annex 6, are far more important. That's the heart of the operating parts of the annexes. And there are certain of the articles that are also extremely important.

CAPTAIN MISENCIK: Okay. Thank you, Mr. Zeigler. I don't have any other questions.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Mr. Chairman. We have no questions. Thank you.

CHAIRMAN FRANCIS: Korean Air?

CAPT. KIM: No questions, sir. Thank you very much.

CHAIRMAN FRANCIS: Barton ATC?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: No questions, Mr. Chairman. Thank you.

CHAIRMAN FRANCIS: Mr. Donner, sir?

MR. DONNER: No questions, sir.

CHAIRMAN FRANCIS: Greg?

MR. FEITH: Yes, sir. I do have some questions. And I am going to beg your pardon, Mr. Chairman. I know that you were talking about not having any redundant questions but I just want to make sure that I have the picture.

Mr. Zeigler, in brief terms, what do you do as a POI or as a -- international geographic inspector as far as oversight is concerned? I heard you say that you don't do en routes, you don't have to review manuals, you don't approve training programs. You do take some sort of violation action when there is a violation that occurs. Given the number of airlines that you were overseeing, what is it in the broad sense that you focus in on to take corrective action on a 129 operator?

THE WITNESS: Well, of course, the first thing that we do on all the carriers is try to maintain their op specs up-to-date. Whenever they make changeseither in aircraft or places that they're -- they want to go, they're supposed to submit changes to us and we have to keep their op specs updated.

They're -- as I mentioned, the inspections that we do are set forth in our annual work program, and we are required by our annual work program, the NPG, to do a station facility inspection, a trip records inspection, a ramp inspection, and depending on the airport, a de-icing inspection if it's one of those that's located in the northern part of the country for each airport within the U.S. that that airline operates to.

MR. FEITH: Okay. Now, you -- and this is where I got confused because you told Captain Misencik that you don't get their manuals and the updates to their manuals, yet you -- you do track their op specs, so you -- you're getting that on a recurrent basis to understand when the changes are coming down the line in their op specs, is that correct?

THE WITNESS: I don't follow you there.

MR. FEITH: You said that you don't -- you don't have any manuals from the carrier that you're responsible for.

THE WITNESS: That's correct.

MR. FEITH: But you do track the op specs andchanges to their op specs.

THE WITNESS: We -- we maintain the op specs in our office.

MR. FEITH: Okay. With that in mind, how are these changes communicated?

THE WITNESS: Well, the airline if they wish to make any changes, such as adding an airport or taking an airport away or if they buy three new airplanes and they want to add those aircraft, they must let us know. They send a copy -- their blank op specs pages which we give to each airline, and they fill out these new pages and send them to us in duplicate. And we review it and we either approve it or maybe we find some mistakes and send it back to 'em. But in any case, once it's approved then it goes into their file.

MR. FEITH: Okay. Let me -- let me just digress a little bit because, again, I got confused with the communication. You said you don't communicate on a regular basis with your counterpart in the foreign government.

THE WITNESS: That's correct. These -- what we're talking about on op specs is back and forth between us and the airline.

MR. FEITH: Okay. Now, if there is a problemwith the op spec, do you deal directly with the airline or you --

THE WITNESS: Yes, sir.

MR. FEITH: Okay.

THE WITNESS: With the airline.

MR. FEITH: And that resolution is directly with the airline. How about your counterpart? Is there ever an interface with your counterpart, your foreign counterpart in the --

THE WITNESS: No, sir.

MR. FEITH: Should there be?

THE WITNESS: Might not be a bad idea.

MR. FEITH: Do you have a -- an assistant POI that assists you? I -- I -- I see that you were responsible for one, two, three -- about eight airlines prior to your reassignment with the -- the current carriers that you have, but at the time of the accident you had about eight airlines. Do you have an assistant that helps you with all of these airlines?

THE WITNESS: No, sir.

MR. FEITH: How much time do you spend with each of these carriers or overseeing each of these carriers?

THE WITNESS: With each one?

MR. FEITH: Uh huh.

THE WITNESS: An awful lot of time, believe me.

MR. FEITH: Is there enough time in your day to oversee all of these carriers?

THE WITNESS: Well, again, our -- our ramp inspection, our work program, all the inspections that we're required to do by our work program only take up supposedly a certain percentage of our time, so we do have other things to do. But we accomplish as a rule 100 percent of our work program every year.

MR. FEITH: But you're only one person looking at nine different airlines.

THE WITNESS: Yes, sir. In some of these inspections at -- at other out-stations are done by other inspectors at -- at those stations. However, we try at our office to make an effort for each airline that we're assigned to do an inspection at each and every facility that they come into. In the case of Korean Airlines, because they came into so many different places in the United States, there was just simply no way I was ever going to have time to go around to all of 'em.

MR. FEITH: Do you need a PO -- an assistant?

THE WITNESS: Do I need an assistant?

MR. FEITH: Yeah.

THE WITNESS: Well, it wouldn't be bad, but where our staffing level is, that's -- there's no way that's going to happen.

MR. FEITH: Do you think that because of that staffing level that there might be a compromise to the oversight of 129 operators into the United States?

THE WITNESS: I don't think so because, again, we have offices scattered throughout and -- and wherever the airline goes we can always call upon inspectors in those offices to go do these inspections for us.

(Pause)

MR. FEITH: If the chairman will allow me, I'll pass to the Board of Inquiry while I sort out the rest of my questions real quick.

CHAIRMAN FRANCIS: All right. Pat?

MR. CARISEO: I -- I have a couple questions. Why are -- why are you no longer involved in inspecting Korean Airlines?

THE WITNESS: Well, as I said earlier, sir, we had a new inspector come into the office so we rearranged all the airlines. And what we were trying to do is instead of having so many different airlines in different countries, we tried to put them all with one -- you know, from one country with one inspector. And since we had this new inspector come in we just redivided all the airlines up. It had nothing to do with Korean being Korean or anything else. I just ended up with the three Chinese airlines and two Japanese airlines.

MR. CARISEO: Does this other inspector have a similar workload that you do?

THE WITNESS: Yes, sir. He does. All inspectors in our office do.

MR. CARISEO: You had mentioned that you would probably like an assistant. Is -- have you expressed your desire to your higher-ups that maybe you need some additional resources?

THE WITNESS: I think they're well aware that we need additional resources, sir.

MR. CARISEO: And what has their answer been?

THE WITNESS: They're trying to get the people, but --

MR. CARISEO: Thank you.

MR. BERMAN: Mr. Zeigler, you're the principal geographic inspector assigned to Korean Air?

THE WITNESS: Not now. I was.

MR. BERMAN: You were, --

THE WITNESS: Yes.

MR. BERMAN: -- sorry.

As such, when you were doing that, did you receive any assistance from other geographic inspectors elsewhere in the United States?

THE WITNESS: Oh, yes, sir.

MR. BERMAN: How did they report their findings to you?

THE WITNESS: By either fax or through the PTRS system.

MR. BERMAN: How often did you review the PTRS findings from Korean Air?

THE WITNESS: Every time we had anything come into the office for any given airline it was delivered -- on the upload/download it was delivered to the inspector responsible.

MR. BERMAN: Have you ever had a finding from PTRS that was -- caused you to take further action?

THE WITNESS: Would you repeat that?

MR. BERMAN: Have you ever had a finding through the PTRS from another geographic inspector that caused you to take further action on Korean Air?

THE WITNESS: Yes, sir. At least one or two occasions I received PTRS reports from other inspectors and forwarded them both to the KCAB and the Korean Airlines.

MR. BERMAN: Was there ever a P -- a PTRS --

THE WITNESS: And -- and in -- in the case of Korean Airlines themselves, they did respond to me.

MR. BERMAN: Was there every any input from other geographic inspectors about non-compliance with clearances?

THE WITNESS: I don't -- I'm sorry. What?

MR. BERMAN: Was there ever any PTRS or other input from other parts of the country on Korean Air about non-compliance with air traffic control clearances?

THE WITNESS: Oh, with air traffic control? No, sir.

MR. BERMAN: Okay. Did you ever get out to Guam to inspect station or conduct ramp -- ramp inspections?

THE WITNESS: Yes, sir.

MR. BERMAN: When was your last visit to Guam?

THE WITNESS: I was on Guam I believe it was in May or June of '97.

MR. BERMAN: Inspecting Korean Air?

THE WITNESS: Korean Air, Asiana, All Nipon, all the carriers that -- the foreign carriers that came in there.

MR. BERMAN: Did you observe flightoperations --

THE WITNESS: Yes, sir.

MR. BERMAN: -- approaches and departures?

Does the FAA classify foreign air carriers as to their compliance with Federal regulations or as to their ability to operate in the United States?

THE WITNESS: Not that I'm aware of, sir.

MR. BERMAN: They don't classify them as class one, two, or three?

THE WITNESS: Not the airlines, no, sir.

MR. BERMAN: Do they classify the foreign --they classify the foreign civil aviation bureaus, that's right.

THE WITNESS: Yes, sir. Under the assessment program.

MR. BERMAN: Did any of the carriers that you oversee or have overseen operate in countries that were classified below class one?

THE WITNESS: Yes, sir.

MR. BERMAN: When -- when you are in that situation, do you take any other or different actions as far as your oversight of that air carrier?

THE WITNESS: Well, on those that are from category two countries we do increase surveillance on them.

MR. BERMAN: What do you do?

THE WITNESS: More and more inspections, more thorough inspections.

MR. BERMAN: What would be a more thorough inspection?

THE WITNESS: We try to get really nitpicking with them.

MR. BERMAN: Can you give me an example?

THE WITNESS: Well, on a ramp inspection normally the -- if you were to take the ramp inspection form, it calls to you to inspect a considerable number of items. Generally speaking, you do not have the time on any given ramp inspection to literally hit every one of those items because usually the aircraft's only going to be there for an hour. And if you went through everything on there it might take two or three hours.

So, in the case of one of these that -- that we really wanted to take a hard look, we may end up delaying the departure in order to hit some of the other items that we wouldn't ordinarily do on a routine ramp.

MR. BERMAN: So you -- you do a more thorough ramp inspection, but do you ever get further into the manuals or the flight procedures of those airlines?

THE WITNESS: No, sir, because we don't haveany -- any approval authority over the manuals.

MR. BERMAN: Have you ever grounded an airplane during one of your ramp inspections?

(Pause)

THE WITNESS: Temporarily, yes, sir.

MR. BERMAN: And have you ever grounded a Korean Air airplane?

THE WITNESS: No. No, sir.

MR. BERMAN: Okay. No further questions.

CHAIRMAN FRANCIS: Mr. Feith, are you --

MR. FEITH: I just have a couple --

CHAIRMAN FRANCIS: -- reorganized?

MR. FEITH: Yes, sir. I just have a few follow-up questions after listening to Mr. Zeigler.

As Mr. Berman was just asking about your ramp inspections and doing more thorough inspections and you had mentioned that you may in fact delay a flight or temporarily ground an airplane, are there any political ramifications if you in -- if you do delay a flight or ground an airplane?

THE WITNESS: Well, there could be, I suppose.

MR. FEITH: Have you ever --

THE WITNESS: Well, I --

MR. FEITH: -- felt those ramifications?

THE WITNESS: -- you know, the few delays that we've caused have been relatively minor. I'm talking a matter of an extra 15 to 30 minutes. And usually there are other things that are delaying their departure anyway.

MR. FEITH: So you don't --

THE WITNESS: Clearances or whatever.

MR. FEITH: So you don't get any feedback from above?

THE WITNESS: No, sir.

MR. FEITH: As far as corrective action on the PTRSs, you had said that on PTRS findings those PTRS findings are submitted to the KCAB or to the other foreign authority and to the airline. How do you know if corrective action has been taken?

THE WITNESS: Well, when I sent a copy of it to the airline, I asked them to tell me what action they had taken, and then they responded and they told me what they had done.

MR. FEITH: What if the action isn't satisfactory to you?

THE WITNESS: Then we could write 'em another letter and -- and tell 'em that it wasn't satisfactory and we need that they do something else.

MR. FEITH: Do you ever have a problem withhaving corrective actions taken on PTRS findings --

THE WITNESS: No, sir.

MR. FEITH: -- that are made?

I have no further questions.

CHAIRMAN FRANCIS: Mr. Berman mentioned the assessment program and the categorization of -- of authorities worldwide. It's a program that's been going on now for six or seven years. It's a very important program. It's one that's expanding. IKO's taking over leadership of this program. And as -- as we can see here, there are some very serious constraints in terms of the 129 Program. Hopefully, and I think already we're seeing the assessment program and the way that it's being run leading to -- to some serious and -- and significant improvements in -- in aviation safety around the world. So I -- I think that that's something that the FAA started a number of years ago and for which they deserve some credit. It's also very much helping to deal with some of the issues that we've talked about here today.

I believe that's the end of the day. We will reconvene here at 9:00 tomorrow morning. And enjoy your evening in Hawaii.

(Whereupon, the proceedings were adjourned, to reconvene at 9:00 a.m., Wednesday, March 25, 1998.)

Wednesday March 25, 1998[edit]

http://www.ntsb.gov/events/kal801/trans_980325.htm

UNITED STATES OF AMERICA NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C.

PUBLIC HEARING IN CONNECTION WITH THE INVESTIGATION OF AIRCRAFT ACCIDENT KOREAN AIR FLIGHT 801, B-747-300 AGANA, GUAM AUGUST 6, 1997

Hawaii Convention Center Ballroom A, B and C 1833 Kalakaua Avenue Honolulu, Hawaii 96815 Wednesday, March 25, 1998 9:00 a.m.

Chairman, Board of Inquiry THE HONORABLE ROBERT T. FRANCIS

Board of Inquiry

RONALD L. SCHLEEDE Deputy Director, International Aviation Safety Affairs Office of Aviation Safety

BEN BERMAN Chief, Operational Factors Division Office of Aviation Safety

MONTY MONTGOMERY Chief, Information Technology Division Office of Research and Engineering

PAT CARISEO Transportation Safety Specialist Office of Safety Recommendations and Accomplishments

Technical Panel

GREGORY FEITH Investigator-in-Charge

PAUL MISENCIK Operational Factors Investigator

MALCOLM BRENNER Human Performance Investigator

GARY HAMMACK Airport Crash/Fire/Rescue Investigator

GREGORY PHILLIPS Aircraft Systems Investigator

CHARLES PEREIRA Aircraft Performance Investigator

RICHARD WENTWORTH National Resource Specialist, ATC

SCOTT DUNHAM Air Traffic Control Specialist

Public Information Officer

PAUL SCHLAMM Office of Government, Public and Family Affairs

General Counsel

DAVID BASS Office of General Counsel

Parties to the Hearing

FEDERAL AVIATION ADMINISTRATION Harold Donner, Spokesman

BOEING COMMERCIAL AIRPLANE GROUP Kevin Darcy, Spokesman

KOREAN AIR COMPANY, LIMITED Captain Sang Rok, Kim, Spokesman First Officer Steven Chung, Official Assistant to Captain Kim

NATIONAL AIR TRAFFIC CONTROLLERS ASSOCIATION Charles Mote, Spokesman

BARTON ATC INTERNATIONAL, INC. Edward Montgomery, Spokesman

GOVERNMENT OF GUAM Ron Dervish, Spokesman

A G E N D A

AGENDA ITEM:

Calling of Witnesses, Witnesses Sworn and Qualified by the Hearing Officer, and Witness Questioning

Captain Lee, Jung Taek Flight Crew Operation Korean Air Seoul, Korea

Afternoon Session Continuation of Witness Questioning

Park, Choon Sik Director, Academic Flight Training Korean Air Seoul, Korea

Captain Park, Pyung-Woo Deputy Director, Flight Operations Korean Air Seoul, Korea

Juan Rosario Director Guam Civil Defense Agana, Guam

Ciriaco C. Sanchez Deputy Fire Chief Guam Fire Department Agana, Guam

Joseph Mafnas Deputy Chief of Police Guam Police Department Agana, Guam

Captain Mary Humphreys-Sprague Inspector General U.S. Navy Southern Command Miami, Florida

P R O C E E D I N G S

9:00 a.m.

CHAIRMAN FRANCIS: Could we get everyone to sit down, please, and we'll get started?

(Pause)

CHAIRMAN FRANCIS: Our next witness starting out this morning will be Captain Lee, flight operation -- flight -- flight crew operation of Korea Air.

Whereupon,

CAPTAIN LEE, JUNG TAEK

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF CAPTAIN LEE, JUNG TAEK FLIGHT CREW OPERATION KOREAN AIR SEOUL, KOREA

MR. SCHLEEDE: Captain Lee, please state your full name and business address for the record?

(Captain Lee's responses in Korean are transcribed herein verbatim from the English translation.)

THE WITNESS: Yes, my name is Jung Taek Lee, and my business address is Korean Air Building locatedat -- Seoul, Korea.

MR. SCHLEEDE: And what is your present position with Korean Air?

THE WITNESS: I am currently a pilot at the Korean Air for Boeing 747 Classic, and also, I am a pilot instructor, SLS -- for chief pilot, the highest ranking -- third-level highest ranking -- pilot.

MR. SCHLEEDE: Thank you very much. Captain Misencik will begin the questioning.

CAPTAIN MISENCIK: Good morning, Captain Lee.

THE WITNESS: Good morning.

CAPTAIN MISENCIK: How long have you been a -- with Korean Airlines, sir?

THE WITNESS: I have been working for Korean Air starting May 1985.

CAPTAIN MISENCIK: How long have you been an instructor with Korean Air on the 747?

THE WITNESS: I was first appointed to the position of instructor pilot for Boeing 747 in April 1996.

CAPTAIN MISENCIK: Are you qualified to instruct both on the airplane and on the simulator?

THE WITNESS: Let me start. Generally speaking or as a matter of principle, instructor pilot is qualified to teach both simulator and the actualaircraft. However -- however, in the case of Boeing 747 Classic simulation instruction is sourced out to contractors. They -- they are dedicated instructors hired from outside. And in-house instructor pilots handle aircraft instruction.

CAPTAIN MISENCIK: How often do you instruct in the simulator?

THE WITNESS: I believe it's less than five times a year simulator training.

CAPTAIN MISENCIK: What are your duties as a instructor in the airplane? What do you mostly do as a instructor?

THE WITNESS: The duties of an instructor pilot is to train pilots assigned to me, for example, for simulator and actual aircraft instruction.

(Pause)

THE WITNESS: Okay. The interpreter interjection was to clarify one technical term, which -- which was answered as examiner pilot.

Part of my duty -- additional duties is to refer the pilot who has completed the training to the examiner pilot.

CAPTAIN MISENCIK: During your experience as a simulator and aircraft instructor, what percentage of these training events are observed by the KCAB?

THE WITNESS: Let me first tell you about the case of the simulator training. First of all, we are not doing a whole lot of simulator training while I was in charge of that responsibility. I -- I do not have any recollection of the inspection on the part of the KCAB.

So, let me go on to answer with respect to aircraft training. I did receive spot checks from KCAB or a spot check from KCAB.

CAPTAIN MISENCIK: Do you have a recollection for what percentage of your airplane rides were observed by the KCAB?

THE WITNESS: Well, sitting here off the top of my head I can't recall the precise percentages. However, let me try to give you as best answer as I can. However, according to my personal recollection I received about three to four checks each year.

CAPTAIN MISENCIK: Captain Lee, are you aware if the -- any of the KCAB inspectors that oversee Korean Air are type-rated on the 747 Classic and are current?

THE WITNESS: Yes, I do. My understanding is that there are two of them at KCAB.

CAPTAIN MISENCIK: Two -- you say two instruct -- inspectors that are current and qualifiedon the 747 Classic? Is that what you said?

THE WITNESS: I want to double check my --the question. The way I heard it was that whether there were -- there are two inspectors with the KCAB who holds 7247 -- 747 type-rating. Is that correct?

CAPTAIN MISENCIK: Yes. Are they -- are the KCAB examiners or the KCAB inspectors current and qualified on 747 Classic airplanes? The -- the examiners or inspectors that oversee Korean Airlines or Korean Air, I'm sorry.

THE WITNESS: I do not know as to what type of type-ratings they may have.

CAPTAIN MISENCIK: Okay. Captain Lee, discussing briefings and checklists now, are approach briefings required by Korean Air in all circumstances?

THE WITNESS: Yes, approach briefing is to be done under any -- in any cases. It's an absolute must.

CAPTAIN MISENCIK: What is Korean Air's goal in requiring an approach briefing? What is the intent? I'll further clarify. Which approach is required to be briefed upon arrival at -- at an airport?

THE WITNESS: Approach briefing is absolutely necessary for the sake of safe landing of an aircraft. In addition, a pilot must have constantly watch out on the weather conditions and the traffic conditions atthe destination airport. In addition, a pilot must also keep it under consideration that in case the situation at the destination airport becomes so bad that wouldn't allow safe landing. Hence, as a result, a diversion or deviation may be necessary. The pilot must also carefully review airport's approach charts.

The pilot must also have a detailed discussion as to division of labor or division of business responsibilities for -- with respect to approach as well as landing. The approach briefing should be done prior to TOB briefing.

INTERPRETER: I'm sorry. Interpreter interjection. Let me correct my mistranslation. Not TOB but TOD.

THE WITNESS: In doing so, the underlying intention of these efforts are to ensure safe landing of the aircraft.

Let me tell you some specifics of the approach briefing that we practice. We receive information based on ATIS, A-T-I-S, and NOTAMS that we receive from the destination airport. We check, review, and conduct briefing as to the expected approach methods based on the A-T-I-S information that we receive from the destination airport. That's all.

CAPTAIN MISENCIK: If a pilot anticipates avisual approach, what approach briefing would he give if the ATIS, A-T-I-S, indicates a -- an instrument approach is the approach in use?

THE WITNESS: A pilot is supposed to review and have a briefing of the information from the A-T-I-S.

CAPTAIN MISENCIK: -- referring to Exhibit 2N, 2 November. If we could put that on the screen?

Captain Lee, if you could -- this is the approach for ILS runway 6-left that was in effect on August the 6th, 1997. If you could indicate to us what a -- a briefing for an approach ILS 6-left localizer, glide slope out of service would -- would be like according to Korean Air procedures, please?

THE WITNESS: This can be kind of a complex answer, so let me give you one segment -- let me give an answer segment by segment about the landing briefing.

First of all, we put in front of us the expected approach briefing charts and open it. In the other hand we hold this landing briefing card inside the cockpit as shown on this overhead projector transparency picture. Briefing is done when all the rest of the crew are in a position to concentrate on that.

Let me give you an example of briefing. Number one, weather. You'll see here A-T-I-S uniform coming up. Wind calm, visibility seven miles, scattered 1600, temperature 27, altimeter 296 -- 29 --2986, glide slope out of service.

Number two, star. As to TOD, the current altitude is 41,000, so we'll start descending 17 minutes before the airport. Number one and number two, Nimitz VOR indicates 11.3 -- oh, let me -- 115.3. There is no particular altitude speed restriction. There isn't any arrival route.

Number three, using runway, type of approach, type of transition. Using runway indicates 6-left. Type of approach is localized approach. The transition level indicates 180.

Number four, review of instrument approach procedure. Here we perform briefing of the applicable chart -- chart. The airport name is Agana Airport. Chart number 11-1. Issue date August 2, 1997. The effective date is August 15. Minimum safe altitude is 2200 feet. Airport elevation is 279 feet. This chart is a DME requirement chart. DME can be -- the DME is acquired or emanating from Nimitz VOR. It is a type of arc approach. The initial approach fix hammer, seven, DME. It is a seven-mile arc.

When the 259 radar is passed from Nimitz VOR, number one, ascends 110.3 to the localized brief. Number three and number -- number -- number one and number two are both sets course 603.

Let me tell you a little bit about the current profile. 2600 feet maintained until the arc is drawn. 2000 feet up to final approach six or 1.6 DME. 1440 feet up to VOR air space or a sky. 2.8 DME for missed approach point. 256 feet with respect to the elevation prior to touchdown.

Missed approach procedure is climb to 2600, turn right via Nimitz VOR, radio 242 to Flake. And hold -- hold to southwest. Right turn. 062 in-bound. MDA is 560 feet. Time to map is one minute 50 seconds to the final approach fix point.

In -- in the event of a missed approach --let me come back to that issue later on. Instead, let me go on to number five, crew's action and call out.

PNF call fixable altitude --

INTERPRETER: interpreter interjection. Let me retranslate it. PNF, please call fixed altitude.

THE WITNESS: Call DME as well. When missed approach is performed I'm going to call a call-around call and flap 20 call. Flight engineer, please set thrust to go around. PNF, please set to flap 20. Whenpositive climb, landing gear up by order. By order set IES -- I'm sorry. Let me correct my mistranslation. IAS.

After you go up to 2600 feet, set right turn heading to 270. Also set number one localizer frequency to VOR as well. Go to Flake and execute parallel entry. If there is any deviation whatsoever during approach, please advise me.

Number six, parking spot and taxiways. I'll do re-briefing upon receiving any relevant information.

Number seven, other abnormal conditions and configurations. If any abnormalities should take place during flight, then whoever spots it first advise me, please. I'll take action based on the checklist. Are there any questions? That's all.

CAPTAIN MISENCIK: Thank you, Captain, for the sample briefing. What you described to us, is that a standard briefing according to Korean Air procedures that you could expect every crew to perform?

THE WITNESS: This is the standard briefing that we teach.

CAPTAIN MISENCIK: When you mentioned the --the time for the missed -- for the missed approach to the missed approach point, when the missed approach point is based on DME as it is on this particularapproach we were talking about, would you expect the flight crew to still time the -- the final approach segment?

THE WITNESS: From final approach point to missed approach point the primary is 2.8 DME and the time is based on the ground speed as shown down below, one minute and 53 seconds.

CAPTAIN MISENCIK: In this case, would you expect the flight crew to also start a timer to time the -- the final segment?

THE WITNESS: Timing starts at the point of passing the final approach point.

(Pause)

FIRST OFFICER CHUNG: We'd like to clarify the question to Mr. -- to Captain Lee, with your permission, Mr. Chairman.

(First Officer Chung spoke to Captain Lee in Korean.)

THE WITNESS: I'm sorry. I misunderstood the question. Yes, timing has to be done.

CAPTAIN MISENCIK: During the approach briefing, checking the dates and currency of the approach plates, is that standard procedure at Korean Air?

THE WITNESS: Yes, that's the case.

CAPTAIN MISENCIK: Captain Lee, non-precision approaches, are they normally hand-flown or flown using the autopilot?

THE WITNESS: It is entirely up to the judgment of the instructor pilot whether either hand-fly -- hand-flying or autopilot mode is to be used. However, in the initial period of flight for the sake of flight control -- better control, manual flying mode is more frequently practiced. That is for the initial phase of the training process. For the later stage of the training process auto -- the autopilot mode is more frequently instructed.

When manual flight is being executed, it starts from under altitude 10,000 feet. When the weather condition is IMC, then the autopilot's mode is suggested -- recommended. The use of autopilot indicates a non-precision. It's limited to MDA only. That's all.

CAPTAIN MISENCIK: Do Korean Air procedures require that the correct navigation frequency is tuned and identified?

THE WITNESS: Yes, it is a requirement, and that's the responsibilities of all the crews -- all the crew involved.

CAPTAIN MISENCIK: What is Korean Air policyregarding reading back clearances? As in the case of Flight 801, would Korean Air policy require the crew to read back "glide slope unusable"?

(The following conversation between Captain Lee and the interpreter took place partly in English and partly in Korean.)

INTERPRETER: -- take over landing -- take over --

CAPTAIN LEE: Take off.

INTERPRETER: Oh, take off --

CAPTAIN LEE: Take off clearance landing, clearance runway, cross clearance.

(Pause)

INTERPRETER: Why don't you please -- court reporter, why don't you take it directly from the witness?

CAPTAIN LEE: Genuine clearance or suitable clearance --

INTERPRETER: Assuming that the court reporter typed the first part, the important clearance has to be done in terms of numerical representation.

(Resumption of translation)

THE WITNESS: Especially the important clearance, especially that involved the number --numerical numbers that you have to read back. Involving take-off clearance, you must read back. And also, the -- the clearance that involved the numbers you must read back. And also, the others that -- the requirement by ATC you must read back fully. But also, when we receive the clearance and we are not sure expecting the controller going to give us the confirmation we instruct our pilots to read back as you heard.

In case of Korean Airline 801 in clearance the "glide slope unusable" is the additional information. In general, if you knew this additional information you don't need to read back. But in this case -- in this case it's after the -- there's additional information or not, the read-back could be really different. In other words, this is very important information. In this case, in order to confirm you like to read back -- you must read back. That's all.

CAPTAIN MISENCIK: Captain Lee, what is Korean Air policy regarding a pilot following a navigational indication that has been reported inoperative or unusable? How should a pilot regard a glide slope indication that may appear normal to him but has been reported unusable or inoperative?

THE WITNESS: If he received this informationof "glide slope unusable," then he must not use the --that instrument or that -- that glide slope.

CAPTAIN MISENCIK: Captain Lee, in non-precision approaches, is it Korean Air policy to use step-downs or a constant descent for the approach?

THE WITNESS: Basically, we are teaching them to use a step-down method. But when the weather condition is BMC and also pilot -- when pilot select the medial -- medium altimeters -- altitude and also in the condition that he or she will maintain the above the altitude he might choose the constant lower-down for the passengers' sakes. But what we emphasize is he must maintain the -- the chart-depicted altitude. That -- that's all.

CAPTAIN MISENCIK: Are there specific training scenarios for constant descent approaches?

(Pause)

THE WITNESS: Could you repeat the question again, please?

CAPTAIN MISENCIK: Yes. Are there training scenarios or profiles in the simulator which teach constant descent technique?

THE WITNESS: As I said earlier that basically the -- the training is -- that basically when we training we teach them to step down.

CAPTAIN MISENCIK: Captain Lee, has Korean Air considered the monitored approach technique for instrument approaches?

THE WITNESS: We were introduced to this monitored approach method but we didn't take that as our approach method. We decide the PF is choose the approach and landing. But all -- PIC can take over the any time in this -- during this period -- period for the safety. That -- that's all.

CAPTAIN MISENCIK: During flight checks, check rides, and other evaluations, are the PNF and the flight engineer also being evaluated?

THE WITNESS: Yes, in case of the simulator they are evaluated at the same time. But when it's in the airplane check it's up to their individual schedule they are evaluated officially. But also, that means the PNF or flight engineering is be evaluated or checked by second-handedly. That's -- that's all.

CAPTAIN MISENCIK: During check rides are pilots evaluated for their approach briefings?

THE WITNESS: Yes, they're evaluated.

CAPTAIN MISENCIK: Captain Lee, in training could you describe the roles of the PF and the PNF during a non-precision approach both with autopilot on and autopilot off, what their specific duties areaccording to Korean Air procedures?

THE WITNESS: I will tell you the -- the first -- the autopilot on, in case of autopilot on. PF's supposed to control -- take over all the --control by himself -- I mean for himself. But some part of it he can order to PNF. A PNF supposed to implemented the ordered the job. But the rest of the crew who doesn't hold the control switch or who doesn't touch the control switch or the -- nothing to do with airplane flight, then they supposed to monitor.

Then I'll tell you the autopilot off. PF basically ordered all the related matters. PNF supposed to implemented all the ordered -- ordered matters. And also, PNF's supposed to advise PF if there's a -- a certain matter that's skipped by PF. That's it.

CAPTAIN MISENCIK: Which pilot states or sets the next step-down altitude in a non-precision approach?

THE WITNESS: In the case of autopilot on, PF's supposed to do it. But when it's autopilot off then by the PF's order, PNF's supposed to do it. But also, I mentioned earlier that even though in case of autopilot on a PF can order the PNF. That's it.

CAPTAIN MISENCIK: What is the procedure forusing the altitude-select window for step-downs in a non-precision approach?

THE WITNESS: Your question regarding only the altitude window or --

CAPTAIN MISENCIK: The altitude select, A-L-T S-E-L window selecting the altitude.

THE WITNESS: In case of descending I will tell you. PF set not only the altitude window but also set the altitude regarding the information that he received from A-T-I-S.

I'm sorry. There's a misinterpretation. I'm not sure I got this one right or not, but PF set the altitude above the altitude that he received in window. I'm sorry. I think I -- I --

PF's supposed to set the altitude that he received from the clearance above altitude window.

CHAIRMAN FRANCIS: -- clarification?

FIRST OFFICER CHUNG: Yes, the -- the cleared altitude from the air traffic control will be set in the window. It should be translated in the window, not above the window, obviously. The cleared altitude is set in the altitude select window.

CHAIRMAN FRANCIS: All right.

(Resumption of translation)

THE WITNESS: And just before descending PF'ssupposed to set the altitude mode to S-E-L mode. S-E-L -- which mode?

(Pause)

THE WITNESS: PF's supposed to set the altitude to -- altitude just before descending S-E-L position mode. Then he's supposed to put the speed to the VS mode -- VS position mode. And then he turned the VF control knob to "strengthen." When its altitude is catched he is supposed to change to altitude hold mode. Then he's supposed to pre-set the altitude that indicated the chart -- the next -- next step. That's it.

CHAIRMAN FRANCIS: I think we've got another request for clarification here from KAL.

FIRST OFFICER CHUNG: Rather than a point-by-point clarification, may we have your ruling at this point to intervene somehow to clarify the translation process on these critical matters? I'm afraid we're getting the wrong impression from the people present as to what Captain Lee's saying. He's -- we're having a lot of difficulty at this time.

CHAIRMAN FRANCIS: That's all right with me. Does anyone have a problem with that? Paul, is that all right with you?

CAPTAIN MISENCIK: That's all right.

CHAIRMAN FRANCIS: I mean the purpose of this is to -- is to get a clear explanation, so whatever we have to do to do that we'll -- we'll do.

FIRST OFFICER CHUNG: I'll clarify for the record. Speaking for Korean Airlines, First Officer Steve Chung. And at this point I would like to --unless anyone objects at any particular point, I'll go ahead and translate for Captain Lee. Thank you.

(Pause)

CHAIRMAN FRANCIS: All right. We're just --we're a little concerned about the official record here and how this will work. I -- I guess I would say that -- that I'm with that in that we will have the ability ultimately to go back in the original Korean and -- and reexamine the -- the translation that's being done by you. So, let's -- we will go ahead and allow this but with the understanding that the official record will be subject to -- to clarification.

FIRST OFFICER CHUNG: Mr. Chairman, thank you. We would insist upon that as well that after the Board hearing that all translation matters be checked as to the clarity and accurate translation on -- on our behalf.

(Pause)

CHAIRMAN FRANCIS: All right. Let's go aheadthen and -- and do it that way for -- and we'll see how it works here.

FIRST OFFICER CHUNG: Thank you.

CHAIRMAN FRANCIS: I think this may facilitate.

FIRST OFFICER CHUNG: Thank you for your consideration.

(First Officer Chung of the Korean Air Company, Limited translated both questions posed in English to Korean and Captain Lee's responses in Korean to English.)

CAPTAIN MISENCIK: Okay. I'll state the question one more time, then. During a non-precision approach, what would be the procedure for setting the altitudes in the altitude select window?

THE WITNESS: To start from the beginning again, the cleared altitude clearance from the air traffic control will be set in the altitude window to begin with. The pilot flying will set the next altitude into the altitude select window just prior to descent to the next altitude.

Forgive me, he would set the altitude selector switch into the -- "select" position. He would set the VS mode switch on the VS mode. Using the vertical speed control knob he would start -- initiatethe descent. Once the selected altitude is captured he would select altitude -- "altitude hold." After this process, he can set the next altitude on the chart. And that's -- that's it.

CAPTAIN MISENCIK: Would the pilot flying on a non-precision approach expect the altitude warning light and chime to remind him of the step downs?

FIRST OFFICER CHUNG: Would you repeat that question one more time, please?

CAPTAIN MISENCIK: Sure. Would the pilot flying a non-precision approach expect the -- the light and the chime on the altitude warning to remind him of the step-downs?

THE WITNESS: That's correct. The pilot flying would expect that.

CAPTAIN MISENCIK: During the non-precision approach, what mode -- this is only for a non-precision approach -- what mode is normally set on the autopilot flight -- flight director mode selector?

THE WITNESS: Would you repeat the question, please?

CAPTAIN MISENCIK: During a non-precision approach -- that would be NDB, POR, or localizer approach -- what mode is normally selected on the flight director?

THE WITNESS: Are you referring to the flight director modes on the 747 Classic or the navigation selector switch?

CAPTAIN MISENCIK: I'm -- I'm referring to the -- the flight director modes that would provide guidance to the command bars.

THE WITNESS: The captain would use the mode A and the first officer position would use B mode on the flight director switches.

CAPTAIN MISENCIK: Okay. I'd like to clarify. Would he use for the flight director "heading VOR Loc ILS land"?

THE WITNESS: Now I understand. That is the navigation mode. For the NDV approach he would select the "heading" mode. For either the VOR or the localizer approach he would select the VOR Loc mode.

CHAIRMAN FRANCIS: Okay. Could I just make a comment here? This -- this is a very obviously important part of this hearing, and I want to make sure that everyone, the questioner, the interpreter, and the witness are -- are clear about the questions and the answers. And if we need to repeat this several times in order to ensure clarity we will, but -- but please let's make certain that we don't go away from any question or any issue without everyone being totallycomfortable with what's being said.

THE WITNESS: For the NDB approach he would use the "heading" mode. For the VOR or the localizer approaches he would use the VOR Loc mode. That's --that's the answer.

CAPTAIN MISENCIK: On a full ILS what mode --what navigation mode would be selected?

THE WITNESS: For the ILS approach he would select the ILS mode on the mode selector switch. For an auto-land, he would select the "land" mode on the nav switch.

CAPTAIN MISENCIK: Thank you for the clarification on that.

(Pause)

CHAIRMAN FRANCIS: Paul, are -- are we clear on ILS without glide slope?

CAPTAIN MISENCIK: Yes. Yeah, we are.

CHAIRMAN FRANCIS: Okay.

CAPTAIN MISENCIK: At least I am.

CHAIRMAN FRANCIS: If you are we're happy.

CAPTAIN MISENCIK: Okay.

What are the required pilot responses to mechanical alerts from the GPWS?

THE WITNESS: There are two alerts, two different types of alerts to the GPWS. First, for thepull-up I will tell you. He would disengage both the autopilot and the auto-throttle. He would increase thrust to the maximum setting and raise pitch to the 20 degree climb position. He would not change the aircraft configuration as to the landing gear or the flap setting. The radio altimeter would be revert to -- to ascertain terrain clearance. Once terrain has been confirmed to be cleared he would lower the nose to increase air speed.

For the GPWS alerts I will tell you about that next. The sink rate terrain to low gear to low flaps, glide slope. For these alerts as -- as a -- as a recall action the pilot is supposed to change the flight path or the configuration to make sure the alert warning sound disappears. That would be it.

CAPTAIN MISENCIK: What rate of descent is normally used on the 747 Classic during step-downs, and how is it set?

THE WITNESS: Basically, the rate of descent would change when the descent gradient changes. It would be about 300 foot per nautical mile, maximum of 400 feet per nautical mile. In terms of vertical speed, on the average of 1000 foot per minute, maximum of 1200 foot per minute. That's all.

CAPTAIN MISENCIK: Going back to themechanical GPS call-outs, what would be the pilot response for sink rate call-out?

THE WITNESS: As a recall action the pilot should correct the flight path angle to see to it that the warning disappears.

CAPTAIN MISENCIK: Can either pilot call for a go-around on approach?

THE WITNESS: Anyone can advise as to go-around.

CAPTAIN MISENCIK: But if I understood your previous question, the PIC makes the final decision. Is that correct?

THE WITNESS: That's correct. You're correct.

CAPTAIN MISENCIK: According to Korean Air procedures, what circumstances would -- require a go-around on a non-precision approach?

THE WITNESS: First, assuming the aircraft does at the MDA and at the missed approach point there is no visual to the runway, he would perform go-around. Secondly, below 500 feet in the case of an instrument failure he would perform a go-around. Thirdly, at any time the pilot feels that it is in the interest of safety he can perform a go-around at any time. That's all.

CAPTAIN MISENCIK: Captain Lee, do you have knowledge of how many of Korean Air approaches in line operations are non-precision approaches?

THE WITNESS: Would you repeat the question, please?

CAPTAIN MISENCIK: Do you have knowledge of how many approaches in normal line operations at Korean Air are non-precision approaches?

THE WITNESS: At the home base of -- of Seoul Kimpo Airport we always use -- I correct that statement. We often use non-precision approaches. At domestic airports of -- in particular Chachu (ph) Airport we also use the non-precision approaches. The 747 Classic has many destination airports in Southeast Asia or Middle Eastern countries. In these areas it's quite often we see non-precision approaches. Finished.

CAPTAIN MISENCIK: On the non-precision approaches that you see in route qualifications and --and IOE, what percentage of the airports have the --would you estimate have the DME and the VOR not located on the airport?

THE WITNESS: I don't believe I can give you a percentage figure. However, the 747 Classic at Korean Air, we have about 30 destination airports. I would say over half the airports the -- the VOR DME isnot co-located with the field. That's all.

CAPTAIN MISENCIK: One question referring to a go-around. On a normal go-around, what pitch do the pilots normally rotate to on a -- on a missed approach or on a go-around?

THE WITNESS: For a normal go-around, initially you'd raise the pitch to 12 degrees. After landing gear is up, you would adjust the pitch to maintain V2 speed plus 10 knots.

CAPTAIN MISENCIK: Captain Lee, based on your review of all the exhibits, including the CVR transcript and the flight data recorder read-outs, what is your assessment of the crew performance relative to Korean Air training, the policy, and -- and the procedures?

CHAIRMAN FRANCIS: Let's make sure -- very sure that this is properly understood.

FIRST OFFICER CHUNG: May I have another opportunity to translate that? Would you repeat the question for the translator, Mr. Misencik?

CAPTAIN MISENCIK: Sure. Based on the review of all the exhibits, including the CVR and flight data recorder read-outs, what is your assessment of the accident crew's performance relative to Korean Air training and procedures?

THE WITNESS: What I felt -- what I perceived from the CVR contents, I feel that CVR contents cannot possibly ascertain the entire crew action of the flight crew. We don't necessarily give credit to these things, but there's also body language involved. Of course, this is not part of our procedure. I would, however, like to emphasize that just based on what's contained in the CVR we cannot draw crew performance evaluations just on the CVR contents.

Anyway, what I felt overall was that the accident crew's standard call-out compliance was less than what I -- what we are taught. That suffices an answer.

CAPTAIN MISENCIK: Captain Lee, what changes have been made or are being discussed to be -- or being discussed in the training procedures as a result of this accident?

THE WITNESS: Since the 801 accident is still under investigation I would not want to make comments about the analysis. But based on the CVR and the DFTR results up to now we have implemented many changes since the accident. First, about simulator training, we -- we emphasize the use of TKAS, GPWS, and localizer procedures.

Also, we -- secondly, we -- we emphasizestandard call-outs. We have made sure that pilot flying will call out -- the pilot flying will call out all actions that he's carrying out. The pilot not flying will aggressively make all necessary advice. And after second advice, if there is no response that he would aggressively take over controls.

We have diversified the simulator training profile into three different categories. This is in regard to the simulator check profile. This gives the evaluator pilot the option to select any of the three scenarios at his option and -- would you repeat the end? And this is one way that we fortify the check process. That's all.

CAPTAIN MISENCIK: Okay. Thank you, Captain Lee. I think Dr. Brenner has some additional questions.

DR. BRENNER: Captain Lee, in 1989 Korean Air experienced an accident involving a DC 10 airplane at Tripoli, Libya in which the airplane landed short of the runway in fog conditions. Did the company make any safety changes as a result of this accident?

THE WITNESS: At that time I was a first officer on the MD 82. From my position I don't think I -- I do not know what changes specifically took place as a result of the accident that you talk about. I donot want to say that Korean Air did not make any changes as a result of the accident. It's just that I do not know from my position at the time.

DR. BRENNER: Do you use the radio altimeter for category one or better approaches?

THE WITNESS: Would you specify what you mean by above category one approach -- category one or better?

DR. BRENNER: Category one visibility or better visibility.

THE WITNESS: The radio altimeter does not have direct relationship to the visibility. It depends on the type of approach that we're flying. For a category one approach or a non-precision approach we use it as -- we have the option to use it as a reference. That's it.

DR. BRENNER: Thank you.

Mr. Chairman, this completes our questions.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman.

(The rest of Mr. Lee's response in Korean was not translated.)

CHAIRMAN FRANCIS: We'll -- we'll go back now to the normal interpretation if we can, please.

(Pause)

(The following is a verbatim transcript of the English translation of Mr. Lee's questions posed in Korean and Captain Lee's responses made in Korean.)

MR. LEE: Did you get my translation, by the way? Did you get my translation? Can you raise your hand?

Oh, okay. Let me repeat it. Because most of the questions that I originally intended to ask have been covered by the questions that have been just asked, let me just go on to ask one question only.

INTERPRETER: Okay. Let me then translate. Here it goes.

(Resumption of translation)

THE WITNESS: You received "glide scope unusable" information prior to departure -- I mean by "you" the crew of the accident flight -- prior to the departure at the Kimpo International Airport through NOTAM. And also, prior to arrival you receive the same "glide scope unusual" information -- unusable information from A-T-I-S. And in addition, you receive the same information, "glide scope unusable" at the time that the accident flight was cleared for approach from the CERAP.

INTERPRETER: Let me correct -- correct glide slope to glide scope. Glide scope to glide slope.

(Resumption of translation)

THE WITNESS: Listening to the contents of the CVR extracted from the accident, we can see that on numerous occasions first officer and the flight engineer kept asking the question whether glide scope -- glide slope was working or not. You just told us during your testimony that it is absolutely against your training instructions to try to execute landing when there is any problem with the glide slope.

The question I'm driving -- trying to drive at is that to -- in the CVR contents when the first officer and the flight engineer kept asking the question, "Is glide slope working?" I want to give it a benefit of doubt as to how the question was framed. I would say that under a different possibility, a different cultural context or circumstance the first officer and the flight engineer might have asked "Glide slope is not working so it should not be done this way."

So, my question is whether the way the question was framed is because of the Korean culture that kind of inhibited lesser officer from presenting advocacy or challenging the chief pilot?

THE WITNESS: We do not know under what kind of circumstances the crew of the accident flight wereoperating. We do not also know whether the -- the signal or the increment was actually used just based on the effect that there was an advocacy or inquiries on the part of the crew. That's all.

MR. LEE: Thank you.

(End translation of Mr. Lee's questions. Translation of Captain Lee's responses continued.)

CHAIRMAN FRANCIS: Thank you. FAA?

MR. DONNER: Thank you, Mr. Chairman. Just a few questions.

Captain Lee, how many sets of approach plates are available to a 747 crew during flight?

(Captain Lee's response is not translated into English.)

MR. DONNER: I'm sorry, sir. I'm not receiving answers on this.

(Pause)

INTERPRETER: -- hear me?

(Pause)

INTERPRETER: We are experiencing some technical difficulties here, some glitch which is preventing us from communicating. I'm trying to ascertain whether the witness is -- the witness can hear me or not, but he's not responding.

(The interpreter and the witness conversed in Korean.)

INTERPRETER: Now he can.

MR. DONNER: I think we're all right now.

(Resumption of translation)

THE WITNESS: I'm not sure whether I clearly, unequivocally understood the point of your question, so it may be probably advisable for you to ask the question just one more time.

(The interpreter and the witness conversed in Korean.)

(Resumption of translation)

THE WITNESS: Okay. Please go ahead and repeat the question just one more time, please.

MR. DONNER: Thank you, sir. Are any approach plates permanently installed on -- on board the aircraft?

THE WITNESS: Yes. Basically, the captain and the first officer have Jefferson manuals that they are individually handed out. It includes the airport charts and the en route charts for the airports that we regularly provide carrier service. There is also one copy of the Jefferson manual in flight.

(The interpreter and the witness conversed in Korean.)

INTERPRETER: Let me restate my previous translation. Here it goes. There is an aircraft boarding manual also.

(Resumption of translation)

THE WITNESS: Which includes en routes charts for alternate airports and en route airport.

INTERPRETER: Oh, I'm sorry. Emergency airports.

(Resumption of translation)

THE WITNESS: That's all.

MR. DONNER: Thank you, sir.

Does the flight engineer have any role in reviewing or monitoring approach plates?

THE WITNESS: Yes. In addition to the primary responsibilities assigned with the flight engineer. The flight engineer would also help find instrument panel and visual cue.

Let me slightly modify my answer. The flight engineer would also monitor the instrument panel and help find the visual cue. That's all.

MR. DONNER: Thank you.

May I refer you please to Exhibit 2A, page 24?

(Pause)

MR. DONNER: And this is just a point ofclarification. Near the bottom of the page there's a statement that the four-day CRM program is given only to pilots.

THE WITNESS: Yes, I'm looking at it.

MR. DONNER: And on page 25, the next page, near the top of the page there's a sentence, "Advocacy teaches the first officers and flight engineers to intervene when necessary." My question, sir, is do your flight engineers also receive crew resource management training?

THE WITNESS: CRM is not part of my training responsibilities. However, to my knowledge, flight engineers do receive the CRM training.

MR. DONNER: Thank you. One final question please on Exhibit 2 November.

THE WITNESS: Yes.

MR. DONNER: And this is the ILS approach to runway 6-left at Agana. Can you tell me, sir, if the outer marker is a required piece of equipment to conduct this approach?

THE WITNESS: Are you referring to the ILS or localizer approach?

MR. DONNER: I'm referring to the ILS approach with the glide slope inoperative.

THE WITNESS: Once DME is on out -- the outermarker doesn't have to be operative.

MR. DONNER: Thank you very much, sir. I have no further questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: No questions. Thank you, Mr. Chairman.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: Thank you, Mr. Chairman. Just one quick question.

Do you know how many times this flight crew flew into Guam before the accident?

THE WITNESS: The circumstance -- let me restate it. The nature of the matter is such that I cannot give you an answer in a nutshell. Let me be more -- more specific. The captain and first officer and the flight engineer, they do not always travel together in the same flight. Also, the -- the aircraft involved is a 747 Classic, but you can easily imagine that the crew involved might have flown in a different type of aircraft previously. That's all.

MR. DERVISH: Well, how about the captain? How many times did he fly into Guam?

THE WITNESS: My understanding -- I heard that it was once that he had flown to Guam prior to the accident, but I am not sure.

MR. DERVISH: Thank you, Captain Lee.

CHAIRMAN FRANCIS: I think that information was both in the record and in Mr. Feith's opening statement.

Boeing Company?

MR. DARCY: Mr. Chairman, we have no questions for Captain Lee. Thank you.

CHAIRMAN FRANCIS: Barton?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions.

CHAIRMAN FRANCIS: All right. I think that -- we've got Mr. Feith.

MR. FEITH: Thank you, Mr. Chairman. I just have several questions.

Teddy, could you put up the approach plate that we were using earlier in -- in Captain Lee's testimony, please?

(Pause)

MR. FEITH: Captain Lee, you had given us a briefing about the approach plate and the information on the approach plate, and I don't recall if you had briefed -- part of the approach plate. It's the remark at the initial approach fix. Could you just brief whatthat remark means at the initial approach fix? Right there where the pointer is.

THE WITNESS: Do you mean to be ask me to describe what the remark is about?

MR. FEITH: Yes.

THE WITNESS: The initial approach fix, its name is Hummer, and its location is 7.0 DME from the Nimitz VOR 3.4.3 radiar -- radar -- 343 radar -- radio.

MR. FEITH: And the 7.0 that the pointer is pointing to refers to the mileage from where to where?

THE WITNESS: That indicates the distance from the Nimitz VOR.

MR. FEITH: Thank you. You had spoken briefly when Captain Misencik was asking questions about the crew's briefing as it was depicted on the CVR. Could you please describe if the briefing that was conducted by the captain for the ILS with the localizer inoperative covered all of the appropriate information necessary to execute that approach?

THE WITNESS: I found the question kind of long, so can you just give me the gist one more time?

MR. FEITH: You have read the CVR. Was the captain's briefing to the other crew members inclusive of all of the information that would be expected by Korean Air in an approach briefing?

THE WITNESS: Just based on the taped contents in the CVR I cannot say that all the related matters were covered. However, -- but when you read the CVR transcript you can come across a phrase, quote, "As I told you before," unquote. Judging from that even though the crew did not follow certain format I can feel it would be fair to say that the crew discussed briefing.

MR. FEITH: Thank you. With regard to the CVR transcript, it was noted that there were two altitude alert sounds recorded on the CVR. However, there was no reaction by the flight crew to either of those altitude alerts. Does Korean Air have a specific procedure for the pilots to call either 1000 feet above a selected altitude or upon capturing the desired altitude?

THE WITNESS: Yes. According to our procedure we are supposed to make the 1000 above call prior to 1000 feet above the selected altitude. I meant 1000 level. That's all.

MR. FEITH: Let me see if I understand. They call 1000 feet above the altitude and then also call when they are level at the desired altitude?

THE WITNESS: No, that's not true. The first call will apply to the case when it is 1000 feet beforethe select altitude. It is the other way around from your understanding.

MR. FEITH: Should the crew, either the pilot flying or the pilot not flying, have called the altitude as the captain had requested based on the CVR when he had asked for the altitude of 1440 feet to be set into the altitude window? There was an -- should they have called that altitude upon reaching that altitude? Should someone have said 1440?

THE WITNESS: Would you repeat your question one more time?

MR. FEITH: Should either of the pilots have reacted to the altitude alert when the airplane descended below 1440 feet on the approach?

THE WITNESS: I just told you that we are supposed to -- to call out before -- at the 1000 feet level before or below the select altitude. Not below but before the select altitude.

MR. FEITH: And I understand that part of your answer. My question is because there was an altitude alert recorded twice on the CVR and there was no reaction to those altitude alerts, should there have been based on procedures from Korean -- at Korean Air?

THE WITNESS: As I just told you, our crew --requires us to make a call at 1000 feet before theselect altitude.

MR. FEITH: Okay. Thank you, Captain.

CHAIRMAN FRANCIS: Wait a minute now. Are you -- are you happy with that answer?

MR. FEITH: I'm not sure that the captain understands my --

CHAIRMAN FRANCIS: Well, let's -- let's make sure that somebody helps us clarify the question here.

INTERPRETER: May I in -- may -- may the interpreter interject? I'm pretty positive the witness understood the translated question, but his position seems like he wants to just keep repeating his position instead of directly hitting the point of the question. I made some presumptions, but that's my interpretation in between the lines.

MR. FEITH: I would like to get a -- a clarification because we have two altitude alerts. This airplane went through two altitudes, the alerts went off, yet no one reacted, and I want to know if there is in fact a policy or procedure that the crew should have taken some sort of action to that alert.

FIRST OFFICER CHUNG: Mr. Chairman, may we assist the witness to understand Mr. Feith's question in Korean? Do we have your permission to do that?

CHAIRMAN FRANCIS: Yes, sir.

(The following is a verbatim transcript of the English translation of First Officer Chung's Korean translation of Mr. Feith's question and Captain Lee's response in Korean.)

FIRST OFFICER CHUNG: Why -- why don't you ask him the second part of the question that the -- the call should be made not just at the time when 1000 feet is reached before the select altitude but also the time when desired altitude has been captured?

THE WITNESS: Yes, prior to crossing the --the 1000-feet mark before the selected altitude and the aircraft goes on to capture the desired altitude, then the PNF, the pilot not flying, is supposed to call out "desired altitude captured."

(End translation of First Officer Chung. Translation of Captain Lee's responses from Korean to English continued.)

MR. FEITH: Thank you. With regard to the GPWS, does Korean Air have any procedures for reacting to the GPWS call at 500 feet on a non-precision approach?

THE WITNESS: Up to the time of the accident the -- the procedure prior to the time of the accident, it was not required, the 500-feet call. Let me just elaborate a little bit. As for our Boeing 747 Classicaircraft, with respect to radio altimeter one type includes auto-call, the other type does not include auto-call. With the type that does not have auto-call, it is the job of flight engineer to make the call. In such a case the 500-feet call would not be made in the non-precision approach. However, in the case of a auto-call regardless of non-precision or precision approach the 500-feet call is to be made. That's it.

MR. FEITH: At 500 feet, since this airplane had auto-call, the GPWS called 500 feet. Is there a policy for a practice at Korean Air for the flight crew to execute a go-around when executing a non-precision approach and receiving that GPWS call?

(The interpreter and Captain Lee conversed in Korean.)

CHAIRMAN FRANCIS: I think there's the request for a clarification here.

FIRST OFFICER CHUNG: Mr. Chairman, we'd like to enter for the record that the translation process is fairly accurate and literal. However, we're running into an -- a pattern here. The gist of the meaning is not being transferred and there's a great deal of misunderstanding throughout this session. May we intervene at this time again?

CHAIRMAN FRANCIS: On this question go ahead.

FIRST OFFICER CHUNG: Thank you.

(First Officer Chung translated both questions posed in English to Korean and Captain Lee's responses made in Korean to English.)

MR. FEITH: What I'm asking is does Korean Air have a policy or a practice that when a flight crew receives a GPWS call of 500 feet during a non-precision approach that the crew automatically execute a missed approach or go-around or do they evaluate and continue the approach?

THE WITNESS: We do not have a procedure that mandates a go-around at 500 feet automatically. That is, in regard to the GPWS calls.

MR. FEITH: But since the flight engineer did not make a 500-foot call, would that -- would that change had the flight engineer made the 500-foot call?

THE WITNESS: Are you asking our thoughts or opinions?

MR. FEITH: Is there a policy that had --on -- on those airplanes that don't have automatic 500-foot call, if the flight engineer had made that call, would that have necessitated a go-around by the flight crew?

FIRST OFFICER CHUNG: I believe he said there's no procedure to -- that mandates a go-aroundwhether it's an auto-call or a flight engineer-derived, you would not go around at 500 feet.

MR. FEITH: Are you aware of any other airlines that use the practice of automatic go-around at 500-foot GPS call?

THE WITNESS: I have not heard of such an airline.

MR. FEITH: Okay. Thank you.

Captain Lee, on the transcript of the CVR the captain at 15:41:14 -- and you don't need to turn to it, I'll read it to you -- the captain made a call in response to a checklist item and his response -- the captain's response was, quote, "No flags, gear flap," end quote. Can you tell me what he would be referring to when making that call, particularly regarding the "no flags" call?

THE WITNESS: The phrase "no flag" implies that no instrument -- not any single instrument on the instrument panel has a flag indication throughout.

MR. FEITH: Would that include the ILS flag?

THE WITNESS: It includes all flags.

MR. FEITH: Captain Lee, you had answered a question for Dr. Brenner, I believe, regarding cultural issues that may have been an influence in one of the discussions or the discussion about the glide slope. Based on your reading of the CVR, do you believe there are any other cultural factors or influences that you see in the way the crew was reacting or interacting throughout the course of time that the CVR covers?

THE WITNESS: May I verify that I did make a remark regarding cultural something when Dr. Brenner answered? I don't remember specifically answering in regard to cultural aspects.

CHAIRMAN FRANCIS: Was that possibly a question from Mr. Lee?

MR. FEITH: That may have been, I'm sorry. Yes.

Basically what I'm -- I'm just asking is, is -- is there -- was there possibly an inhibition by the first officer or the flight engineer to question the captain throughout the period of time where commands were being given or actions were being requested by the captain?

THE WITNESS: I do not feel that way.

MR. FEITH: And one last question, Captain. You had made a statement regarding -- I think it was with -- to Captain Misencik -- when you were describing how the non-precision approach that involves a step-down is flown. I believe you had -- or at least it is my understanding of what you said that a pilot may infact do a constant-rate descent for passenger comfort, more or less. Did I understand that correctly?

THE WITNESS: I put a caveat on that remark when I said that. And the condition was that he would set each altitude on the approach plate limiting the step-down and satisfy those altitude limitations. That was a condition that he would perform this.

MR. FEITH: So, if I understand that correctly, the step-down procedures would still be followed during the course of the approach even with a constant-rate descent?

THE WITNESS: I definitely remember saying that in VMC conditions provided that all altitude step-down fixers are satisfied above that limitation that we have the -- we simply exercise the option to perform this, and it implies that we can do it, not that we teach it or we -- it is not taught that we do this.

MR. FEITH: Two questions to that. One, this approach was flown at night, and given that they went from VMC to IMC conditions on the approach, would this be a prudent practice by a flight crew to exercise?

FIRST OFFICER CHUNG: You're referring to the constant --

MR. FEITH: Constant rate.

FIRST OFFICER CHUNG: -- descent gradient?

THE WITNESS: Of course, when I said VMC conditions before, that -- I did not include nighttime. I believe this is a matter of phrasing it, but I'm talking about VMC conditions in daytime. Visual conditions, I'm sorry. And I would say in the case of the 801, this would not apply.

MR. FEITH: Well, that would be my second question is, given the flight profile that has been revealed during the course of the investigation using FDR and radar information which depicts 801 at a relatively constant rate descent, does captain believe that this type of approach was being flown that night?

THE WITNESS: I'm not an expert in the analysis of flight data recorders, but I have seen the data myself. In my opinion, the altitude was captured at 1440 feet. I also believe that it was captured at 560 feet.

MR. FEITH: What makes him believe that?

THE WITNESS: First about the 1440. We have performed some simulations in the same type of aircraft. I would say that the -- the pitch-up indicated would not have been simply from a configuration change. And the power was increased. Just prior to that event we also noticed a vertical G being slightly increased, it appears, vertical G. AndI believe at this point it tells me that the captain is controlling through a vertical speed mode. I am not an expert on the subject, of course.

Regarding the 560 feet, if I may use the --summary in the exhibit, just prior to the point where the captain disengages the autopilot for the purpose of go-around the pitch -- we have the appearance or the effect -- an effect of the pitch raising somewhat. That's my opinion on why I think that.

INTERPRETER: Mr. Chairman, may I talk to the interpreter just very briefly?

CHAIRMAN FRANCIS: Are you through with that question, Greg?

MR. FEITH: Yes. I'm just formulate --unless you've got a follow-up to that question --

CHAIRMAN FRANCIS: No, I'm --

MR. FEITH: -- just thinking --

CHAIRMAN FRANCIS: -- I'm not sure -- go any -- anywhere further with that.

(Pause)

MR. FEITH: I have no further questions.

CHAIRMAN FRANCIS: Thank you.

Monty?

MR. M. MONTGOMERY: I have no questions. Thank you.

MR. CARISEO: No questions, Mr. Chairman.

(First Officer Chung continued to translate both the questions posed in English to Korean and Captain Lee's responses from Korean to English.)

MR. BERMAN: Captain Lee, it sounds like you've reviewed the cockpit voice recorder transcript. I'll make some references to it but read from it for you.

At 15:37:07 -- correction. At 15:33:38 the captain refers to, "What's the number for Guam 17?" and the first officer replies, "17." Do you know what that is in reference to? 17?

THE WITNESS: The accident -- the accident aircraft was installed with the ANS system. When you approach the destination airport you change the legs page to make the destination appear so that you can know your final distance to the destination as well as the time to the destination. And they're aware to the fact that the ANS has a built-in error associated. That's it.

MR. BERMAN: Okay. At 15:37:07 the flight crew refers to INS DME display. Is that the same display as the DME from VOR?

THE WITNESS: That -- that particular point in the CVR has been cut off or interrupted. Butspeaking in general, after having checked the flight plan for the accident air -- aircraft, number 17 refers to the Guam Airport. Number 16 is the Nimitz VOR. That would be my answer.

MR. BERMAN: Where is the INS display located in the cockpit?

THE WITNESS: On the center pedestal, as he put it, the center console, right next to the captain on his right. Across the center console right next to the first officer is the display number two. On the aft portion of the same console is number three.

MR. BERMAN: All right. Thank you.

Let me ask you to help us understand the instrumentation. If the mode control panel altitude selector were set at 1440 and the altitude capture had engaged and then the altitude selector were changed to 560 before the altitude 1440 were held, what would be the effect on the aircraft?

CHAIRMAN FRANCIS: Let's be very certain that this question is fully understood, please.

FIRST OFFICER CHUNG: Okay.

THE WITNESS: I understand your questions to mean this is the pilot not having engaged the altitude hold switch and continuing to set the next altitude.

MR. BERMAN: This is correct. If thealtitude 560 were set prior to altitude hold.

THE WITNESS: That would -- differ depending on how much time lag or delay there was after the altitude hold switch was engaged. The altitude capture mode has a certain transition layer or something to that effect. If it's -- if the autopilot is in the altitude capture transition phase or period and at that time if the altitude selection was lowered it maintains the pitch -- it means the -- maintains the pitch at the time of the adjustment? Would that be correct? It maintains the pitch -- pitch at -- as -- as -- at the time of the -- the switch being changed.

MR. BERMAN: So, it would descend below --

FIRST OFFICER CHUNG: I'm sorry. Go ahead.

THE WITNESS: As long as you don't touch the speed mode switch, that -- that -- that is what would happen.

MR. BERMAN: So it would descend below 1440?

THE WITNESS: Of course, that is true provided once again that the -- prior to capture that this action was taken place.

CHAIRMAN FRANCIS: It would go through 1440?

FIRST OFFICER CHUNG: He -- he said yes, it would go through 1440 but this is under the premise that we stated before is what he said.

MR. BERMAN: Prior -- as long as it was done prior to altitude hold being engaged?

THE WITNESS: That's correct.

MR. BERMAN: Okay. And I know we've discussed this before, but I think we need to revisit once -- one more time. Does Korean Air have a required call-out by the pilot not flying if the airplane descends through an assigned altitude?

THE WITNESS: I have said that the standard call-out covers the altitude capture call.

MR. BERMAN: Right. And if the altitude is not captured is my question now.

THE WITNESS: I'm not sure I understand the content of the question.

MR. BERMAN: I'm understanding that the required call-out is "the altitude has been captured." My question now is what is the required call-out in the absence of altitude capture?

THE WITNESS: All crews are supposed to monitor the altimeter while the altitude is changing. If for some reason such as mechanical failure or just anomalies that the airplane fails to capture an altitude, it is expected that the first crew to notice this with call it out.

MR. BERMAN: Okay. I understand.

Referring to the approach chart for the ILS approach to runway 6-left executing the approach with the glide slope inoperative, what would the crew do if the outer marker were not received in this approach?

THE WITNESS: It would seem that the crews would not be aware that the outer marker was -- whether the outer -- outer marker was operating or not. They would not know until they passed that point. But since the -- but since they have a DME and assuming that the DME was operating correctly, the -- they would know when they were at the outer marker position.

MR. BERMAN: Okay. Thank you.

How do pilots in general identify, when they are going to use a constant descent method, the position or time to begin the descent on a non-precision approach?

THE WITNESS: We don't recommend the constant descent method, as I said before. But if they were to do it, we would base this decision with reference to the airport -- to the final airport elevation.

MR. BERMAN: Okay.

THE WITNESS: Yes, of course.

MR. BERMAN: Okay. Thank you.

You testified earlier that about half of the airports served by the 747 Classic have the VOR and DMElocated off the field.

THE WITNESS: I'm saying that one airport will have many different types of approaches. And I'm including all those.

MR. BERMAN: Okay. And how many of those airports does the approach use the DME that's located off the field?

THE WITNESS: I believe -- I understand that I explained that about half the airports have the DME non co-located with the field.

MR. BERMAN: Okay. How many at the -- of how many of those airports does the ILS or localizer approach use the DME distance that is located off the field?

THE WITNESS: Would you repeat that question, please?

MR. BERMAN: At how many of these airports does the ILS or localizer approach use DME information located off the field?

THE WITNESS: At this time I don't really know. I can't put a finger on that.

MR. BERMAN: Okay. Referring to the Jefferson manual that you said was carried aboard the aircraft, the third manual, are the airport approach charts for Guam included in that manual?

THE WITNESS: I believe the -- at the time of the accident the Guam chart was included in the individual charts -- individual crew-carry possession charts.

MR. BERMAN: But not in the aircraft charts for emergency airports?

THE WITNESS: That's correct.

MR. BERMAN: If we could return briefly to the -- this issue of the constant descent approach. You said that they don't -- Korean Air doesn't recommend this method.

THE WITNESS: Yes, that's true. I am talking about training -- during training.

MR. BERMAN: Is it prudent to condone that type of procedure in actual line operations?

THE WITNESS: That is -- I believe that's entirely up to the discretion of the pilot in command and we neither condone nor disparage those practices.

MR. BERMAN: But you are aware of these practices?

THE WITNESS: Yes, I'm aware in practice.

MR. BERMAN: Thank you.

(End translation)

CHAIRMAN FRANCIS: Thank you very much, Captain Lee. This has been a -- an extraordinarilylong morning for all of us but I suspect particularly for you, and we appreciate your tolerance. I don't like to take -- breaks in the middle of witness testimony because there is a -- a benefit for continuity. We thank you very much for your -- for your patience and for your testimony. Thank you.

We will now take a break for lunch and reconvene at 1:00.

(Whereupon, at 11:55 a.m., the proceedings were adjourned for lunch, to reconvene at 1:00 p.m. the same day.)

A F T E R N O O N S E S S I O N

1:00 p.m.

CHAIRMAN FRANCIS: All right. Our next witness this afternoon will be Captain Park, director of Academic Flight Training, Korean Air.

MR. SCHLEEDE: It's Mr. Park.

CHAIRMAN FRANCIS: Excuse me. Mr. Park, not Captain Park.

Whereupon,

PARK, CHOON SIK

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF PARK, CHOON SIK DIRECTOR, ACADEMIC FLIGHT TRAINING KOREAN AIR SEOUL, KOREA

(First Officer Chung resumed the duties of translating both the questions posed in English to Korean and Mr. Park's responses from Korean to English.)

MR. SCHLEEDE: Mr. Park, please give us your full name and title and business address for our record?

THE WITNESS: My name is Park, Choon Sik. Iwork in the city of Seoul, Tim Chung Dum (ph) area, at the Academic Facility.

MR. SCHLEEDE: And what is your position at the Academic Facility?

THE WITNESS: I am the chief academic coordinator for academic instruction. My job is to maintain the academic programs for the different types of training that goes on. We also administer management programs for the instructors and for the CRM programs.

MR. SCHLEEDE: Could you please give us a brief summary of your education and experience that qualifies you for your present position?

THE WITNESS: I attended a four-year university and majored in Political Science. In '75 I entered the Air Force as a lieutenant. And in 1960 I went through the U.S. Air Force navigator training qualification program. I also have training in instruction as an instructor.

Then I separated from the Air Force in '69 and entered the Korean Airlines at that time. Until 1977 I was in the position of a navigator -- flight navigator for Korean Airlines. After that time I transitioned to a flight engineer and I have served in the 727 aircraft, A300, and the 747. Then I worked asa flight engineer and also as an instructor. In 1994 I went from a regular flight engineer to a -- to current position.

MR. SCHLEEDE: Thank you, Mr. Park. Captain Misencik and Dr. Brenner will continue the questioning.

CAPTAIN MISENCIK: Good afternoon, Mr. Park. Are you still current and qualified as a -- a flight engineer at Korean Air?

THE WITNESS: No, I left the line in 1993 from line duties.

CAPTAIN MISENCIK: What role do you have in the flight operations training program, the training manual for training pilots? Have -- did you have any role in developing that program?

THE WITNESS: I don't have direct involvement with the manuals development as such, but my primary duties are to -- for initial qualification, maintaining proficiency, and CRM training.

CAPTAIN MISENCIK: What role does the KCAB have in approving or accepting Korean Air procedures and manuals?

THE WITNESS: At the current time the -- all of the aircraft operations manual, training manuals, procedures as well as policies need to be approved by KCAB.

CAPTAIN MISENCIK: Is there a record of comments and criticisms made by the KCAB in approving the flight operations training manuals?

THE WITNESS: Up to now there -- fortunately, up to now there have not been any such remarks.

CAPTAIN MISENCIK: Okay. Mr. Park, I'd like to just kind of give you an outline of what we will talk about today. It's three main topics.

FIRST OFFICER CHUNG: Go ahead.

CAPTAIN MISENCIK: The simulator training and standardization of procedures, CFIT training, and crew performance and CRM.

THE WITNESS: Okay.

CAPTAIN MISENCIK: In simulator training, what percentage of training is observed by the KCAB?

FIRST OFFICER CHUNG: Could you say KCAB checkers?

CAPTAIN MISENCIK: KCAB checkers or -- yeah.

THE WITNESS: Rather than percentage figures, there -- they observe two to three times annually.

CAPTAIN MISENCIK: Does that mean total for the airline they observe two to three simulator training sessions?

THE WITNESS: That is correct. However, for type rating check rides we use the designated checkingsystem. But as far as KCAB direct, two or three times annual.

CAPTAIN MISENCIK: I just want to clarify that. That's airline-wide there's -- the KCAB observes two to three simulator training sessions?

THE WITNESS: Not specifically to say that they look at the session but that they -- excuse me. As an inspection program of sorts to overall manage and oversight two or three times a year.

CAPTAIN MISENCIK: Are there -- is there a record of comments that they have made on these inspection events?

FIRST OFFICER CHUNG: They -- I don't believe he's answering the right question. He's said -- They look at the -- they look at many training records is what he said.

THE WITNESS: They observe training processes. They also look at the training results.

CAPTAIN MISENCIK: I -- I understand. But the question is, is there a record that the -- at Korean Air of the times that the KCAB has done these things?

THE WITNESS: They are supposed to give us corrective action -- recommended corrections when they have their inspection. And they will give us list ofthings that we are performing incorrectly. So yes, there would be a record.

CAPTAIN MISENCIK: Do you recall any specific comments that the KCAB may have made relative to training?

THE WITNESS: I certainly cannot recall all the remarks that they made, but we have been identified as -- for recurrent training needing more varied destinations in our simulator training.

CAPTAIN MISENCIK: Are there any types of checks, flight checks, check rides that the KCAB is required to observe instead of a designated company checker or examiner?

THE WITNESS: Yes, there are. For the smaller type aircraft for captain checks that they are required to perform direct inspections or evaluations. And once annually they also perform an evaluation of the designated checkers.

CAPTAIN MISENCIK: When I asked earlier how many simulator sessions the -- or training events the KCAB observes, the answer was two to three. That must have been -- we must have misunderstood each other. Could you clarify that?

FIRST OFFICER CHUNG: Actually, that -- he would like to correct that and say not about sessions. There's really less inspection of the sessions --simulator sessions that go on.

CAPTAIN MISENCIK: I -- I'm not sure I understand that.

CHAIRMAN FRANCIS: Can we -- can we clarify that? I think we'd better start over again here 'cause I think there's a --

THE WITNESS: As far as observing simulator sessions, KCAB does not come out and inspect simulator sessions.

CAPTAIN MISENCIK: Okay. Basically, you --are you saying that the KCAB does not -- does not observe training periods? They only observe check rides? Is that correct?

THE WITNESS: KCAB does look at check rides. The two to three times that I mentioned was their inspection of the education program.

CAPTAIN MISENCIK: Okay. I just really have to clarify this. There's no training -- no training sessions observed by the KCAB, but they observe a number of proficiency checks or type rating rides, is that --

FIRST OFFICER CHUNG: Would you clarify that as to whether you're referring to simulators right now?

CAPTAIN MISENCIK: Okay. In the simulator,does the KCAB observe any training periods that are not flight checks or type rating rides?

THE WITNESS: You're correct. There are no direct observations of training for proficiency -- I'm sorry, for type rating check in the simulator.

CHAIRMAN FRANCIS: Now, wait -- wait a minute. Right to the last phrase there I think I was clear. There is no observation in the simulator of training sessions but there may be in the simulator observation of check rides or proficiency rides, is this correct?

THE WITNESS: I'm sorry. I was -- I was confused.

(First Officer Chung and Mr. Park conversed in Korean.)

FIRST OFFICER CHUNG: They're asking about simulators right now.

(First Officer Chung and Mr. Park continued to converse in Korean.)

FIRST OFFICER CHUNG: Again, this -- may I clarify? This is in reference to KCAB oversight?

CAPTAIN MISENCIK: That's correct. What I want to know is we'll break it down and separate training from check rides.

FIRST OFFICER CHUNG: Go ahead.

CAPTAIN MISENCIK: How many times does the KCAB observe training sessions, the simulator training sessions profiles one through 10 or whatever the profile is up to the check ride?

THE WITNESS: They don't have appreciable number of training sessions that they observe. However, for the check ride simulator -- simulator check rides they do observe it from start to finish.

CAPTAIN MISENCIK: Okay. And in the simulator check rides what percentage are observed by the KCAB?

THE WITNESS: As I said before, for smaller aircraft types for simulator check ride, the KCAB participates directly. Your question was what percentage -- percentage of --

(Mr. Park interrupted the interpreter in Korean.)

FIRST OFFICER CHUNG: Oh, he said almost all small aircraft type simulator check rides, almost all are observed by KCAB.

CAPTAIN MISENCIK: And in the 747 Classic, what percentage of proficiency checks and recurrent check rides, type rating rides are observed by the KCAB?

THE WITNESS: For the larger aircraft typeswe mainly use designated examiners.

CAPTAIN MISENCIK: So, are you saying there's a small percentage or --

THE WITNESS: I don't exactly remember the percentage figure.

CAPTAIN MISENCIK: But there are records? Are there records?

THE WITNESS: If you need further proof of the records then I can provide them to you once I return.

CAPTAIN MISENCIK: Thank you. Each of the training profiles described in the training guide appear to be two hours long. How are these profiles used in the training curriculum?

THE WITNESS: Basically, the -- each simulator session is really composed of four hours. The two hours you're referring to is divided by pilot flying and pilot not flying.

CAPTAIN MISENCIK: At the end of the two hours what happens? Do they swap pilot flying roles?

THE WITNESS: That's correct.

CAPTAIN MISENCIK: And then the -- the profile is repeated?

THE WITNESS: Yes, they do use the same profile.

CAPTAIN MISENCIK: Are simulator instructors encouraged to follow the scenarios in each profile or are they encouraged to modify the -- the scenarios in any way?

THE WITNESS: These are -- profiles are really lesson plans and they should follow them throughout.

CAPTAIN MISENCIK: The training profiles list the VOR DME for runway 3-2 approaches at Kimpo as the most common non-precision approach. How do pilots receive training in different types of non-precision approaches?

THE WITNESS: It's -- it is true that the --the 3-2 approach that you mentioned is the mainly used non-precision approach. What -- we have one localizer approach profile, and I personally feel that this is insufficient. Our plan is to diversify the non-precision types of approaches and to -- to increase the requirement on these.

CAPTAIN MISENCIK: During recurrent training proficiency checks, which scenario is used? Is it for a non-precision approach?

THE WITNESS: As I've just stated, the VOR DME approach is the mainly used scenario, but from this year we're going to use more diverse types ofapproaches.

CAPTAIN MISENCIK: Thank you.

Are there any non-precision approach scenarios used in training where the DME used for the approach is not located on the airport?

THE WITNESS: Up to now, no. We teach the basic principles of a non-precision approach, that they would be able to appropriately -- when they review the approach plate they would be able to react accordingly according to the needs of the approach.

CAPTAIN MISENCIK: Could you describe some of the scenarios used in simulator training which help pilots adapt to unexpected situations during approach procedures?

FIRST OFFICER CHUNG: Unexpected scenarios you said?

CAPTAIN MISENCIK: Yes. Unexpected situations.

THE WITNESS: I believe you're referring to pilot incapacitation. As far as responses to that situation, we have a standard call-out procedure at critical point during flight such as during the approach. If the PF would not react to a challenge by the PNF, then the PNF is taught to aggressively take over controls.

In addition, the 1000-feet point and the 500 points are designed so that -- to check the aircraft's stabilization along final, and at these times if the aircraft is found not to be stabilized then the PNF would be using the same principle, take-over controls if he had to.

CAPTAIN MISENCIK: Has the KCAB ever commented on the -- the fact that the non-precision approach scenarios seem to be limited to very few --very few approaches?

THE WITNESS: We have had -- we have had the feedback to that effect by KCAB.

CAPTAIN MISENCIK: Is that -- when -- when did you get that feedback?

THE WITNESS: Since the accident KCAB has said that the destination airport is not varied enough and the types of approaches are not varied enough.

CAPTAIN MISENCIK: Are there training scenarios where a pilot is expecting a -- a full ILS but there is a diversion to a -- an airport with a non-precision approach that is not a standard Korean Air destination?

THE WITNESS: Yes, periodically on the aloft profile we would run into something like that.

CAPTAIN MISENCIK: According to Korean Airprocedures, could you list the -- the responses to the GPWS alerts as in the training manual? I know there was some -- the reason I'm saying this is there was some confusion from an earlier testimony.

THE WITNESS: It is -- the concept is covered in -- included in the training manual. As to GPWS alerts, we're supposed to make immediate avoidance actions. But the method will defer -- differ depending on the mode of the GPWS alert.

CAPTAIN MISENCIK: Has Korean Air received material from the Flight Safety Foundation relative to CFIT?

THE WITNESS: We have a VTR, audio-visual educational aid from that Flight Safety Foundation.

CAPTAIN MISENCIK: And how has this information been put to use by Korean Air in the CFIT training program?

THE WITNESS: Basically, the main CFIT device of the GPWS equipment is covered in the academic instruction material. However, if we should talk about the manual that we obtained from -- that we obtained and the VTR materials -- we would like to add these points to the ground school instruction.

CAPTAIN MISENCIK: Does -- could you describe Korean Air CFIT training program or how it's utilizedin the training curriculum now -- Mr. Park?

FIRST OFFICER CHUNG: Would you repeat that question, please?

CAPTAIN MISENCIK: Yeah. Would you describe how CFIT is -- CFIT awareness is used in the Korean Air training curriculum?

THE WITNESS: I'll speak of the current system of training. As I said, the GPWS systems education is covered in ground school. The avoidance procedures are covered under the procedures section of ground school. The simulator training syllabus contains two scenarios. Since we received that previously mentioned material we are planning on incorporating the -- the written material into our training.

CAPTAIN MISENCIK: Mr. Park, with the CRM program that you have, could you describe basically the -- the format or the curriculum of the CRM program that you have at Korean Air at this time?

THE WITNESS: We originally obtained the program from the United Airlines in 1986. The entire material has been translated into Korean and we're using that now. Of course, all of the CRM programs that -- different programs have the same objectives, but we have sort of a laboratory -- we have thelaboratory type is what we have.

CAPTAIN MISENCIK: How long of a course is it? And is it -- does it involve all Korean Air employees?

THE WITNESS: The course is three nights, four days, and requires about 39 hours of instruction. And it would apply not to all employees but to all air crew members.

CAPTAIN MISENCIK: Mr. Park, how do you measure the success of the Korean Air CRM program?

FIRST OFFICER CHUNG: Excuse me. I'm not sure if I said that properly. May I have another chance at it? You say how is --

CAPTAIN MISENCIK: How is success -- how is success measured? How do you know that the CRM program is working?

FIRST OFFICER CHUNG: How do we know that the CRM program is working?

THE WITNESS: We do not have a appropriate way to measure the success of our program. But in order to make this program successful we have made efforts in two different directions. One, the CRM awareness is introduced to the CRM seminar courses. And the practice will be worked out in the aloft scenarios. The evaluation team would evaluate the CRMprogram each year. And we seek for that area which applies most to our airline. And that has been selected as our task of the year. Then we try to reflect this into the aloft training.

CAPTAIN MISENCIK: This CRM program, has it changed since -- since the accident?

THE WITNESS: The CRM seminar portion has not changed.

CAPTAIN MISENCIK: What -- what has changed?

THE WITNESS: Each years aloft is conducted in the second half -- the latter half of the year. And up to now it's been hour and 30 minute aloft. And our plan is to increase this time to two hours and 30 minutes.

CAPTAIN MISENCIK: Mr. Park, based on your review of the exhibits, including the CVR and the flight data recorder, how do you assess the accident crew's performance relative to CRM and crew coordination?

THE WITNESS: Before I give an evaluation or an assessment, may I speak first about some standards? The goal of our CRM program involve interaction through the processes of inquiry and -- advocacy to come up with effective solutions, and if I look at it from that standpoint and then if I look at our crew -- accidentcrew, then it is difficult for me to say that they performed up to that standard in general.

CAPTAIN MISENCIK: Mr. Park, since the accident could you give us a -- an indication of what changes or what -- you -- you listed some, but what changes or contemplated changes may occur as a result of this accident in the academic department?

THE WITNESS: Since the investigation is still under going -- is still under going we have implemented only part of this program. Last year latter half through special educational program every crew member was reviewed on the instrument approach procedures. The CFIT, the VTR program, and the contents were introduced to the crews. As I said before, the aloft profile is planning to be increased to two and a half hours to change the CFIT academic curriculum programs. Those are the -- the changes underway at this time.

CAPTAIN MISENCIK: Okay. Thank you, Park --Mr. Park. I'm -- I have no further questions. I think Dr. Brenner has -- has some follow-on.

DR. BRENNER: Yes, Mr. Park. In 1989 a Korean Air suffered a CFIT, C-F-I-T, accident in Tripoli, Libya. Are you aware of any safety changes that resulted from this accident?

THE WITNESS: At the time I was not in a managerial position so I'm not too familiar with this, but from what I have discovered in the process of upgrade from a first officer to a captain 14 hours of additional instrument flying was added to the program and in terms of simulator sessions two types of CFIT-related GPWS warnings were included in the simulator session. As far as academic instructional system, it used to be tutorial style and it was changed to CBT, computer-based training style or method, so that it became a tutorial plus the CBT kind of a program at that time.

DR. BRENNER: Thank you. Were there any special considerations for adapting the CRM program to Korean culture and values?

THE WITNESS: That's a difficult problem and I would like to talk to you about it through an example. All air crew members participating in a CRM education program -- at the time of entering into the program about 80 percent of all crew members feel that they are qualified or fall in a category -- I'm sorry? That they're best qualified air crew. They grade themselves to be in the upper category. But at the end of the program those who when they reassess their cockpit operations styles and such, this number fallsto somewhere around 10 percent.

At the same time, they do gain this new value system, new value system wanting to become more adept at running an efficient cockpit management. And this statistic is the -- the same between our figures and that of the United Airlines. So I believe that the CRM processes do not speak of appreciable difference.

But when it comes to actual application in the cockpit I think there are some differences. Japan Airlines is an example of a company that two years ago adapted this kind of a program and in the same geographical area as Korean Airlines, and they do not speak of cultural differences in that situation.

The only remark I would like to make is that when it comes to the environment of cockpit operation that they -- that it needs to become culture-free in order to obtain our objective of safety standard. So, not so much cultural adaptation but driving the crews toward a culture-free state more in order to -- this culture-free cockpit environment to reach the objectives of safety rather than cultural adaptation or cultural aspect to approach the safety objective from this -- this angle.

DR. BRENNER: Thank you, Mr. Park. And just to clarify for me, if I understand, your company foundthat the United Airlines program was successful and did not need to be adapted to a Korean -- Korean emphasis?

THE WITNESS: We -- to this day we're not really compelled to change this program as it is, but taking into consideration the rapid state of cockpit automation we need to develop -- further develop and improve this program. We feel this need at this time.

DR. BRENNER: Thank you. And there was an earlier question, in this accident do you think that the subordinate crew members were inhibited from questioning the captain. I'd appreciate your views.

FIRST OFFICER CHUNG: I'm sorry. The last part I stepped on you.

DR. BRENNER: Oh, I would appreciate his views.

FIRST OFFICER CHUNG: That they felt which way, sir?

DR. BRENNER: That they felt inhibited --

FIRST OFFICER CHUNG: Inhibited.

DR. BRENNER: -- from questioning the captain.

THE WITNESS: In the Oriental culture there is a -- the concept of modesty, but when I look at the overall cooperative atmosphere among the crew members I do not really feel that way.

DR. BRENNER: Thank you, Mr. Park.

That completes my questions, Mr. Chairman.

(End of translation by First Officer Chung. Regular interpreters resumed translation duties.)

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman. I have only question. I'll confirm the factual approach.

When you see the factual report page 10, page 11, and page 12 according to personnel information the number one captain, second first officer, thirdly --third is a flight engineer. If you see that each paragraph end -- the end of the -- each paragraph -- he says that -- that record doesn't show the time or date of the -- of the crew members who received the certain education. What I'm referring to is the CRM program. As far as I know, since we MOTC -- MOCT inspect and also from the personal training record I -- I could confirm this record, yet you mentioned earlier that from this record it's -- it's impossible to check from the personal training record. Is that correct?

Then since your -- you didn't receive this kind of report it's -- did you -- have you ever asked and required to the NTSB to modify this kind of records or this kind of procedure?

THE WITNESS: After the certain program ortraining is finished, all the result is recorded in computer, but what type of the content of -- in that record I'm not sure as to why I -- I'm -- don't understand why this kind of a report is necessary. Even though it's -- here it says that cannot check the record but actually there's a -- that kind of a record is available. I'm sorry. It's unfortunate that I -- I will be -- were not able to modify.

MR. LEE: That's the question. Thank you.

CHAIRMAN FRANCIS: Then I would ask if -- if this is the case that this could be presented to us for the record, please, through the KCAB.

Do you have a further question?

MR. LEE: Yes, I understand.

CHAIRMAN FRANCIS: Do you have a further question or is that -- KCAB?

MR. LEE: No more questions.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: We have no questions, Mr. Chairman.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Korea Air?

CAPTAIN KIM: No questions, sir.

CHAIRMAN FRANCIS: Barton?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: I just have a few questions.

(First Officer Chung resumed translating both the questions posed in English to Korean and Mr. Park's responses from Korean to English.)

MR. FEITH: Can you explain to us how pilots are upgraded, what the -- what the requirements are as based on seniority?

FIRST OFFICER CHUNG: Pilot -- which part, sir?

MR. FEITH: How are pilots upgraded?

THE WITNESS: Not based on seniority but by flight experience.

MR. FEITH: What would be the requirement from upgrading from a first officer to a captain with regard to flight experience?

THE WITNESS: I'm not qualified to speak on this from an expert point of view, but from what I knowfor the military background pilots about 3000 hours and for the -- background 4000 hours.

MR. FEITH: Let me make sure I got this correct. This captain on Flight 801 had about 9000 hours. He had transitioned off of another aircraft, 727. The first officer on this airplane had about 4000 hours. When would he be ready to upgrade to a captain if it's based on flight experience?

THE WITNESS: As I told you before, as far as the policy for upgrade I'm not really the man to talk to about. But if you need to, I can go into some detail for you. I would need some time.

MR. FEITH: Let me move to something you may know more about. How are instructor pilots selected?

THE WITNESS: Most of our simulator instructors are line experienced, retired pilots on a contract basis with Korean Air. As far as line instructors, as in the case of Captain Lee that just testified this morning, that's based on flight experience and overall experience that they would be selected. As far as the exact figure, I don't have that.

MR. FEITH: Is there any special training curriculum for a instructor pilot once he has been selected?

THE WITNESS: Yes, there is. Ground school is 13 hours, eight hours on simulator instruction and on how to -- how to use the simulator equipment. That includes actual hands on at -- in -- at the instructor position. And after they are checked at the line through a flight check then they're designated as flight instructors.

MR. FEITH: Thank you.

You had spoken earlier about the involvement with the KCAB as it regards your training program. Have you ever -- have you ever had to modify or change any of your training curriculum because of deficiencies or suggestions given to you by KCAB?

THE WITNESS: Yes, there are many instances in the past, but in particular, as I mentioned, the recurrent simulator profiles regarding the accident. Those would be the types of changes and it occurs all the time. As further examples of Guam approach scenarios and other difficult approach profiles, he says, for non-precision approaches have been updated.

MR. FEITH: Mr. Park, can -- I'd just like to ask a question about the GPWS minimums call-outs. Is there any specific training a pilot receives when the oral GPWS call-outs occur? Is there any action that is required of the crew?

THE WITNESS: Would you please specify your question more clearly?

MR. FEITH: On the CVR, it is recorded that the GPWS was doing the 500-foot call-out and then counted down from 100 feet. The crew did not talk about it from what was on the CVR, and there, from my point of view in reading the CVR, did not appear to be any reaction to those call-outs. Is there a procedure or a policy at Korean Air that would require the crew to either identify those call-outs and/or react to those call-outs?

THE WITNESS: First, why the CVR has those --why the CVR recorded what we hear I don't -- I can't imagine why this happened. Yeah, we teach this during instrument flight rules education. All simulator training and procedures teach immediate responses to minimum GPWS call-outs.

MR. FEITH: So, what would the appropriate response have been?

THE WITNESS: The fact that they did not make appropriate reaction to those call-outs is the part that I can't understand myself.

MR. FEITH: Thank you. One -- one last question. Are the instructors provided any special training with regard to CRM and the evaluation of CRM?

THE WITNESS: Not the seminar instructors but those who perform this at -- in the line. The proficiency check ride items and all check rides have a graded section for CRM. So, we do give a grade on the CRM interaction.

MR. FEITH: Well then, following onto that question, if you find a deficiency or a problem with CRM, how do you implement change because this is more of a behavioral type change, not so much a procedure? How do you influence that kind of change?

THE WITNESS: In this case, the chief pilots at the line would be consulted for appropriate solutions.

MR. FEITH: You may have already asked this -- answered this once before, but in your experience or your knowledge of the airline operations, have you ever heard of or observed a reluctance to the changes that would naturally come with a CRM program from previous operating, for lack of better words, culture where the captain was typically an authoritative figure in the cockpit?

THE WITNESS: You'd be surprised to find out we do not have any kinds of resistance as you speak of. Just the contrary, all of the managers have been accepting promoting of the CRM concept, and ourpresident of the company as well has been known to promote the program.

MR. FEITH: Given the fact that the managers accept it, do the line pilots accept it?

THE WITNESS: It is true that most of our line captains have educational experiences that stem from United States. Most of -- most of our aircraft have been purchased from the United States so that actual training would take place in the U.S. as well in a lot of the circumstances. So most of the captain are familiar with U.S. customs and the training philosophies.

When it comes to the younger people in our airline, we -- the media -- the media --

FIRST OFFICER CHUNG: I would say their thoughts are more progressive due to the influence by the media I believe is what he's saying.

(Resumption of translation)

THE WITNESS: So that have we not come a long ways from the old way of thinking.

MR. FEITH: If I can just get a summary of yes or no, given all of that explanation is there a reluctance on the line pilot part to accept all of the training philosophies and this -- this new way of doing business in the cockpit?

THE WITNESS: Yes. I feel as I see it, yes. They're positively accepting of the new changes.

FIRST OFFICER CHUNG: Is that -- is that clear?

MR. FEITH: Yes, I guess it is if -- if that is his -- his belief that there is an acceptance of --of this in the cockpit, yes.

One more thing, and that is you had spoken of the first officer taking aggressive action in a situation that may call for such action to be taken, i.e. or that is, when the captain may not respond to the second call that a first officer makes. Have you ever trained this, observed this in the simulator or in line operation?

THE WITNESS: This is specified in the standard call-outs. The standard call-out instruction specifically states the action to take in this instance, so I -- it is trained.

MR. FEITH: Okay. My question, I guess, is, to be very simple, have you ever observed the first officer take command of the airplane from the captain?

THE WITNESS: I have not seen it.

MR. FEITH: Thank you. I have no further questions.

MR. CARISEO: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Go ahead.

MR. BERMAN: Mr. Park, based on what you've said, I understand that Korean Air has received the Flight Safety Foundation controlled-flight-into-terrain training program.

THE WITNESS: Yes.

MR. BERMAN: Had the airline received this program prior to the accident?

THE WITNESS: Yes, we did.

MR. BERMAN: Had you used it in your training curriculum prior to the accident?

FIRST OFFICER CHUNG: He would like you to clarify which material you're talking about again, sir?

MR. BERMAN: The training manual and the videotape.

THE WITNESS: Last year's latter half recurrent ground school, the videotape was shown to all crew members.

MR. BERMAN: Mm-hmm. Had you used the CFIT checklist produced by the Flight Safety Foundation?

THE WITNESS: Not yet.

MR. BERMAN: With respect to pilot upgrades based on seniority and flight experience, how many pilots have failed the upgrade program from first officer to captain in the last five years?

THE WITNESS: I do not remember as to the number, but I would say a significant number.

MR. BERMAN: Can you give me an estimate of the percentage of upgrade candidates who failed?

THE WITNESS: I wasn't expecting to answer that question so I don't know.

MR. BERMAN: And what is the company's procedure for the pilots who fail the upgrade to captain? What -- what happens to them?

THE WITNESS: As to the action taken subsequent to that, we don't handle that. That is handled by a separate board.

MR. BERMAN: Okay. Would you please provide this information for the record? The percentage of upgrade candidates who fail and the company's actions afterwards.

THE WITNESS: Do you need that by a certain time?

MR. BERMAN: No. No, sir. Just please provide them when you can.

THE WITNESS: Okay.

MR. BERMAN: Thank you. No further questions.

MR. M. MONTGOMERY: I have no questions. Thank you, Mr. Chairman.

CHAIRMAN FRANCIS: I just have a comment, I guess, rather than a question. But I'm not sure what -- what exactly you mean by a culture-free cockpit. I'm not sure that on the face of it I would -- I would accept that there is such a thing. I would just say, I guess, that there's an enormous amount of very work --good work being done on culture in the cockpit and cross cultures in the cockpit, and -- and I hope that all of us that are involved in this industry and -- and in aviation safety will be paying a lot of attention to this, and as you commented earlier, that we'll be constantly adapting to -- to what we learn as we go on.

Thank you, Mr. Park, for your -- for your contribution.

(Pause)

CHAIRMAN FRANCIS: He's -- Mr. Park is excused.

THE WITNESS: Thank you very much, Chairman.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: And we'll go from Mr. Park to Captain Park now as the next witness.

We will continue with the translator from the -- front here. I think that's facilitating a little bit, and then when we finish with this witness we'll go back to the interpreters in the rear of the room. Thatis, assuming Steve is holding out all right.

FIRST OFFICER CHUNG: -- holding up.

CHAIRMAN FRANCIS: You holding up okay, Steven?

FIRST OFFICER CHUNG: Yes, I'm sorry. I --

CHAIRMAN FRANCIS: This is -- this is real work, I know.

FIRST OFFICER CHUNG: One more --

CHAIRMAN FRANCIS: -- appreciate what you're doing.

FIRST OFFICER CHUNG: Thank you --

CHAIRMAN FRANCIS: If we can continue through this witness it's very helpful I think.

FIRST OFFICER CHUNG: We appreciate the opportunity you're giving us. Thank you, Mr. Chairman.

Whereupon,

CAPTAIN PARK, PYUNG-WOO

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF CAPTAIN PARK, PYUNG-WOO DEPUTY DIRECTOR, FLIGHT OPERATION KOREAN AIR SEOUL, KOREA

MR. SCHLEEDE: Captain Park, please give usyour full name and business address for our record?

THE WITNESS: My name is Pyung-Woo Park. Currently I work at the Korean Air Flight Operations branch located at the Seoul City --

MR. SCHLEEDE: And what is your position at Korean Air, please?

THE WITNESS: Currently, I am the flight operations -- at Korean Airlines deputy director for Flight Operations.

MR. SCHLEEDE: Could you please give us a brief summary of your training, education, experience that qualifies you for your present position?

THE WITNESS: Graduated from the Korean Air Force Academy in 1966. Was commissioned and served for 10 years in the Korean Air Force. In the Air Force I mainly flew as a pilot on the C46 and the C54 type aircraft. I separated in 1976 May the -- May the 4th. I'm sorry, May the 31st.

I entered Korean Airlines in May the 19th of 1977 as a flight engineer on the 707. I transitioned to first officer in November of 1980, and May the 15th of 1985, I became a 707 captain. As a captain I flew in the MD 82 and the 747 Classic before I became a 747-400 captain in 1991. I'm currently also serving as a 747-400 line captain and an evaluator, and I have atotal time of approximately 14,300 hours. Excuse me, 18,300 hours.

I have been in the current position since November 20 -- 20th of 1996, as the deputy director. At the current position I'm mainly in charge of personnel matters, scheduling matters, and overall management and oversight of our flight crew members at Korean Air.

MR. SCHLEEDE: Thank you very much. Captain Misencik and Dr. Brenner will continue.

CAPTAIN MISENCIK: Good afternoon, Captain Park.

THE WITNESS: Good afternoon, sir.

CAPTAIN MISENCIK: At the time of the accident, what was your title at Korean Air?

THE WITNESS: I was the deputy director at the time as I am now.

CAPTAIN MISENCIK: Okay. Captain Park, does Korean Air receive or solicit input from pilots regarding items of concern to them?

THE WITNESS: It does not occur frequently, but we do have cases of this happening.

CAPTAIN MISENCIK: Have pilots expressed concerns that you recall regarding training or flight procedures?

FIRST OFFICER CHUNG: Would you repeat that question, sir? I'm sorry.

CAPTAIN MISENCIK: Have pilots expressed concerns to management regarding the training program or flight procedures?

THE WITNESS: Yes, that all -- also occurs every now and then.

CAPTAIN MISENCIK: Do you have any recollection of some examples of some of the issues that pilots have raised in the past?

THE WITNESS: I'll give you one example. On the Classic 747 non-precision procedures according to the training manual published by the Boeing Company prior to the final approach fix they're supposed to run the landing checklist. Some line captains when they applied the Boeing procedures exactly that the workload involved in looking for visual cues as well as performing checklist items, that they were too busy to conduct this. Therefore, we requested -- they requested that the procedure be changed to perform the landing checklist prior to the final approach fix.

We collected this kind of information. We turned it over to the evaluations section and they verified as to this fact. And the chief pilots got together and discussed this matter thoroughly. And wefelt that this was -- this needed to be changed, so we contacted the Boeing Company at that time.

We expressed our desire to change the procedure to the Boeing Company, asked for their opinion as to the safety of making these procedural changes. After being advised that it did not infringe on flight safety we did change the procedure. By filing to the KCAB we received approval for this change to procedure.

CAPTAIN MISENCIK: Has Korean Air management in the past received any items of concern from pilots regarding the island of Guam or the approaches there?

THE WITNESS: Not prior to the accident.

CAPTAIN MISENCIK: Since the accident am I to assume that there has been some --

THE WITNESS: We have had verbal reports as well as captain report on written format come through about DME, the outer marker, and the glide slope not appearing as they were -- as they were reported to appear.

CAPTAIN MISENCIK: Do you have written records of those reports?

THE WITNESS: Of course, not the oral reports that I remember, but the written reports, I should have some in my office.

CAPTAIN MISENCIK: Has there been any input from the pilots regarding the -- the complexity of the approaches into Guam or the -- the terrain?

THE WITNESS: No, there have not been any comments in that regard.

CAPTAIN MISENCIK: Captain Park, how many airports on Korean Air's route structure do not have a VOR and DME located on the airport?

THE WITNESS: Excuse me. I don't have, again, exact figure as to how many airports exactly, but as an example John F. Kennedy Airport, the Canarsi (ph) approaches to runway 1-3 would be an example. Also, at Anchorage Airport and Frankfort Airport the VOR's located outside the airport. We did not feel that this kind of data required any kind of statistical percentage figures, so we didn't -- we don't have any data that relates to your question.

CAPTAIN MISENCIK: Captain Park, are there records kept or do you have any idea how many missed approaches are made in a given year?

THE WITNESS: We have not had the need to categorize missed approach -- missed approach instances into a percentage figure.

I should add something to that. The reason we don't do that if we -- if the management's actionkept track of the number of missed approaches we felt that this would force undue pressure on the pilots to perform the -- force a landing when they should go around. That's why we don't have -- we don't track that.

CAPTAIN MISENCIK: Mr. Park had already indicated the amount of -- the quality of CFIT training that is being considered or implemented into the academic curriculum. Could you tell us what management is doing with the CFIT initiative, if there is a CFIT program in -- in the works?

THE WITNESS: We did -- at the time we didn't put a name on it as such as a CFIT, but -- even prior to 1993 we took the initiative to make the CFIT concept an awareness. I'd like to give you some examples of the kind of education regarding CFIT.

Starting from the initial education for people that are new hires, transition and qualification and through recurrent training that occurs on a regular basis, so we've conducted CFIT education. Particular, in 1993 using the medium of "Flight Safety Magazine," which is used by the management to -- as a material for overall flight safety education. We have numerous articles that -- regarding the CFIT education. And in September of 1996 we took the more detailed CFITmaterial in the same medium and connected this educational training throughout the -- the pilot force.

What I've just disclosed to you is entered as our exhibit in -- under 2S.

CAPTAIN MISENCIK: Captain Park, the information that you entered as an exhibit, the articles on CFIT, how are those -- how is that information circulated to the pilots?

THE WITNESS: The -- the -- these articles as well as other items are distributed through the individual mail boxes at our company.

CAPTAIN MISENCIK: The -- the articles as they are distributed, is there a -- a -- is it required reading? Is there a -- a survey taken of the pilots that respond to these articles?

THE WITNESS: All educational training materials transmitted to the crews the crews are required to read. We verify as to whether they read these material or not through periodic or no-notice inspections during recurrent and simulator training.

CAPTAIN MISENCIK: Most of these -- you have pilots from a -- a number of different countries and backgrounds flying at Korean Air. What language are these articles transmitted to the pilots?

THE WITNESS: It's usually in English.

CAPTAIN MISENCIK: Do you recall if any of these articles had focused on the lessons learned from the Cali accident?

THE WITNESS: Would you specify the question one more time?

CAPTAIN MISENCIK: Do you recall if any of the flight safety CFIT accidents had information relating to the -- the American Airlines Cali accident?

THE WITNESS: Personally I do not remember sitting here.

CAPTAIN MISENCIK: What is the Korean Air policy regarding Enhanced Ground Proximity Warning Systems in aircraft?

THE WITNESS: We have been aware of the performance advantages to the EGPWS for some time. We have received material on the subject.

Since this hearing is related to the 801 accident in particular, may I make one comment about the 801 accident? At the time of the accident the EGPWS was not in a practical -- was not practically implemented. However, for the aircraft to come on line scheduled for June of this year, new aircraft, this aircraft should have the EGPWS device installed.

CAPTAIN MISENCIK: Is there a plan to retrofit other aircraft with EGPWS?

THE WITNESS: My understanding is that the current models of the EGPWS, it is not practical to retrofit older airplanes because of the modifications involved.

CAPTAIN MISENCIK: Captain Park, would you please describe the training at Korean Air for special airports and for unfamiliar airports, please?

THE WITNESS: Excuse me. As far as the special airports, this would apply to Korean Airlines any special circumstances regarding not only the flying part but on the ground; for instance, the CIQ process itself. But certainly including arrivals, approaches, departure, any flight procedures requiring particular care would be classified as special airport.

Continuing on to air traffic control capabilities, the facilities -- NAV/AID facilities, approach lighting systems, obstruction training classes, we take those into consideration. Those airports that have these considerations to make it more difficult, then we would classify it as a special airport. This also takes into account the weather factors.

(Pause)

THE WITNESS: For special airports prior to the route training as a part of the academicinstruction they learn route procedures in the particular special airports. And we emphasize these special airports during route academic training. Then they come to experience it firsthand during the what we call the route training in-flight.

For the unfamiliar airport, these are applied to any airport that the company airplane has not accessed within the last year, more than a year. When we operate into the unfamiliar airport, we would normally schedule it so that the PIC would be a designated examiner standard or better. If this should prove not practical we'd require captain with more than 1500 hours in type as PIC. If that should also prove to be impossible, the last -- carrier with, say, 1000 hours PIC in type and an instructor-qualified person would go. If we don't have the screws to schedule into -- that meets either -- any of these three criteria then we would not operate into that airport.

CAPTAIN MISENCIK: Captain Park, we'll refer to Exhibit 2D. 2D page one.

Put it on the screen, please.

(Pause)

CAPTAIN MISENCIK: Item three describes the terrain. This is an excerpt from the -- the English translation of the audio-visual presentation used byKorean Air for familiarization with -- with Guam, and item three describes the terrain in the vicinity of the airport. Do you consider that the description of the terrain is adequate or descriptive enough of the terrain on the approach course to runway 6?

THE WITNESS: The audio-visual system is used in general as part of the general education for airport familiarization, and in this case the 803-feet high Mount Macana (ph) is very specifically mentioned. And it also talks about the minimum safe altitudes that are -- that apply to Guam Airport.

CAPTAIN MISENCIK: The fact that the -- the refer to Mount -- I hope I'm pronouncing it right --Macaya -- Macana, 803 feet, is located north of the Nimitz VOR and Mount Jumoan (ph) is 11 miles south --south -- southwest, in your estimation is that adequate guidance that there may be a higher terrain in the vicinity of the VOR?

THE WITNESS: I take this to -- I analyze this to mean that there's a -- a mountain near the VOR.

CAPTAIN MISENCIK: If you'll refer to page three now of the Exhibit 2D, item 14. Item 14 states, "You will be guided from over Apra (ph) Harbor to localizer. You will then perform a visual approach as in this picture." Do you consider this statement maycondition a pilot to -- to expect a visual approach in all circumstances?

THE WITNESS: I -- we -- I do not feel this way. The reason we teach all pilots at Korean Air that instrument -- flight instrument approaches are safer and perhaps less -- as easier to perform than the visual approach so that even if approach clearance would give us a visual clearance we would ask -- go back and ask for an instrument approach clearance and try to fly that.

CAPTAIN MISENCIK: Captain Park, how do you consider the 801 accident in the context of CFIT? Do you consider this a CFIT accident?

THE WITNESS: It is incumbent upon the Board to make the final determination as to the classification of 801, whether this is a CFIT accident or not. However, speaking as a pilot I would like to interject my personal opinion on the subject.

I think that the CFIT accident categorization would pretty much require normal operation of instruments, but in the case of the 801 all the information that was available to the pilot was significantly different than the reality as they found it during approach. They anticipated the glide slope to be completely out of service but they have -- had ano flag indication, some sort of indication in the cockpit. The weather factor, the weather conditions that the crew actually ran into were significantly worse than what the ATIS had -- had them expect. Unfortunately, in the process of giving the approach clearance by the CERAP if the -- the approach control had just once more confirmed the glide slope as being out of service to the pilots I think that this accident would -- could have been prevented. That's all.

CAPTAIN MISENCIK: Captain Park, do you feel that Korean Air pilots by the statement on the -- by the statements that you made about always preparing for a -- an instrument approach conditions them to possibly always expect a electronic glide slope?

THE WITNESS: I would not think so.

CAPTAIN MISENCIK: During proficiency checks and type ratings, what is the failure rate for Korean Air pilots?

THE WITNESS: It's difficult for me to say, but based on my experience and knowledge as a manager along the entire spectrum of training I think about four percent. If we were to include the Jaju Abinishio (ph) program, the figure would come up to something like 10 percent would be my guess.

CAPTAIN MISENCIK: Do you have any specificfigures on the failure rate among type rating rides?

THE WITNESS: As far as I know, the -- I believe this -- the numbers are about three to four percent with type rating checks.

CAPTAIN MISENCIK: What are the most common -- common reasons for failure? Do you know?

THE WITNESS: If you were to take initial training, they may have inadequate systems knowledge. Then they would just fail it simply during the oral phase of the check. For some checks it's usually on procedural matters. Our company has really high standards when it comes to flight -- flight evaluations. For instance, the tolerance for the altitude restrictions is minus zero feet. We have instances where the -- during approaches or departures they would fail for not -- for failing to keep an altitude or remain within track.

CAPTAIN MISENCIK: After a pilot receives his type rating in an airplane, what further training does he receive regarding IOE or route qualification?

THE WITNESS: As I said before, after the person gets a type rating they would, depending on the aircraft type, receive further education starting with about 30 hours of ground school for the route. After that education's complete. After the academic portionwe perform 30 take-off and landing practices in the simulators. This process -- this process involves maximum operational limitations for that aircraft, maximum crosswind, maximum tailwind, severe turbulences, wind shear conditions. We give them the opportunity that requires maximum performance on the part of the pilot proficiency and put 'em through that program. After that, simulator training simply.

After they've gone through that then they enter into route training that covers every air field that they will be qualified to fly into from that point. The -- the qualification granted by the KCAB on their route qualification or route experience is --requires one round trip or two one-way flights to that destination in order to be considered qualified by the KCAB. After that they would receive the -- their check rides, and for the smaller aircraft types, meaning the F100 Blocker, F100, and the MD 82, they would receive check directly from a KCAB checker. For the larger aircraft types they would receive check rides through the designated examiners. Once they have passed the check ride then they're route-qualified at that point.

CAPTAIN MISENCIK: What is the Korean Air policy for -- let me back up. How -- generally, how many hours does that route qualification take?

THE WITNESS: It differs by aircraft type. For the 747 Classic about 130 hours.

CAPTAIN MISENCIK: And that -- that route qualification is -- includes -- or IOE is an integral part as we understand IOE, is that correct?

FIRST OFFICER CHUNG: Would you repeat that question, sir?

CAPTAIN MISENCIK: I said the IOE is a integral part of the route qualification. I mean there's not a separate IOE. It's -- they're done concurrently or consecutively I guess.

THE WITNESS: It is incorporated into the route -- IOE's incorporated into the route.

CAPTAIN MISENCIK: What is the Korean Air policy for first officers flying the airplane?

THE WITNESS: We recommend first officers --direct experience in controlling the airplane to improve their proficiency levels.

CAPTAIN MISENCIK: What percentage of flight legs or flight segments are flown by first officers?

THE WITNESS: I believe about 30 percent.

CAPTAIN MISENCIK: What percentage of approaches and landings do first officers make?

THE WITNESS: Since we -- since we consider giving controls to the other pilot both take-off andlanding would be considered giving -- it would be the same as the previous answer.

CAPTAIN MISENCIK: What percentage of landings in instrument conditions less than VFR are made by first officers?

THE WITNESS: Among the landings that first officers perform would it not be about half -- 50 percent of the landings they perform would be in some sort of instrument conditions. However, this has to meet the regulation 4-5-6 about transfer of aircraft control and the minimum weather associated with -- for the captain qualification. So, there's limitations on the weather how -- how far they can go. That would be the condition that they couldn't fly instrument.

CAPTAIN MISENCIK: Are you saying that there's different minimums for first officers than for captains? Is -- or -- or what -- what -- what is the implication of what you said?

THE WITNESS: Not that the instrument minimums would be different but the weather minimum, and I'll give you an example. For a precision approach you would have to add 200 feet to the approach minimums to transfer control of aircraft to the first officer. And you would add half mile on the visibility.

CAPTAIN MISENCIK: How about for a non-precision approach?

THE WITNESS: 300 feet on the ceiling. Visibility --

(Pause)

FIRST OFFICER CHUNG: He's converting meters to feet at this time.

THE WITNESS: One and a quarter miles, about.

CAPTAIN MISENCIK: Captain Park, has a pilot ever received an unsatisfactory rating on a check ride because of CRM or poor CRM?

THE WITNESS: As I remember, there have been no instances of a check ride failure due specifically to CRM. But in general line flying there have been instances where there was report of captains' CRM techniques by either the first officer, any of the flight crew members, or even including cabin, there have been instances of disciplinary action.

CAPTAIN MISENCIK: Do first officers and flight engineers ever make reports of poor CRM or CRM concerns regarding captains?

THE WITNESS: Yes, rarely. It does occur.

CAPTAIN MISENCIK: How is that handled?

THE WITNESS: We have that particular individual go through counseling with a chief pilot. If that should not prove to be a solution we try to usethe un-matching policy among the -- those two or whoever -- among the people involved. Once a person is on an unmatched policy with another individual, the two of them would not fly together until one of them got out of that aircraft type.

CAPTAIN MISENCIK: Has the Korean Air ever been warned or been in danger of losing Part 129 authorization to operate into the United States or any of its territories?

THE WITNESS: From what I remember I believe there's one standing case --

FIRST OFFICER CHUNG: Excuse me. May I ask him the answer one more time? I've forgotten the answer.

CAPTAIN MISENCIK: Go ahead.

THE WITNESS: As I know, there's one case still standing regarding operations. That is, as encroached on this, and since it's still ongoing I would not be free to discuss it.

CAPTAIN MISENCIK: But to your recollection that's the only case that may impact Part 129 operations?

THE WITNESS: Yes, this is the only one I'm remembering.

CAPTAIN MISENCIK: During the past -- duringthe past two years preceding the accident are you aware of any other FAA enforcement actions or letters of investigation that have been closed?

FIRST OFFICER CHUNG: Letter of investigation you say?

CAPTAIN MISENCIK: Yes.

THE WITNESS: As a company I don't have any recollections, but there have been instances of individual pilots violating procedures that have been warned by FAA.

CAPTAIN MISENCIK: What changes as a result of the accident have been initiated by Korean Air management or mandated by the KCAB or the FAA?

FIRST OFFICER CHUNG: Did you say after the accident?

CAPTAIN MISENCIK: Yeah, since the accident or as a result of the accident.

THE WITNESS: No actions from the FAA. As far as KCAB over two instances we've been conducted a -- by safety investigation or evaluation assessment by KCAB.

CAPTAIN MISENCIK: What type of changes did the KCAB want Korean Air to make?

THE WITNESS: Excuse me. Corrective actions recommended so far have been that the management crewhave too much flying duty, been told to reduce that. Standard calls have been fortified, and non-precision approaches instead of lumping it together to individualize the non-precision approaches. And to specialize the captains by geographical sector.

CAPTAIN MISENCIK: Are there any changes being considered as a result of the accident by Korean Air that were not mandated by the KCAB?

THE WITNESS: After any significant or after all accidents or significant incidents we always review the matter to make appropriate changes. After the 801 we have implemented the CRS system. As shown by the first -- our first witness today, the briefing procedures have been modified. This new modified checklist for the briefing includes -- excuse me, not includes but it is centered around the Jefferson approach chart. CFIT accident prevention concept has been introduced, and more specific training on crew duty divisions.

Up to now the English standard was a rating of three to enter into flight operations. We have raised that standard to a level for two for English education, and each month 30 people are entering this additional education to get the rating to -- up to two, level two.

It's true that KCAB requested our improving the standard call-out procedures, but we -- on our own initiative we've also implemented better procedures since the first of this year. That's all.

CAPTAIN MISENCIK: I don't have any further questions.

CHAIRMAN FRANCIS: Can I -- we're -- we're drifting a lot here now. Can I ask from now on we make sure the questions that are being asked and the answers are not going over material we've already covered, that they're pertinent, that they're pointed? We're --we're taking an awful lot of time on this and a lot of it is becoming redundant and some of it isn't really pertinent.

CHAIRMAN FRANCIS: Malcolm, do you have questions?

DR. BRENNER: Yes, I do, sir.

On the CVR the captain made a comment, "Really sleepy, and they make us work up to maximum." Please respond to his comment.

THE WITNESS: It has been discovered that the three accident crew members had sufficient rest before the beginning of this flight. They had over 30 hours of sufficient time to rest. That was for the pilot and the first officer. As far as the engineer had over 50hours to rest.

Physiologically speaking, when you are flying well past midnight by local standard it is obvious that people would be tired. I believe the accident captain expressed his state of tiredness forthrightly. Would that not give warning to the other two crew members to be on the look out for the captain falling asleep? Looking at the CVR since he performed every item on the checklist I don't believe he fell asleep at any point.

DR. BRENNER: Thank you, Mr. Chairman.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman.

CHAIRMAN FRANCIS: And we're going to continue with the interpretation in the front of the room.

(First Officer Chung continued to translate, translating both the questions and answers from Korean to English.)

(Mr. Lee began to ask his first question in Korean.)

CHAIRMAN FRANCIS: Could you -- could you give -- excuse me. Could you leave time for some interpretation? I don't -- I'm not sure we're going to challenge his memory quite that much.

MR. LEE: As I've -- as we have asked CaptainLee this morning, we asked a question about the autocratic nature of maybe the captain, the first officer, and the other crew relationship, would it have had any impact on this accident flight. Please comment on whether this factor should be considered into the investigation.

THE WITNESS: I would be confident in my answer. I don't believe these crew members have particular problems with CRM.

MR. LEE: If you have reason for your answering in such confidence, please provide the reason.

THE WITNESS: After the accident we have testimony from a contract -- otherwise foreign pilots, captains that work for our company. They spoke about captain -- the accident captain to us as having excellent personal relationships in the cockpit.

As far as the first officer, he's a person that I know personally that I've had meals with at destination airports in one or two occasions. He has a -- a reasonable approach into doing everything. He was of the type that would not -- he would speak his mind if he felt that it was necessary.

As far as the flight engineer, he worked with me together in the same company for a long period oftime. He's active about all things. He has leadership ability. He was bright and outgoing. He loves sports and he was just an active, overall good person.

No one in the company, to my knowledge, ever spoke of these three members' teamwork as a team --

(Pause)

MR. LEE: Thank you. That's all.

CHAIRMAN FRANCIS: Thank you.

(First Officer Chung continued to translate, translating the questions posed in English to Korean and Captain Park's responses from Korean to English.)

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Thank you, Mr. Chairman.

Captain Park, you stated that since the accident your company has received reports of occasional DME outer marker and glide slope malfunctions.

THE WITNESS: That's true.

MR. DONNER: Did your crews pass this information to local FAA air traffic control authorities in Guam?

THE WITNESS: Since we don't fly to Guam anymore since the accident I have not taken personally the steps to pursue this further.

MR. DONNER: Are you aware that it's arequirement of the Federal regulations to report such information?

THE WITNESS: Since the report was submitted to me within company -- internal company report that I was not able to get back to the pilots about the following actions.

MR. DONNER: Could -- would you refer, sir, to Exhibit #12A? 19.

(Pause)

MR. DONNER: On the right-hand side the radio communications have time 15:39 and 44 seconds. The approach controller told Korean Air 801 that the glide slope was unusable. Is that correct?

THE WITNESS: That's true.

MR. DONNER: And on the next page, page 20. At time 15:40 and zero seconds the first officer makes the statement "not usable."

THE WITNESS: Yes.

MR. DONNER: I believe, sir, that you stated that the approach controller did not tell the crew that the glide slope was unusable. Did I misunderstand you?

FIRST OFFICER CHUNG: Sir, would you repeat that question, please?

MR. DONNER: Yes. I believe I heard the captain say that the approach controller had not toldthe crew that the glide slope was unusable.

THE WITNESS: He did tell them.

MR. DONNER: I believe you also stated, sir, that the weather was worse than reported and had the crew known that the outcome might have been different?

THE WITNESS: Yes, I did say that.

MR. DONNER: Sir, do your crews fly differently if they anticipate a rain shower on the final approach than they would if they did not have that information?

FIRST OFFICER CHUNG: One more time, please? Would you repeat the question?

MR. DONNER: Would -- would your crew have flown the approach differently if they were told that there was rain on the final approach?

FIRST OFFICER CHUNG: Did you say rain or rain shower, sir?

MR. DONNER: I'll say rain.

THE WITNESS: Would that -- would they not have paid just a little more attention.

MR. DONNER: Thank you. I have no further questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman.

I'd like to refer the Board of Inquiry andthe witness to Exhibit 2F as in Foxtrot, please?

(Pause)

MR. MOTE: I refer specifically to the second paragraph. Approximately sixth sentence with regard --this is the Korean Air Company's record of the level three English test which was apparently taken by the flight crew of Korean Air 801, and I refer specifically to the portion which reads that "The ATC tests correct understanding and proper uses of ATC transmissions." Do you see that -- that section, Captain Park?

THE WITNESS: That is true.

MR. MOTE: I ask you, sir, Captain Park, if you have an opinion as to why since the crew of Korean Air 801 received an approach clearance with the standard terminology of "glide slope unusable" in addition to the NOTAM and ATIS information containing the outages, do you have an opinion as to why this crew may not have comprehended the fact that the glide slope was in fact not operational?

FIRST OFFICER CHUNG: He wanted me to ask you one more time your question.

MR. MOTE: Given the fact that the flight crew of Korean Air 801 was in receipt of the NOTAM, ATIS, and the standard American ATC approach clearance containing the term -- the standard ATC term "glideslope unusable," do you have an opinion, sir, as to why the flight crew may have -- may not have comprehended that the glide slope was in fact not operational?

THE WITNESS: I would agree with you that this -- the approach clearance was -- was standard. However, we cannot assume human beings to be perfect. Especially the first officer -- accident first officer during his Air Force received training in the U.S. Air Force in the United States.

MR. MOTE: Thank you, Captain. One additional question.

With reference to the phraseology issued in the approach clearance and the fact that the Korean Air flight crew had completed the Korean Air English tests with regard to ATC phraseology, do you think that Korean Air's English testing program is adequate to allow Korean Air crews to operate safely in United States air space?

THE WITNESS: I would not agree with that assessment since every employee is required by our company to enter with a minimum level of English standard. And this level three standard that we set forth has undergone objective review by a native speaker --

FIRST OFFICER CHUNG: He referred to it as aforeign person.

(Resumption of translation)

THE WITNESS: -- as to its validity and its standard. I myself have been subjected to this level three.

MR. MOTE: Thank you, Captain. No further questions.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: No questions.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: No questions. Thank you.

CHAIRMAN FRANCIS: Barton?

MR. E. MONTGOMERY: Yes, Mr. Chairman. One question.

Captain Park, could you describe the sources of weather information available to the crew?

THE WITNESS: We receive predicted weather --forecast weather from the start of flight to the end. In flight they would receive weather information through the Volmet (ph) process -- updates. Once they're closer to -- close to the destination they would receive weather data from the ATIS at the destination. But in tropical weather conditions where there's frequent weather changes, they should get special weather updates from the air traffic controlavailable to them.

MR. E. MONTGOMERY: Thank you. One subsequent question.

In tropical conditions where there are --conditions are changing rapidly, do you make use of on-board systems to determine weather?

THE WITNESS: No, we would receive the information through ATC. In new aircraft with the ACAR system that would -- can get weather through that updating system.

MR. E. MONTGOMERY: Thank you, Mr. Chairman. No more questions.

CHAIRMAN FRANCIS: Korean Airline?

CAPTAIN KIM: No questions.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: Captain Park, I just want to follow up on one question that Mr. Donner had -- had alluded to earlier regarding the reporting of out-of-service navigation aids to the controller in Guam. Do you have a practice or a policy that encourages flight crews to report a navigational aid as being out of service anywhere that you all fly, not just into Guam?

THE WITNESS: If the weather -- excuse me. If the equipment operation should prove to be different than what is expected then using the channels that Isaid before it would be reported to the appropriate people. If I look at most of our operating experiences most of the equipment have been found to be in -- in the order that it was reported -- that it was reported to have been operating in.

MR. FEITH: Prior to the accident approximately how many flights did you have going into Guam in a day?

THE WITNESS: I remember once a day prior to the accident. One a day.

MR. FEITH: Would Flight 801 have been the one a day flight?

THE WITNESS: Yes.

MR. FEITH: On -- on days prior to the accident had any other flight crews brought to your attention any problems with any of the navigational aids at Guam, including the glide slope?

FIRST OFFICER CHUNG: The -- not before --before the accident, but after the accident people come forward and said the -- it was true that the equipment was failing to operate and we did not report it were the words.

MR. FEITH: Can you just repeat your answer, Steve?

THE WITNESS: But prior to the accident theydid not report of this fact either to me or to the company. After the 801 accident at Guam and after the accident they came forward and told me that there were unreliable indications at Guam, but only after the accident.

MR. FEITH: Were those reports provided to you in writing or were they verbal?

THE WITNESS: It was a verbal report.

MR. FEITH: Could we get that information in writing and provide it to us? Because we were not aware of those reports.

THE WITNESS: Once I return I will direct the captain that I spoke with to make -- to recall what he said to me and make appropriate reports.

MR. FEITH: Thank you very much.

CHAIRMAN FRANCIS: Are we talking about the glide slope here or other pieces of equipment?

THE WITNESS: Glide slope.

FIRST OFFICER CHUNG: He was speaking of the glide slope.

CHAIRMAN FRANCIS: Thank you.

MR. FEITH: Captain Park, there was earlier testimony regarding non-precision approaches and the fact that Korean Air trains the step-down on a non-precision approach if in fact the step-down procedureis charted. However, Korean Air knows that their line crews can on occasion make a constant-rate descent approach for basically passenger comfort. With the follow-up to that, is that not tacit approval by Korean Air since they know that their crews are doing that?

THE WITNESS: I believe I need to clarify your conceptual understanding of what we explained this morning. When Captain Lee spoke of the -- the -- on this matter this morning there were conditions attached to this statement he made. Those prior conditions were that visual conditions had to be ascertained first and that they met all the DME step-down fix requirements while they're performing the constant rate of descent. Of course, we emphasize the step-down procedure.

MR. FEITH: Is this a safe practice given the fact that you don't train for it but the crews are initiating this type of approach on their own?

THE WITNESS: In order to promote or ascertain safety we are definitely teaching the step-down technique. However -- however, the condition that the runway is in sight for landing and once again the DME fixes on the approach chart goes -- step-downs are all satisfied. I do not think that this -- as long as those two conditions are met I do not believe this is an unsafe practice as such.

MR. FEITH: Given what you've just explained, all of the conditions that must be met, is there anything in writing that explains what you just explained to us?

FIRST OFFICER CHUNG: I believe he's saying no because this is an application of technique incumbent on each pilot. It's pilot technique. And we only teach the step-down is what he said.

MR. FEITH: As a senior manager at Korean Air I would like to have you describe to me your idea of the crew's performance on Flight 801 given your level of knowledge about the accident. And before you answer, let me just take this one step further and say did this meet Korean Air's policies and procedures and standard of operation? Yes or no. And if yes or no, give us the reason why.

THE WITNESS: If we just take the data as we have today that they strayed from our Korean Air standard procedures.

MR. FEITH: I have no further questions.

MR. CARISEO: No questions, Mr. Chairman.

MR. BERMAN: Captain Park, if these pilots were going to fly a constant descent, non-precision approach, how would you expect them to handle the mode control panel altitude selector?

FIRST OFFICER CHUNG: Excuse me. You mean the accident crew or it doesn't matter?

MR. BERMAN: Doesn't matter.

FIRST OFFICER CHUNG: Okay.

THE WITNESS: As a manager I always emphasize step-down procedures and I really don't want to answer this question, but I'll give you the best one I can. And in reference to the Guam Airport, of course.

First, you start at 2600 feet at Guam. Once the altitude is captured and it's put in the altitude hold mode, you would set 2000 on the window, which is the next altitude. I would require or request the first -- excuse me, the pilot not flying to continue to call out the DME for me. Once I crossed the DME in-bound for the 2000-foot restriction then I would descend down to 1440 feet. Once again I -- again, once I fixed -- crossed the restriction for the 1440, then I would set the MDA and call for the descent.

MR. BERMAN: So, you've described the step-down procedure there.

THE WITNESS: This is not a step-down, merely rate maintaining, constant rate, yet making sure that we don't -- crossing restrictions. At no time will I allow a constant rate descent in this case.

MR. BERMAN: Do you believe a pilot flying aconstant rate of descent approach might set the next lower altitude at an earlier time?

THE WITNESS: I do not think so.

MR. BERMAN: Have you ever seen in training operations or in line flying operations when a pilot is flying a non-precision approach step-down method where the pilot will set the mode control panel altitude down to the next step-down altitude too soon?

THE WITNESS: I have personally not seen it.

MR. BERMAN: Based on information we have in this country about air carrier pilot training, would you please query your air carrier checkers and trainers and provide this information to us for the record?

FIRST OFFICER CHUNG: I understand this is based on United States?

MR. BERMAN: Based on some United States experience where we see this happening during training at least, please inform us from a further survey of your training and checking pilots whether this has been known to happen during your training.

THE WITNESS: I understand your request and it will be complied with.

MR. BERMAN: Thank you. One more question on this descent. When you fly this approach, would you use vertical speed mode or a pitch mode?

THE WITNESS: On the Classic 747 please clarify what you mean by the pitch mode? I understand the VS mode. What do you mean by the pitch mode?

MR. BERMAN: A pitch hold mode.

THE WITNESS: I have not heard of that mode before.

MR. BERMAN: So you would use a vertical speed mode?

THE WITNESS: That's true.

MR. BERMAN: Okay. Thank you.

You've testified about pilots' training percentages who failed to complete check rides. How many and what percentage of pilots who are upgrading from first officer to captain fail completely to make their upgrade and do not make the captain position?

THE WITNESS: So far this is not an accurate figure to my knowledge, but it's about three to four percent.

MR. BERMAN: And of those pilots who fail to achieve the upgrade, what does Korean Air do with them? Do they maintain their previous first officer position or what?

THE WITNESS: We do not treat this matter lightly. There is a certain set procedure that this person would be subjected to and all the evaluationteam members would gather together for a fair evaluation of the individual. First, they would look into the exact reason why that person came to fail the program. Once this exact analysis is over, they -- the person would be handed to --

FIRST OFFICER CHUNG: Flight Operations personnel department would be my best shot at that.

THE WITNESS: This is -- a board is what I should call that. A board at that point with the recommendation from the evaluation team would make the determination whether the person will continue as a flyer or go to a non-flying status and whether he's appropriate for a particular type of aircraft.

MR. BERMAN: Captain Park, have you been involved in the decisions at Korean Air about the procedure for responding to GPWS alerts?

FIRST OFFICER CHUNG: Would you repeat that one more time, please?

MR. BERMAN: Have you been involved in the decisions about what the procedures will be for responding to GPWS alerts?

THE WITNESS: I did not participate in that.

MR. BERMAN: You testified earlier that the KCAB said that Korean Air was to individualize its non-precision approaches. What does that mean?

THE WITNESS: Up to now the non-precision --the general title was left up to the instructor to decide whether this would be a -- NDB approach, a localizer approach, and VOR DME approach and that would satisfy that. But since the change the -- the procedures will specify whether this will be a localizer approach, an NDB approach, or a VOR DME approach.

MR. BERMAN: And just to clarify, this is in training now?

THE WITNESS: Yes, that is training.

MR. BERMAN: Okay. Thank you very much. No further questions.

CHAIRMAN FRANCIS: I'd like to ask a clarification on one question.

I believe that the captain said that Korean Airlines does not keep track -- any record of their missed approaches?

THE WITNESS: That is true.

CHAIRMAN FRANCIS: I -- I guess this is a comment on my part. I would just say that -- and I'm referring here to the -- to the checklist from the Flight Safety Foundation which is part of the package that -- that your airline now has. In the section under "Company Management," there is an item whichsays, "Places no negative connotation on a diversion or missed approach." This gets at the highest points for this. This -- that's half of -- if you can translate that, and then I'm not asking for -- for an answer. If you just translate that.

And -- and I would say that while I understand the -- the reason that the captain gave that you don't keep track of -- of missed approaches I think that if we're going to be in an environment where we're preempting -- preventing accidents before they happen rather than doing accident investigations such as we are here that it's incumbent upon airlines to develop a trust and a corporate culture attitude so that it's clear to their crews that there's not punitive -- there are not punitive connotations to going around.

(Captain Park began to respond in Korean.)

CHAIRMAN FRANCIS: Can I just finish? Be --because -- and he doesn't have to answer this. Because I -- I think that -- that the value of knowing how many times people go around, where they're going around, and why they're going around, if you can do this in a non-punitive context is enormously valuable in terms of preventing the accident. So, he might be interested in talking to some of the airlines around the world that do have very highly developed programs in this area.

(Captain Park responded in English.)

THE WITNESS: I'd like to comment some more, sir.

FIRST OFFICER CHUNG: May he make a comment in closing?

CHAIRMAN FRANCIS: Absolutely. Sure.

(Resumption of translation)

THE WITNESS: As a person representing the 1600 flight operations crew members for Korean Airlines I would like to make this statement to the chairman --Mr. Chairman and everyone present here for these --this Safety Board investigation.

Looking back upon this accident we feel that most of our management up to now has been in the level of perhaps too short-term, short-sided, and superficial in its nature. We from this point on for the purpose of ascertaining flight -- safe flight operations we plan to make long-term plans and spare no resources in ascertaining this final objective of flight safety. Accordingly, we will adjust our management systems and invest all the more heavily into training and program development.

For the benefit of everyone here, I would like to say there's -- starting on the 1st of April the company has -- is under contract to receive expertconsultation of comprehensive nature from a well-known and well-respected international organization.

And for everyone who contributed into the investigation and all the processes up to now I would like to say -- acknowledge our word of thanks and gratitude.

To the family members of the deceased we'd like to pass on from the flight crew members of Korean Airlines our word of condolences.

Thank you very much.

CHAIRMAN FRANCIS: We appreciate very much the spirit of your remarks, and I'm sure that I can speak on behalf of -- of everyone here to -- in saying that if any of us in any way can be of help to you in this program we certainly stand ready to do so.

Thank you, sir, and you're -- you're released from your testimony.

THE WITNESS: Thank you very much.

(End of translation)

CHAIRMAN FRANCIS: We will now take a break. It's 4:20 by my watch. Why don't we come back in 20 minutes at 20 to five and we'll continue with the next witness.

(Whereupon, a brief recess was taken.)

CHAIRMAN FRANCIS: Could we start again,please?

The next witness will be Mr. Juan Rosario, the director of Guam Civil Defense.

Whereupon,

JUAN ROSARIO

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF JUAN ROSARIO DIRECTOR GUAM CIVIL DEFENSE AGANA, GUAM

MR. SCHLEEDE: I don't believe you'll need the headset right now, sir.

Please give us your full name and business address for the record?

THE WITNESS: My name is Juan B. Rosario, and I live in Chalampago (ph), Guam

MR. SCHLEEDE: And what is your current position with the Government of Guam?

THE WITNESS: I'm currently the director of Civil Defense, Guam Emergency Service Office.

MR. SCHLEEDE: Could you please give us a brief summary of your education and experience that brought you to this position?

THE WITNESS: My -- prior to January 17, 1995, my educational and experience are in the business and finance in the public and private sector. After the January 17 I was appointed by the governor --current governor -- the director of Civil Defense.

MR. SCHLEEDE: Thank you very much. Mr. Hammack will continue.

MR. HAMMACK: Thank you.

Thank you for being with us, Mr. Rosario.

Can you briefly describe your duties and responsibilities as civil defense director?

THE WITNESS: I am responsible for the everyday, daily activity in civil defense both in training, management, and budget for that matter also.

MR. HAMMACK: Thank you. Can you tell us how and when you were notified of this accident?

THE WITNESS: On August 6 approximately 2:18 in the morning my duty officer, Bennett Cabrera, called me and advised me that there was a plane went down at Nimitz Hill. He didn't -- wasn't sure exactly where it is.

MR. HAMMACK: What did you do after that?

THE WITNESS: I immediately jumped out of bed and got into my clothes and went down with him. He stopped by and picked me up because we both live in thesame villitz.

MR. HAMMACK: What time did you arrive at the accident?

THE WITNESS: I was at the gate approximately 2:34 in the morning.

MR. HAMMACK: When you refer to the gate --can we have Exhibit 16I, page 2, please?

(Pause)

THE WITNESS: Yes.

MR. HAMMACK: Do we have the pointer that Mr. Rosario -- there you are.

(Pause)

THE WITNESS: I believe that's the -- I believe that's the gate that I went and -- when I got there in the morning that was the gate.

MR. HAMMACK: Do we have a focus problem with that or is it me?

THE WITNESS: Say again, sir?

MR. HAMMACK: For Teddy. Do we have a focus problem?

(Pause)

MR. HAMMACK: Okay.

(Pause)

THE WITNESS: That -- that is the gate.

MR. HAMMACK: Okay. Can you tell us aboutyour actions and observations once you arrived at the gate?

THE WITNESS: When I got there -- actually, I was with my duty officer. When we got there I met with the police chief Gil Regist (ph), and because of the situation there existing I immediately took control at the gate.

(Pause)

MR. HAMMACK: Can we have the lights back up, please?

(Pause)

MR. HAMMACK: When you took control at the gate, what were your responsibilities?

THE WITNESS: The situation there at that time was very chaotic simply because there was a lot of people hanging around wanting to go into the -- to the accident site. And so, it was necessary to take control and not only necessary to take control but you -- we set up the command post because my responsibility is to coordinate all the Government of Guam resources in -- in delivering the needed supplies, manpower to the accident site to -- you know, like the volunteers, the triage team. Everybody wanted to get down there, so we just simply had to control it.

MR. HAMMACK: Your function at the gate, wasthat more of a control of the resources or were you in overall command of the entire rescue operation?

THE WITNESS: No, sir. The -- my role simply is with that command post is for me to coordinate, like I said, the resources of -- of Guam. What I did in this incident, I activated the Emergency Operations Center, which is at Civil Defense. By operating the Emergency Operations Center I have activated all the government agencies that are involved as responders. It is my job to receive whatever is requested from the incident site to deliver that resource.

MR. HAMMACK: By the incident site you mean down at the wreckage?

THE WITNESS: That's correct, sir.

MR. HAMMACK: Okay. And to coordinate the resources of the Government of Guam, you did that from the command post there at the gate?

THE WITNESS: That's correct, sir.

MR. HAMMACK: How did you do that? By radio or --

THE WITNESS: We have -- I have a cell phone. And when I got there I immediately called my deputy director and I told him to go down to the Civil Defense and activate the Emergency Operations Center and telephone all the responders -- the response activitycoordinators and to show up at the Emergency Operations Center.

And one of those activation was the Guam Telephone Authority, which I requested that they show up and -- and put in two land lines and deliver more phones for, you know, when it's needed.

MR. HAMMACK: Are you aware of any problems with notification of emergency forces?

THE WITNESS: In what -- in what context?

MR. HAMMACK: The -- the dispatch of emergency services.

THE WITNESS: I --

MR. HAMMACK: Any -- any problems with --

THE WITNESS: Not -- not that I know of at that point in time.

MR. HAMMACK: Are you aware of any problems in locating the wreckage?

THE WITNESS: At first, yes. But after driving up the hill, Nimitz Hill, I was aware where it was already then, so I -- I knew where to go from that point on.

MR. HAMMACK: Well, I'm -- I'm thinking about initially when you were first notified of an accident. Did you -- were you advised then of where the wreckage was?

THE WITNESS: No, sir. Other than Nimitz Hill.

MR. HAMMACK: You were advised that it was on Nimitz Hill --

THE WITNESS: Yes.

MR. HAMMACK: -- initially?

THE WITNESS: I was advised, but the exact location I was not advised.

MR. HAMMACK: Are you aware of any problems gaining access to the wreckage?

(Pause)

MR. HAMMACK: By the emergency services?

THE WITNESS: From the gate side?

MR. HAMMACK: Yeah. From the gate to the wreckage itself.

THE WITNESS: Well, when I got there, like I said, there was -- there were problems simply because there was a lot of people. There was about 300 people there milling around. And at that time a lot of the responders then were coming in. And I -- in order to control it we had to identify from the incident site what is needed. And basically, the first call was for triage teams, doctors, and volunteers, and those are the people that we let in first.

MR. HAMMACK: Okay. We'll get back to that alittle bit more in a minute.

Can you tell me who was in overall charge of the rescue operations?

THE WITNESS: At that time when I went there I was advised that Ciriaco -- Chief Ciriaco Sanchez was the incident commander at the -- at the accident site.

MR. HAMMACK: And where -- where exactly was Chief Sanchez at that time?

THE WITNESS: I don't know the exact location where he was at at that point in time. I only know that he was at that site.

MR. HAMMACK: He was down at the wreckage?

THE WITNESS: Right.

MR. HAMMACK: Yeah, that's what I wanted to know.

(Pause)

MR. HAMMACK: From your position at the command post, were you able to -- did you have communications with Chief Sanchez?

THE WITNESS: Yes. I did on a couple of occasion, but then the communication between that side was transferred to one of the personnel there at the gate side, and he relays the request to me 'cause I had my hands full with the -- with the gates and the other stuff there, so.

MR. HAMMACK: This was another person at the gate with you?

THE WITNESS: Yes.

MR. HAMMACK: Okay. Did you have the ability to communicate with other jurisdictions, mutual aid resources?

THE WITNESS: Yes, I do. Through the Emergency Operations Center.

MR. HAMMACK: So, how -- how would that work, if you wanted, for example, to get a hold of Navy personnel?

THE WITNESS: Well, my jurisdiction really lies within the Government of Guam, so the -- the only communication that I would have in terms of resources would be through the Guam, and that would be through the Civil Defense Emergency Operations Center.

MR. HAMMACK: So, to perform your functions you used your cell phone to -- to contact your people?

THE WITNESS: Right. I -- as I --

MR. HAMMACK: They --

THE WITNESS: -- said earlier that my deputy director was manning the Emergency Operations Center.

MR. HAMMACK: Okay.

(Pause)

MR. HAMMACK: In communicating with ChiefSanchez down at the accident -- at the wreckage, did he keep you informed as to what resources he needed to --to be allowed into -- into the -- through the gate?

THE WITNESS: Yes, he did.

MR. HAMMACK: Okay.

(Pause)

MR. HAMMACK: Was it you or -- or Chief Sanchez who -- who made decisions such as rescue and evacuation of personnel, that sort of thing?

THE WITNESS: I can't really say. I know I did not make that decision, but I don't know if that was -- you might have to ask Chief Sanchez that question.

MR. HAMMACK: Okay.

(Pause)

MR. HAMMACK: Did you observe any difficulties with access or congestion that interfered with emergency vehicle access to the site?

THE WITNESS: I did observe that there was some problems in the access simply because everybody wants to go in, but every time I called the incident site when I asked them if they would need a particular responder they would say not at this point.

MR. HAMMACK: Well, I'm -- I'm thinking about when the very first people got there I understand therewas a piece of pipe across the road?

THE WITNESS: I'm not -- well, I may be aware of that, but I didn't actually see that 'cause that --it was quite a bit of distance from that site to the gate and I was concentrating on the gate.

MR. HAMMACK: Okay. You didn't get that far?

THE WITNESS: No.

MR. HAMMACK: Okay.

(Pause)

MR. HAMMACK: In -- you don't need to refer to it, but in Exhibit 16 Alpha there's a statement that the Government of Guam had a mobile command post but it was not used. Is that true?

THE WITNESS: That's correct, sir.

MR. HAMMACK: I understand that was out of service and that sometime after the accident the Federal Emergency Management Agency, the local Guam representative said they were going to help you upgrade that thing. Has there been any progress on that?

THE WITNESS: Yes, and incidentally, the director for the Pacific Area of Federal Emergency Management Agency was along with me at that point at the gate and he knew that's what happened. And he did promise that he would take care of the mobile command post. And that is now being addressed at this point.

MR. HAMMACK: Okay. Prior to the accident have -- did you have any mutual aid agreements with the other resources on the island, Navy, Coast Guard, Air Force?

THE WITNESS: We have a mutual of understanding agreement with the Air Force, but we did not have one with the Navy.

MR. HAMMACK: How about the Coast Guard?

THE WITNESS: Neither the Coast Guard.

MR. HAMMACK: Okay. Prior to the accident did you conduct any joint disaster drills or communications exercises with any of these organizations?

THE WITNESS: We did with the Airport Authorities. We did a -- a full-scale exercise. That was in April of the same year that the incident happened. And it went well.

MR. HAMMACK: Where did that take place?

THE WITNESS: In the airport proper.

MR. HAMMACK: On the airport?

THE WITNESS: Yes.

(Pause)

MR. HAMMACK: As you look back on the accident and the planning that you had, did you see any -- the need for any improvements in any of youremergency planning?

THE WITNESS: Yes, sir. We have identified a few, and one of them was, of course, we initiated a --Civil Defense initiated a -- a committee whereby Navy, Coast Guard, Air Force, and Gov Guam come up with a mutual of understanding where all the participant will sign this agreement. And the governor's already given his -- his okay on this MOU, and I understand that Admiral Jansack also may have -- be considering this at this point.

The four -- the four groups that developed this MOU have signed off on it. In fact, I think I gave you a copy of it.

MR. HAMMACK: Will this agreement include a provision for emergency drills involving all these organizations?

THE WITNESS: Yes.

MR. HAMMACK: Will it involve improving communications among all the agencies?

THE WITNESS: Yes.

(Pause)

MR. HAMMACK: Will your pre-planning -- I don't want to get into too much detail, but aside from the -- the general communications and -- and the general planning for the different possible threats youhave on the island, and our particular concern is aviation, will you identify things such as the approach and departure routes of aircraft, that sort of thing since access was a problem here?

THE WITNESS: That's a hard one to --

MR. HAMMACK: Well, perhaps --

THE WITNESS: This -- this much I can say, that in -- in our Guam Emergency Plan we have identified that we do need to plan an exercise with the Airport Authority, and we have already identified also that not only on the proper airport but also outside of the airport. This will become part of the Emergency Plan for Guam.

MR. HAMMACK: Did -- you mentioned a -- the drill you had on the airport. Have you ever had a --an aviation-type drill off the airport?

THE WITNESS: I don't believe so.

MR. HAMMACK: Okay. Do you have an agreement between the Government of Guam and the Airport Authority, a mutual aid agreement?

THE WITNESS: We do now, I believe.

MR. HAMMACK: Okay.

(Pause)

MR. HAMMACK: I understand you weren't here yesterday, but we had some testimony from the -- acouple of the air traffic controllers and they were asked what their response would be if they -- if they knew for sure that there was an aircraft accident off the airport. And my recollection is that they responded that they would call the Coast Guard or they would call the -- the crash crew on the airport. What would your preference be if -- if -- if an air traffic controller on the airport knew that an airplane had crashed off the airport? What action would you like them to take?

THE WITNESS: My preference?

MR. HAMMACK: Yes.

THE WITNESS: Under the Guam Emergency Plan, 911. Emergency 911 is the only way that you can notify on -- on an emergency.

MR. HAMMACK: Is that something that you'll look into after this?

THE WITNESS: Yes.

MR. HAMMACK: Okay. Mr. Chairman, that's all I have.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman.

(The following is a verbatim transcript of the English translation of Mr. Lee's questions posed in Korean.)

MR. LEE: Let me just double check several issues involved here. The Guam Airport Emergency Plan, the applicable range of that plan is limited to the airport premises proper. If an aircraft -- if an accident involving an aircraft takes place outside the airport premises proper then what kind of emergency plan do you have and use?

THE WITNESS: That has yet to be developed at this point. I will state that outside of the airport proper in this case in the absence of any SOP regarding -- from the Airport Authority I would say Civil Defense would work with the Airport Authority in responding to that emergency.

MR. LEE: According to Annex 14 of -- Chicago Conventions, the airport emergency plan covers both the airport premises proper and the areas outside of the airport premises. Do you -- are you saying that you have a plan to cover these areas outside the airport premises proper?

THE WITNESS: Yes. Under the Civil Defense,the Guam Emergency Plan, it covers for all types of disaster. And in this instance, in case of an aviation disaster, we would have to bring in the Airport Authorities and all the agencies that will respond to that emergency.

(Pause)

MR. LEE: At the command post of the accident site or accident area, the command authority was transferred from the Civil Defense to the Navy according to one of the exhibits. The -- were there any problems arising from the change of the guards, the transfer of the command authority?

THE WITNESS: No, sir.

MR. LEE: The -- the Guam Fire Department chief who went to the accident site and the Federal fire chief and Anderson Air Force Base fire chief, they are testing -- testifying that they did not receive any instructions from you as to the fire extinguishing job or rescue operations. Was that the case?

THE WITNESS: No, I did not receive any instruction and I am not -- I am not the person to give that kind of an instructions.

MR. LEE: That makes me wonder who was the person in charge at the accident site?

THE WITNESS: I've already stated that, thatduring the time that Gov Guam responded the incident commander at the accident site is Chief -- Deputy Chief Ciriaco Sanchez until the Navy took over.

MR. LEE: Following this accident, following or in the wake of this accident, was there any actions taken to improve the command structure?

THE WITNESS: Yes. I've stated that under the MOU that we have jointly formulated with the Navy, the Coast Guard, and the Air Force Gov Guam will receive the incident command system training, unified system -- unified command system training by the -- by the Coast Guard beginning as soon as we implement that MOU.

MR. LEE: Thank you very much.

(End of translation)

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: Thank you, Mr. Chairman. I have a few questions.

Upon arriving at the scene, Mr. Rosario, was there a question as to whether the aircraft had crashed on Federal or local property?

THE WITNESS: There was a question, yes. There was a question, but the answer didn't come until much later.

MR. DERVISH: And what was that answer?

THE WITNESS: 11:30 in the morning I was -- i was informed that it is Navy property.

MR. DERVISH: And has that decision changed at all?

THE WITNESS: To my knowledge, on my opinion, I think that has changed, yes.

MR. DERVISH: So you're saying it is Navy property?

THE WITNESS: I'm saying that the -- the --the incident site I believe is now Gov Guam property or have been Gov Guam property. But the gate site is Navy property.

MR. DERVISH: Okay. So where the plane went down is Gov Guam property?

THE WITNESS: I believe that's the --

MR. DERVISH: Okay. Thank you.

THE WITNESS: -- situation, yes.

MR. DERVISH: When you did give command of the command post over to the Navy, what did you do with your log book?

THE WITNESS: When I arrived at the site in the morning, my duty officer had initiated log book. And only -- only -- not only that, we did have an easel board where we identified statistics. When my command was terminated 11:30 by the admiral, the logs were keptby the guards with the Navy. So, from that point on up I believe it became the Navy's log book.

MR. DERVISH: Has that log book ever been returned to you?

THE WITNESS: No, sir.

MR. DERVISH: Once again, what time did you arrive there?

THE WITNESS: 2:30 in the -- 2:34 in the morning.

MR. DERVISH: Could you describe the weather and light conditions at the scene when you arrived?

THE WITNESS: If I remember correctly, I believe it was drizzling off and on. I was kind of damp with a few drizzles here and -- here and there.

MR. DERVISH: And the light?

THE WITNESS: The light was very dark.

MR. DERVISH: Was it too dark to see into the crash area?

THE WITNESS: Yes. Very dark. Cannot see the crash site.

MR. DERVISH: Was there any artificial light brought to the scene?

THE WITNESS: I believe later they did transport some light over there. I wasn't sure what type of lighting that they brought.

MR. DERVISH: And what time would that have been?

THE WITNESS: I'm not sure on the -- on the time element there.

MR. DERVISH: And this artificial light, was it sufficient to light up the area?

THE WITNESS: I -- I don't know that answer. I was not there.

MR. DERVISH: I understand that you've been the director for two and a half years. How many airport exercises have you had in two and a half years?

THE WITNESS: I've been a director three years. Correction on that.

MR. DERVISH: Okay. Sorry.

THE WITNESS: Twice we've had tabletop exercise and one full-scale exercise.

MR. DERVISH: And how many are you required to have by the FAA?

THE WITNESS: I believe one tabletop every year and one full-scale exercise every three years.

MR. DERVISH: So you have complied with the FAA regulations?

THE WITNESS: That's correct, sir.

MR. DERVISH: Bearing in mind that because of Guam's unique situation, military tours are sometimesonly two years, do you think it would be better to hold an exercise every two years except -- instead of every three years?

THE WITNESS: That would be my recommendation, yes.

MR. DERVISH: Will you make that recommendation?

THE WITNESS: Yes, I will.

MR. DERVISH: The overcrowding that occurred at the gate, was there a staging area -- staging area besides the one at the gate?

THE WITNESS: Later on I believe there was further back toward the main highway, I believe, was another staging area. You have to understand that when I activated the Emergency Operations Center I also activated the Port Authority, and I had to have them bring those large reefer trucks and they were there. And then also because of the military's Humvees coming in and responding the area where the gate is, outside the gate was very, very congested. And those are the kind of thing we encountered during the operation.

MR. DERVISH: One of the questions that was asked of you was who was in charge. Were you in charge of the military resources that were at the scene?

THE WITNESS: No, sir.

MR. DERVISH: Who was in charge of the military resources?

THE WITNESS: I don't know that one. I don't know the answer to that one.

MR. DERVISH: Was there a military representative at the command post?

THE WITNESS: Other than the military guards that were there --

MR. DERVISH: How about officers? Any high-ranking officers there?

THE WITNESS: After 11:30 there was one.

MR. DERVISH: Okay. How about before 11:30?

THE WITNESS: Before?

MR. DERVISH: Yes.

THE WITNESS: I don't believe so. I'm not sure. I -- I -- I really cannot say for sure. I don't remember that part.

MR. DERVISH: Did you happen to see Admiral Jansack there?

THE WITNESS: I saw him on his way out, yes. When he relieved me of the command post.

MR. DERVISH: Aside from the recommendations you've made and the improvements you plan, are there any other improvements that you want to tell us about?

THE WITNESS: Well, of course, the general --the Guam Emergency Plan is right now under revision, and we've targeted the date of September 30th of this year to -- to implement those with all those different annexes to include the Guam Airport Authority and also hopefully to include the MOU that will be signed with the governor, Admiral Jansack, and Air Force Colonel Hodges, and Captain Asaro (ph) of the Coast Guard.

This is also in partnership with the Federal Emergency Management Agency. We have an agreement that gives us a -- we do our training in concert with their requirements. So, our -- our role in Civil Defense is preparedness, response, and recovery and mitigation. Those are the four items that we do, and it covers all types of disaster.

MR. DERVISH: Okay. Will you include first responder training and initiatives in there?

THE WITNESS: Yes.

MR. DERVISH: Very good. Thank you. I have no other questions.

CHAIRMAN FRANCIS: Okay. I inadvertently called you out of turn. I meant to have you last. We'll go to the other parties and if you have an additional question or two that you'd like to ask at the end --

MR. DERVISH: Thank you, Mr. Chairman.

CHAIRMAN FRANCIS: -- free to do so.

Boeing Company?

MR. DARCY: The Boeing Company has no questions, Mr. Chairman.

CHAIRMAN FRANCIS: Barton?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions.

CHAIRMAN FRANCIS: Guam? Get another shot.

MR. DERVISH: I'm afraid I'm through with my list. Thank you.

CHAIRMAN FRANCIS: Thanks.

Mr. Feith?

MR. FEITH: Just a couple. Just so that I'm clear for the record today -- I got a little confused. You arrived on scene and about 11:30 you were apparently relieved of command by the admiral?

THE WITNESS: Yes, sir.

MR. FEITH: What was that based on?

THE WITNESS: Based on the premise that he --that -- that the in -- incident site is -- is Navy property.

MR. FEITH: Who made that determination?

THE WITNESS: It was Admiral Jansack.

MR. FEITH: Was there any questioning of that?

THE WITNESS: No, because, see, the indication is that it is Gov -- Navy property because the gate is Navy property. That I have no question. And by virtue of that I assumed that it is Navy property.

MR. FEITH: How has it been resolved since then?

THE WITNESS: I am -- that -- that has been resolved, I believe, up on the upper echelon of management, not -- not with me.

MR. FEITH: I'm just wondering how it was made -- the determination was made that it's no longer Navy property.

THE WITNESS: I'm not sure, but I believe they may have gone to Land Management to -- to research the area.

MR. FEITH: How many employees do you have that work for you or work in your organization?

THE WITNESS: 13.

MR. FEITH: Is that sufficient to handle all of the responsibilities that you have on your organization?

THE WITNESS: No, but budget constraintskeeps us there.

MR. FEITH: How many employees do you believe you need to fulfill your mission statement?

THE WITNESS: I could probably handle three, four more. We have not even touched terrorism yet.

MR. FEITH: We have not what? I'm sorry.

THE WITNESS: We have not even addressed the terrorism type of disaster, which is now I believe a Federal requirement.

MR. FEITH: With regard to your Emergency Plan that you said that it was exercised, I think you said that you had done an emergency exercise at the airport. Was that before the accident or has that been since the accident?

THE WITNESS: Before the accident. It was in April.

MR. FEITH: Oh.

THE WITNESS: That --

MR. FEITH: What -- and you -- and if I understand you correctly, there was no exercise that had been conducted regarding an airplane accident off the airport?

THE WITNESS: To my knowledge, no.

MR. FEITH: What was at that time any kind of mutual aid agreement, what was in place for local firedepartment to work with the on-airport fire department during that exercise?

THE WITNESS: Guam Emergency Plan is the focal agency that addresses those issues, and when the -- those agencies fall under the Civil Defense plan. So if there's an exercise and you -- you -- you make it realistic, then -- then Civil Defense has to step in and coordinate the resources for these exercise.

MR. FEITH: Have you ever had another airplane accident other than commercial transport? Any kind of airplane accident off the airport?

THE WITNESS: No, sir.

MR. FEITH: So you're -- you've never been involved with an aircraft accident of any sort?

THE WITNESS: No, sir.

MR. FEITH: Okay. Have you conducted an off-airport airplane accident exercise since the accident?

THE WITNESS: No, sir.

MR. FEITH: Is there any intention of doing so in the near future?

THE WITNESS: I've already stated that, sir. That the Airport Authorities and Civil Defense will --will be conducting a joint exercise --

MR. FEITH: When?

THE WITNESS: -- a full-scale exercise.

MR. FEITH: When?

THE WITNESS: That has not been determined at this point.

MR. FEITH: Given the fact that you don't have an agreement in place, given the fact that you don't have an Emergency Plan yet been adopted because, if I understand you correctly, it won't be till September 30th, if there is another airplane accident, what do you do?

THE WITNESS: Sir, I beg to differ with you. The Emergency Plan is in effect.

MR. FEITH: Is it --

THE WITNESS: What we're doing is just revising and updating it. And the -- the target date to update it is September 30th, and that was because that's a condition that was placed with the partnership of FEMA and -- and of Guam.

MR. FEITH: Can you describe for me if you had another commercial air transport accident right now, today, what would the agreement be? Who would respond? And who would be in command and how would it happen?

THE WITNESS: The -- the -- actually, the --the commander or the person really in charge is thegovernor of Guam. I draw my authority through the governor. So, the Airport Authority is a -- is in a --an agency of the Government of Guam. So, by virtue of the governor, who is the -- the person in charge of the government agency, that will come into play.

MR. FEITH: I'm just concerned that if we wait till September 30th, which is several months from now, for the plan to be updated, what is going to transpire --

THE WITNESS: I -- I --

MR. FEITH: -- between now and then?

THE WITNESS: I assure you, sir, that we --you know, given the circumstances, we're ready. Our plan works and our plan was implemented during the Paca typhoon. And I don't know if you know this, but during the Typhoon Paca all the -- the -- the resources of Gov Guam was put into play. The coordination was put into play. And we recovered. And I don't believe that anyone has ever recovered the way Gov Guam recovered. And that's because of the Emergency Plan and the direction that the governor gives.

MR. FEITH: And I appreciate that, and I'm sure that the citizens of Guam under those conditions appreciate that. I'm just concerned because of airplane accidents that this is not like a typhoon,it's a little unique, and given the fact that we just had an accident and the plan really never had provisions for an airplane accident I'm just concerned that if we have another one, God forbid, between now and the time it's updated that we may have a coordination problem --

THE WITNESS: I agree with you, God forbid. But if that circumstances should happen, I believe that Guam will be able to take care of it.

MR. FEITH: The MOUs that you -- or the memorandums of -- I should say the mutual aid agreements and any MOUs, you said that they have all been signed and are in -- in place or in the process right now?

THE WITNESS: No. The MOU with the agencies have been signed off by the people that formulated it and now it's awaiting the signature of the governing authority. In this case, it's the governor of Guam and the Admiral Jansack and the colonel in Anderson and Captain Asaro of the Coast Guard. It's just now a matter of getting these four gentlemen together, sitting down, and signing the -- the agreement because it's already been put forth.

MR. FEITH: Okay. Again, I -- I apologize if this seems to be redundant. I'm just trying to catchup because I got a little confused. If that's the case, if it's a matter of getting these four or five people together, is there an anticipated time when this is going to be signed?

THE WITNESS: Yes, when I get back.

MR. FEITH: We would like --

THE WITNESS: I am coordinating it.

MR. FEITH: Okay. We would like to have a copy submitted to us once it is signed for the record, please.

THE WITNESS: You shall have one.

MR. FEITH: Thank you.

(Pause)

MR. FEITH: I have no further questions, Mr. Chairman.

CHAIRMAN FRANCIS: Mr. Cariseo?

MR. CARISEO: One -- one clarification, please.

So, if tomorrow there was an accident and you arrived on scene, would you be responsible for coordinating all the efforts of the Coast Guard, the Navy, the police, would they be reporting to you? How would that work?

THE WITNESS: The -- the way the MOU is set up, if there is an -- God forbid, an accident again,the first responders that go there becomes the incident commander. And it's been agreed that until proper turn to -- the transfer of the incident command, the person that responded first becomes the incident commander. In this case if Gov Guam should respond to a -- to another incident, the -- the incident commander would be the fire chief at that point until such time that jurisdiction, whatever issue is -- is -- is concerned and that proper transfer of the command to that --whether it be the Coast Guard, Navy, or Air Force.

MR. CARISEO: So right now it's whoever gets there first?

THE WITNESS: That's the -- that is the --the way that's set up, yes.

MR. CARISEO: Back to another question. Back in April when you had this on-airport exercise, what exactly did that entail? What type of accident was that?

THE WITNESS: It was -- it was a -- an exercise where they had a -- a plane that was on fire -- crashed and had caught fire, and -- and the fire chief was there and was coordinating. We had a command post set up, also, about 1000 yard away. And -- and again there, we had the command post and we coordinated the resources, whatever the triage team is requiredto -- to be in place, whatever else is needed to -- to fight the fire or -- or -- or to transport the -- the casualties. The triage team will be able to sort out, you know, the most critical and vice versa.

MR. CARISEO: Was this a surprise exercise or were people given some preparation?

THE WITNESS: It was not a surprise. It was already planned. It was a planned exercise. The only thing we didn't know is where in the airport proper it's going -- where this thing's going to be held.

MR. CARISEO: Okay. Was there an evaluation done of the results of that --

THE WITNESS: Yes, the evaluators happen to be the Air Force personnel that was asked to evaluate this, yes.

MR. CARISEO: And what kind of evaluation did you receive?

THE WITNESS: I didn't read the evaluation after that, but I thought it went well, yes.

MR. CARISEO: Thank you.

MR. SCHLEEDE: I just had one question about the actual events involving Flight 801 and the discussion about whose property it was and all that. My question pertains to the command and control of the site and the transfer of that. From your perspective,was there -- were there difficulties because of the transfer of control to the Navy?

THE WITNESS: I -- I really cannot say that, sir, because I was not on the site when there was a transfer. On -- in -- on the command post site there was no difficulty. Everybody was in place. In fact, I even told Admiral Jansack that even though he has assigned someone to -- to the command post, I told him that I would stay back and give him all the necessary support that he needs from the Government of Guam. And I stayed there until 3:00 that afternoon.

MR. SCHLEEDE: This was after the transfer to the Navy?

THE WITNESS: Yes. I -- I wanted to give him all the necessary resources that he -- he -- he needs.

MR. SCHLEEDE: During your post-accident critique, did you become aware of any difficulties that this may have caused regarding the command and control of the accident site?

THE WITNESS: No, sir. No, sir.

MR. SCHLEEDE: Thank you.

MR. M. MONTGOMERY: Thank you, Mr. Chairman.

Mr. Rosario, I am looking at the Governor's Report of Incident, which is one of the exhibits, and in the Governor's Report there is an expression thatthere are some questions that have been presented to the United States Air Force that have -- at the point of time of this writing had not been answered. Have you been satisfied with your -- cooperation with the Air Force?

THE WITNESS: Yes, sir. Definitely, sir.

MR. M. MONTGOMERY: Okay. Thank you very much. That's all I have.

CHAIRMAN FRANCIS: Thank you, Mr. Rosario. You're excused.

THE WITNESS: Thank you, Mr. Chairman.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: The next witness will be Mr. Sanchez, the deputy fire chief, Guam Fire Department.

Whereupon,

CIRIACO C. SANCHEZ

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF CIRIACO C. SANCHEZ DEPUTY FIRE CHIEF GUAM FIRE DEPARTMENT AGANA, GUAM

MR. SCHLEEDE: Please state your full nameand business address for our record.

THE WITNESS: Ciriaco Sanchez. Guam Fire Department, deputy fire chief from Dedadu (ph), Guam.

MR. SCHLEEDE: Could you give us a brief description of your education, training, and experience that qualifies you for your current position?

THE WITNESS: Been in the fire service for 24 years now, and during those years of service I've done courses throughout Emmitsburg, Maryland on management of fire-fighting; Denver, Colorado, advanced arson investigation; and University of Guam. Also, the Guam Community College.

MR. SCHLEEDE: Thank you very much, sir. Mr. Hammack will proceed.

MR. HAMMACK: Good afternoon, Chief.

THE WITNESS: Good afternoon.

MR. HAMMACK: As deputy fire chief, what do you duties and responsibilities?

THE WITNESS: Duties and responsibility --responsibilities as deputy fire chief is I've got to overall jurisdiction on the department's five various bureaus, which is the Fire Prevention, Fire Suppression, EMS Rescue, Administration, and Communication.

MR. HAMMACK: Thank you. Can you pleasedescribe your department's response to this aircraft accident?

THE WITNESS: The department's response to this accident was -- I consider it well given all the factors that we had to encounter down there -- I mean the difficulties of the site.

MR. HAMMACK: Well, if -- if you would take me, please, from the initial notification and sort of give me a history of -- of what happened with your fire department?

THE WITNESS: Okay. At approximately 2:05, August 6th, 1997, I was notified by the -- our fire dispatch that he had received a call from NES Star or Guam Airport Authority Tower that there's a possible 747 aircraft down somewhere in the Nimitz Hill area. And at that point I went ahead and I asked my dispatcher if he could give me an exact location of that possibility, and they said they have no idea at this point in time the exact location of that down aircraft.

So, after we hung up the telephone I got my gears together and I responded to the site. And approximately 2:34 I arrived for the site, and there on the gate I met my northern commander already, which has taken command on the gate with Navy security personnel. What had happened there already was that Engine #7 from the Peet (ph) Fire Station had cut through the chain and a padlock to open the Naval security gate.

So, I also was met on the site -- so I arrive -- the governor of Guam had arrived, also. And I was approached and he had asked me if -- where's this possible plane crash? And I went ahead and I told the governor that I -- at this point in time I cannot give him any exact location. However, we have to take this road and there's a possibility it might be further down the road somewhere.

Also, I have given instructions to my northern district commander until such time you're relieved from this gate you are to take charge, set up command post, and I do not want anyone behind -- beyond this gate without my instructions.

At this point we went ahead, myself, the governor, his driver, and went down the road to the site, possible crash site. And about a half a mile in from the gate we came across the Engine Company #7, Rescues #1 and 2 -- a severed pipeline. And I went ahead and got down from the vehicle and I interviewed my personnel there on the site on the road and asked them if they have located the possible down aircraft. And said, "No, sir. We were just proceeding further into see if that's the aircraft." They had seen some flames further up the street, but they had not confirmed that it was the aircraft.

At that point I went ahead and I gave instructions to Engine Company #7 personnel to try and remove the pipe that was blocking the road. And I had given instructions to Rescues #1 and 2 to proceed with me and to go down to find the possible crash site.

Right as we moved further down, about another 50 yards, we were confronted by two police officer on the scene. And they had already verified that it is the down aircraft and it was located down on the what I would say a black hole, probably, 'cause it was located down real deep and there was no light whatsoever. And the only light we had during that operation -- the immediate respond operation was a flashlight and the small fires that was burning on the aircraft.

So, as we went down, I had Rescues #1 and 2 with me and about three police officers, the governor and his driver. As we came down to the site I -- we started hearing cries for help. And --

(Pause)

THE WITNESS: You've got to excuse me sometimes because it does hit me.

(Pause)

THE WITNESS: I immediately set up a pre-triage area, one up towards the north end of the plane and one in the tail end. And I went ahead and I told my men to split up, Rescue 1 and 2, to head north towards the nose end and Rescue 2 on the tail end and to be split up with the police officers that I had on hand to work with.

There was a total of about nine of us in the original -- initial respond. And we did what we could down there. We had no rescue equipment with us. The terrain was so bad. We went down there with flashlights, rope, that was about it, and a trauma kit. And we tried to pull out the survivors the best way we could and from what we had received in fire-fighting training.

And from there, I took command and I also have informed the governor that, "Governor, sir, with your permission, I'd like to inform that the Rag Unit be activated."

And the governor had responded, "Go ahead and do what you have to do."

So, I contacted Fire Dispatch and I informed Fire Dispatch to activate the RAC Center. By activating the RAC Center, that also puts Mr. Rosario on board. And forever -- for whatever resource I needJohn would then be the man to see that it is accomplished and given to me on the site.

Okay. So, during all of this, I requested to Fire Dispatch to go ahead and activate a Mercy Unit is what we call them, the Naval Hospital Medical Unit, activate the Public Health Unit, GMH, Naval Hospital, and also the National Guard Medical Unit. At that point in time what I saw and what I needed was medical -- medical personnel to come down to assist on the site.

About 3:30 a.m. that day -- that morning, Dr. Eberly (ph) came down to the site. She's our medical director for the fire department. And she became the triage coordinator. I asked her to be the triage coordinator and to coordinate all efforts as far as helping out the injured people.

MR. HAMMACK: Can you tell me how your department was first notified of this accident? Do you know that?

THE WITNESS: Yes. According to our Fire Dispatch, they were notified by the airport tower that there was a possible down 747 aircraft somewhere.

MR. HAMMACK: You mentioned a pipeline blocking the road. How -- how did that piece of pipe get across the road? Do you know?

THE WITNESS: I --

MR. HAMMACK: What caused that piece of pipe to be there?

THE WITNESS: Well, with the evidence surrounding that area I do strongly believe that it was the aircraft.

MR. HAMMACK: And that -- did this prevent rescue vehicles from going past that point?

THE WITNESS: No, I given -- gave instructions to my rescue -- the initial responders I had control of because I was then up on the hill with them and I asked them to pull over on the side and leave your vehicle there and proceed down to the possible crash site and then start rescue operation.

MR. HAMMACK: They got there on foot but they could not get their vehicle past that point, is that true?

THE WITNESS: No, sir. At that moment, no.

MR. HAMMACK: No they could, no they couldn't?

THE WITNESS: They couldn't.

MR. HAMMACK: Could not?

THE WITNESS: Could not.

MR. HAMMACK: Okay. What efforts did you take to move that pipe?

THE WITNESS: Well, I radio informed my --chief officer in charge of the rescue operation knowing the type of vehicles he got and I asked him to proceed immediately to that area where the pipe was to go ahead and coordinate the removal of the pipe, knowing that the type of equipment he carries. His vehicle was equipped with -- lives and a K12 saw and a wench, so that would do the job.

MR. HAMMACK: Prior to that did you try moving it by hand?

THE WITNESS: We tried, yes.

MR. HAMMACK: And what was the result?

THE WITNESS: It was just too heavy. It was too great for human power to move that pipe.

MR. HAMMACK: About how long was it? The piece of pipe, how long?

THE WITNESS: The piece of pipe was between 20 to 50 feet long.

MR. HAMMACK: Okay.

(Pause)

MR. HAMMACK: You mentioned a little bit about the conditions down there by the wreckage. Can you tell me a little more about the environmental conditions, vegetation, the ground slope, lighting, and that sort of thing? The conditions that you had towork in.

THE WITNESS: Lighting was -- we could forget about lighting. There was none whatsoever but our flashlight.

The conditions, when we were down there it was raining. We were going down the slope slipping in the mud. We were faced by all types of vegetation, sword grass ranging from six to eight feet high, and it was just really rough. It's a rough terrain to go down.

(Pause)

MR. HAMMACK: Are you aware of any problems with notification of your fire department or notification of any of your units, notification to respond to this?

THE WITNESS: As far as notifying our units to respond there was no problem.

MR. HAMMACK: Was the response of any of your units delayed for any reason?

THE WITNESS: Yes. Engine Company #7 was delayed because back in Guam we -- we -- we do have problems with condensation build-ups on our brake lines with the apparatus, quote, "air brakes." So, that moment when the operator of that vehicle was draining the airs from his line they were notified to respond. And so what happened there was he had to shut the operation down and start up the engine to build up pressure again before they have to go out.

We might want to take note also that because of the area involved those who were in charge really did not rush to respond because of the dangerous situation with the vehicle not having brakes going up and down the hills.

MR. HAMMACK: Explain to me a little bit -- I need a little amplification on this bleeding of the brakes. Is it policy to have the brakes bled overnight and leave the system empty or -- or was this -- what --what was the situation here?

THE WITNESS: No, it's not a policy to drain and leave the system overnight. It was an unfortunate situation where when we -- the operator was -- doing this process the tragic had happened.

MR. HAMMACK: Once Engine Company 7 got the alarm, how long did it take to recharge the brake system?

THE WITNESS: Say about three to five minutes. According to our investigation reports.

MR. HAMMACK: How -- how do you -- I am sure you still have a condensation problem --

THE WITNESS: Mm-hmm.

MR. HAMMACK: -- because the weather is still the same, but how do you handle the breeding --bleeding of the brake system now?

THE WITNESS: Well, with the new policy in place the bleeding of the brake system will not be allowed unless authorized and approved by the maintenance supervisor. And if they have to do that bleeding, they have to have a backup apparatus before they even bleed the brakes.

MR. HAMMACK: I understand that there was a Federal Navy, I believe, fire station that was closer to the accident site than your closest station, is that true?

THE WITNESS: That's correct.

MR. HAMMACK: Do you know when they were notified?

THE WITNESS: The -- I might just -- may I look at my note here?

MR. HAMMACK: Sure.

(Pause)

MR. HAMMACK: Really, what I'm interested in, was it before or after your department was notified?

THE WITNESS: It was after our department was notified.

MR. HAMMACK: Do you know who notified them,the Federal station?

THE WITNESS: Yes, the Island Fire Dispatch or the Navy Fire Dispatch was notified by our Guam Fire Department dispatcher.

MR. HAMMACK: Can you explain to us who --what Island Fire Dispatch is?

THE WITNESS: The Island Fire Dispatcher is the Federal Navy fire dispatcher out in Guam.

MR. HAMMACK: That's separate from the Guam Fire Department dispatch?

THE WITNESS: That's correct.

MR. HAMMACK: Okay. Since this other -- the Federal fire department was closer to the accident site, do you know why they weren't notified any sooner?

THE WITNESS: I've got no reason whatsoever why they did not respond.

MR. HAMMACK: Is this one of the things you're looking into as an after-action item?

THE WITNESS: Yes. This is one of the things we -- we did. We met with the fire chiefs and we try to work these things out together. We -- we learn from our mistakes, and we don't want to do it again. So, for whatever the reason was we want to correct the matter.

MR. HAMMACK: Does it seem like you're makingprogress in this area as you talk to these other departments?

THE WITNESS: Yes. Yes.

MR. HAMMACK: Are you getting good cooperation from all the other departments, the Navy and Air Force and all them?

THE WITNESS: Yes, sir.

MR. HAMMACK: Any problems -- any resistance from them?

THE WITNESS: No. No problem. Whenever we ask for their assistance they're there. Unless they're -- for some reason they can't respond to help.

MR. HAMMACK: I mean in -- in planning for the next problem are you getting any resistance in the area of cooperation in the -- in the mutual aid agreement area?

THE WITNESS: Not on the Fire Department's standpoint. And that again will be worked on with the Guam Emergency Plan.

MR. HAMMACK: Okay.

THE WITNESS: Oh, the time that you asked, sir, excuse me. The Island Fire Dispatch was notified at 2:10 a.m., August 6th, 1997.

MR. HAMMACK: Can you describe for me the jurisdictional boundaries of the Guam Fire Departmentversus the airport versus the Navy, the Air Force, the Coast Guard if they have a fire department? Are -- are there -- are there clearly defined boundaries as far as -- when you respond to somewhere on the -- or if -- if there is an emergency somewhere on the island, does --do all the different parties know whose territory is whose and who's going to be in charge?

MR. HAMMACK: Yes, I want to -- I want to make it clear that the Guam Fire Department does have an MOU signing with Anderson Air Force Base. We do have an MOU signing with Coast Guard. And Navy, also. So, I would also make it -- like to make it clear that when there's any emergency, whether it be a rescue service or a medical service or -- fire, for suppression service, the Guam Fire Department has the jurisdiction over that area for the island of Guam.

And as far as the joint agreement with the Guam Airport Authority, we do have also a mutual agreement with them. And when the accidents and within the airport proper, we become assisting unit to them. We provide necessary resources that they request from us. And likewise, if it's outside their fence it becomes our game and they will provide also necessary resource.

MR. HAMMACK: Okay. Thank you.

Can you describe the -- the scene for us when you first got to the wreckage as far as -- you already described the terrain for us. Can you describe now the airplane and basically what you saw when you got there? I'm thinking about fire, number of survivors, that sort of thing.

THE WITNESS: Okay. When we first arrived down there, the first thing we heard were the victims yelling for help, crying because of pain. And so, we -- we tried to do everything, like I said, that we could with what equipment we had with us.

And as far as the airplane, it was totally engulfed when we got there. Basic -- basically, it was on its low burning stage already to the point where the fires weren't really bothering the rescuers. We were actually -- the rescue personnel were actually going into the plane checking passengers, if -- who was still alive and who was not.

MR. HAMMACK: And this -- this was the situation when the very first people got there, is that right?

THE WITNESS: Yes, sir. That's the first group of, like I said, nine -- probably nine of us.

MR. HAMMACK: Okay. And that was my next question. There were approximately nine of you then --

THE WITNESS: Yes.

MR. HAMMACK: -- who got there first?

THE WITNESS: Yes, sir.

MR. HAMMACK: And because of access problems the only equipment you had was what you carried in on foot, is that true?

THE WITNESS: That's correct.

MR. HAMMACK: Okay. And you -- you mentioned that you set up two different triage areas. Can you describe for us very basically what triage is and a little bit about how the triage areas operated?

THE WITNESS: Okay. What I did was set up a pre-triage area down on the crash site. So, we'll basically put the -- some of the injuries on the two triage -- I mean the pre-triage area that I set up. Okay. One on the tail end and one on the front --front end, which is the nose. And from there I used again what resource I had down there, manpower, and as the rescuers pulled the victims out from the wreckage I had maybe on the initial response I probably had, like, two -- person tending to the injured persons, which includes myself, the governor, and we just tried to do what we can down there without anything else.

The -- the triage that was set up was for medical purposes. When you set a triage area it'swhere you ID the injury of the victims, severity and the minor. So, what we did was I went ahead and I called one of my assistant fire chiefs also, EMS rescue chief, to set up a -- the main triage area up by the VA -- VOR area, to set up the triage area there so whatever would move from the pre-triage area would go up that way. I selected that area up there because we have ID'd that the Navy helo could actually land up there so we could start evacuating victims to the hospital.

MR. HAMMACK: Thank you.

(Pause)

MR. HAMMACK: Given the fact that -- well, I'm -- I'm trying to get into your -- your decision-making process a little bit, rescue versus fire-fighting.

THE WITNESS: Okay.

MR. HAMMACK: You mentioned that the fires didn't hamper access to the wreckage. Would it be fair to say that your -- your -- given all your efforts to -- to rescue and none to -- to fire-fighting at that --at -- up to this point?

THE WITNESS: My immediate decision was to try to save as much as I can.

MR. HAMMACK: I'm sorry. I missed that.

THE WITNESS: My immediate decision when we got down there is to try to save as much as we can without even taking suppression yet. We -- we had victims right by the wreckage area. We had victims right near the fires, so I asked my men to go over there and let's -- let's pull what we can. Also, considering the fact that there's just no way I could start suppression that fire. So, we went ahead -- they -- they went ahead, they went into that fire with not even thinking about their own safety and started pulling out victims.

MR. HAMMACK: Okay. And -- and for reference, there's the photograph up behind you and there's a laser pointer if -- if you need that to -- to describe anything as we go through it.

Mr. Rosario said you were in charge down there at the wreckage and -- and you've told us the same. Would you say that you were the commander of the rescue operations?

THE WITNESS: I'd say I'm the on-scene commander.

MR. HAMMACK: Okay.

(Pause)

MR. HAMMACK: Can you describe what communications was available to you to call in moreresources or for any reason?

THE WITNESS: The only communication I had was my portable radio.

MR. HAMMACK: With that, who could you --with whom could you communicate?

THE WITNESS: With that I could communicate with my fire dispatchers and with the fire dispatchers they could communicate with whoever we want to talk to.

MR. HAMMACK: Okay.

THE WITNESS: And giving the instructions to them, they could also relay instructions to the command post.

MR. HAMMACK: By the command post you mean up by the gate?

THE WITNESS: Yes, sir.

MR. HAMMACK: Okay. Did you -- down at the wreckage, did you divide responsibilities into sectors?

THE WITNESS: Yes, I did.

MR. HAMMACK: Could you communicate with the various commanders of those sectors?

THE WITNESS: Yes, sir.

MR. HAMMACK: How?

THE WITNESS: They all had their own portable radios.

MR. HAMMACK: Okay. And you --

THE WITNESS: That includes the rescue units.

MR. HAMMACK: And you had a common frequency for them?

THE WITNESS: Yes, sir.

MR. HAMMACK: Okay. And just for clarification, if you wanted to communicate with Navy or any outside agency, you did that by calling your dispatcher and they in turn relayed, is that right?

THE WITNESS: Yes, that was in the initial alarm, okay? But -- sometimes between three and --about 3:30 and 4:00, four a.m. that morning, I was informed by my triage officer Chief Agagi (ph) up on the -- that area right there that the admiral was there. So, it was a relief when my -- because knowing that I've got the governor on my left and I've got the admiral up on the hill I go I'm going to get my resources now.

MR. HAMMACK: Yeah, if they can't do it no one can.

(Pause)

MR. HAMMACK: At the time of the accident did -- did you have the ability to communicate directly with any outside agency or did you always have to go through your dispatcher?

THE WITNESS: Yes, I always have to gothrough my dispatch or the command post.

(Pause)

MR. HAMMACK: Is improvement in interagency communications going to be something you'll look at after the fact?

THE WITNESS: As we speak here, Gary, we're probably putting into service right now the radios that we had ordered, and that would put us into what is known as a Smart-Net unit back on the island. And --

MR. HAMMACK: I'm sorry. I missed that?

THE WITNESS: A Smart-Net unit by Motorola, and this will give us access to police, the Port Authority, the Water Works Authority, and other emergency agencies.

MR. HAMMACK: So, in the future an on-scene commander will have direct communications with these agencies?

THE WITNESS: Yes, sir.

MR. HAMMACK: Okay.

THE WITNESS: In fact, we have also issued cell phones to our district commanders already and it will greatly improve the communication.

MR. HAMMACK: Okay. Thank you.

I want to go back to when you first arrived out by the gate.

If we can get Exhibit 16I, page two up there, please?

(Pause)

MR. HAMMACK: Just before the -- you see some police cars depicted near the severed pipeline.

(Pause)

MR. HAMMACK: Were they there when you got there?

THE WITNESS: No, sir.

MR. HAMMACK: You were already down at the site, then, when they got there?

THE WITNESS: Yes, sir.

MR. HAMMACK: Are you aware of any problem with access they might have caused?

THE WITNESS: I was informed by my battalion chief rescue operations officer that I mentioned earlier that I had left in charge to try to move that pipe that he was having problems with vehicles coming in while they're trying to move those pipes. So, that was the only info I had from the top, but I went ahead also and instructed the Chief Mesa (ph) to do what he has to do to remove those vehicles.

MR. HAMMACK: Once that piece of pipe was moved, did those vehicles -- the presence of those vehicles cause any problems with access?

THE WITNESS: No, sir. Once the piece of pipe was removed we had traffic going through.

MR. HAMMACK: Can you tell me when the first ambulance arrived down by the wreckage?

(Pause)

THE WITNESS: Okay. The first medic arrived at 2:44 a.m.

MR. HAMMACK: Okay. Do you know when the first victim was transported?

(Pause)

THE WITNESS: -- have a time here for you, but I know that the first victim was transported by a Navy security vehicle out to the gate and so as soon as I get the time --

MR. HAMMACK: Okay. You can provide us with the time later.

THE WITNESS: Okay.

MR. HAMMACK: Were there ever any fire suppression efforts initiated?

THE WITNESS: I did have a plan on hand, and I -- as soon as I -- on my incident -- on my command section I had my public information officer with me, I had a runner with me and also set up a communication officer with me, and I had send the -- my runner up to the command post because we had lost radio contact andto tell them of the plan to -- this was after the rescue effort. We had found no more survivors.

The -- so I went ahead and forwarded my suppression plan to the command post. And my runner came back and to inform me that it was tabled. They had a meeting, the Air Force fire chief and the Navy fire chief and Gov Guam fire chief had -- had a meeting, and Air Force fire chief being the, I guess, the best trained for aircraft fire-fighting had told us to let the fire burn itself out.

MR. HAMMACK: By doing that, did it cause any --

THE WITNESS: No, I'd like to also clear that -- the fire we're talking about here is a piece of wing and about two tires of the plane. And this was away from the major body of the aircraft.

MR. HAMMACK: Okay.

THE WITNESS: And it did not impede recovery effort also.

MR. HAMMACK: Have you had a critique of your agency's activities in response to this accident?

THE WITNESS: Yes.

MR. HAMMACK: What sort of things have you learned?

THE WITNESS: We've learned a lot of things. One is communication problems that we had and what we have to do to improve our communication problems with various agencies and other Federal Government. Another thing was the incident command system. Although we --we are trained for that, it was noted that there --there's the need for a refresher course. That also has been done with our commanders out in the field.

MR. HAMMACK: And you're -- you're -- you intend to cooperate with Mr. Rosario and make this one big effort instead of individual efforts, I assume?

THE WITNESS: Yes, fully cooperate.

MR. HAMMACK: Okay. Mr. Chairman, that's all I have.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: We have no questions, Mr. Chairman.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Barton?

MR. E. MONTGOMERY: No questions, Mr.Chairman.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman.

(The following is a verbatim transcript of the English translation of Mr. Lee's questions posed in Korean.)

MR. LEE: -- a number of difficulties. Let me express my thanks from the bottom of my heart all the efforts that you put into -- for the rescue operations.

Let me just check with you on two items. Guam, Air Force, and Navy and fire stations, everybody participated in the rescue operations. The -- when you look at Exhibit 16C, page eight according to FAR regulations the Guam Airport fire station did not go to that accident scene. To my understanding, the airport fire station when it comes to rescue operations and fire suppression has better capabilities, better qualified to deal with aircraft accident-related situations like this compared with other more general purpose type of fire stations.

In the case of this accident, because of this regulation I want to ask how you feel about it, that the airport fire station was inhibited by this formal regulation from going to the accident scene andparticipate in the operations.

THE WITNESS: Well, first of all, I want to go in and clarify that. The ARF unit, Airport Rescue and -- unit from the Airport Authority did send personnel down to assist on both rescue efforts and opinions on how to help us out there to deal effectively with this type of disaster.

And I also want to mention that we are, although not truly capable of handling aircraft-type fire-fighting, we are basically trained to fight fires with aircraft-type. Our vehicles are equipped, not --nothing to be compared with the airport capability, but we're pretty much equipped to keep it on line until we could get any assistance from Air Force, Navy, or the airport crash crew.

MR. LEE: If that was the case, then among the fire engines which went to the crash site AFF foam that is used for fire suppression in relation with fire -- fire arising from accident -- airplane accident, how much of it was available at the time?

THE WITNESS: During this crash we had capabilities to suppress that fire. However, being that type of area, the remoteness of it with the type of vegetations, the -- where it was actually located, it was just impossible, sir, to do any fire suppressionat that moment. We cannot fully activate our suppression unit and our rescue unit until we have order for the bulldozer to come down and make a road down to the crash site. Then again that took about three hours till we get a -- an opening to roll down some kind of apparatus down there or medic unit.

MR. LEE: Let me just ask you one more question. If you look at Exhibit 6A, page 10 among the survivors those who were sitting on 36K, the -- the helicopter pilot who was sitting on there, and he gave a testimony with respect to the survivals. Had there not been a fire there would have been about up to 50 percent of survivors or more survivors. Do you think there is credibility with this testimony from one of the survivors at the time of the rescue operations? Did you ever receive as to the -- receive reports as to the approximate number of survivors?

THE WITNESS: Yes, during the operation I was being informed at all times that -- how many have we pulled from the wreckage and how many have been evacuated from the area.

And as far as predicting just how many survivors we could have rescued from the accident, I --I'm not in that position to predict that, sir.

MR. LEE: Thank you very much. That's all.

(End of translation)

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Yes, thank you, Mr. Chairman, and thank you, Chief Sanchez. I know it's an emotional time as it is for all of us who were there.

Getting back to the questions that were just posed to you, should the airport fire department dispatch its vehicles to the accident scene what would happen to the airport?

THE WITNESS: Sir, I know by Federal regulations that they are not allowed to leave that area.

MR. DERVISH: Is it not true that if they left the airport they'd have to close the airport?

THE WITNESS: That's affirmative.

MR. DERVISH: Concerning fire suppression, there were a number of recommendations made at the time at the scene, the first of which was to dump water. What would that have done?

THE WITNESS: I --

MR. DERVISH: I'm sorry. From a helicopter.

THE WITNESS: Okay. At that point I had informed by assistant fire chief up in the VOR area that was with the admiral to abort that mission as it would gravely endanger the rescuers once they droppedthat water. So they did abort the mission.

MR. DERVISH: And what about the use of foam? What would have that done to the rescuers and the survivors?

THE WITNESS: First of all, again, I'll say it was just no way we could have bring that suppression agent down there.

MR. DERVISH: Very good.

THE WITNESS: The initial respond.

MR. DERVISH: Thank you. The last question I would just pose to you was the testimony of Mr. Barry Small, helicopter pilot from New Zealand. His testimony and I think which was correctly stated that the fire probably caused most of the deaths on the plane, but I think Mr. Small mentioned in his statement that most of that fire occurred immediately upon impact and he also blamed oxygen from the plane for fueling the fire. How much after the time of the crash did you arrive?

THE WITNESS: Could you repeat that again, please?

MR. DERVISH: What time did you arrive at the scene?

THE WITNESS: At the gate or down at the accident site?

MR. DERVISH: Down at the plane.

THE WITNESS: Okay. From -- on the gate area I arrived there at 2:34 a.m. and about another 45 minutes I actually arrived on the crash site.

MR. DERVISH: The plane crashed at 1:42, so you were there about an hour afterwards?

THE WITNESS: Correct.

MR. DERVISH: Thank you.

If I could go back to that map that was just up on the screen, 16I, page two? Thank you.

Putting that in perspective, how long is that road?

THE WITNESS: How long is the what?

MR. DERVISH: What's the distance of that road from the gate to the VOR site?

THE WITNESS: I'd say about three-quarters of a mile.

MR. DERVISH: And the conditions of that day you said were rainy. What was the condition of the road?

THE WITNESS: Wet. Slippery. Muddy.

MR. DERVISH: You also noted that there were vehicles parked on the shoulder of the road that were not blocking the road, but what was the condition of the shoulder?

THE WITNESS: It was just plain muddy and wet.

MR. DERVISH: So, in your opinion, could any vehicles have used the shoulder to drive on?

THE WITNESS: If they would have gone to the right side of -- they would have fallen off the cliff. If they would have gone to the left side, they would have run into the cliff. So they're trapped right there in the middle.

MR. DERVISH: Although this map does show the location of the vehicles and the location of the crash and the large area at the end of the road, what was the entry point into the crash site?

THE WITNESS: The entry point was the entry point we made by --

MR. DERVISH: Could you turn around and show us where you --

THE WITNESS: Could I what?

MR. DERVISH: On the map could you show us exactly where you entered the jungle?

THE WITNESS: Okay.

(Pause)

THE WITNESS: Okay. The entry point would be right here. This area. And on this area it's another steep -- going down towards the crash site we weretalking about another 100 yards, maybe. And to reach the crash site we had to go across all types of vegetation, sword grass, all types of trees, and it was just -- it was very, 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. But with all this we went ahead and tried to go down there and rescue.

MR. DERVISH: You were talking about resources. I know that they were skimpy at first, but did you eventually get enough resources?

THE WITNESS: Yes, sir. For all the requests that I made to do the initial job, I did get the resource I requested for.

MR. DERVISH: Considering the terrain, the weather, the darkness, and the large area that the wreckage was scattered, what kind of resources would you have needed?

THE WITNESS: First, I requested for lighting, and I asked command post and Fire Dispatch to see if they could also dispatch the 8C5, the Navy helo and to assist also in evacuation and lighting if possible, and we did get lights from both the helo and other agencies that responded.

MR. DERVISH: Concerning the helicopters, wasthere a problem with them hovering over the area?

THE WITNESS: Yes. Unfortunately, again, when the choppers arrived, they were giving me the light I needed to continue the rescue effort but, again, I had to ask them to pull away because of the --the wind coming down from the chopper's blade. That didn't help us a bit. It was just adding more fuel to the fire, oxygen to the fire, and also those small debris on the side were beginning to be lifted up by the wind from the chopper's blade.

MR. DERVISH: Imagine the difficulty in getting down into the crash area. How difficult would -- was it to get the survivors up from the crash area?

THE WITNESS: Oh, man. We could triple that amount of difficulty. We had to go back up on those slippery hills without any rappelling gear whatsoever or nothing. We were holding the victims in one arm and holding the tools in the other so we just could make it to the top. And we did this until the point until we could clear a landing site for the choppers and which we did accomplish. We did provide a landing site for the choppers down on the site besides the VOR area.

MR. DERVISH: Engine #7 that was stuck, according to your timeline that you have there, it wasremoved about 0400 to 0430, is that correct?

THE WITNESS: Correct.

MR. DERVISH: So after that it did not become a hazard or block the road?

THE WITNESS: No. In fact, as soon as they removed that severed pipeline the road was open.

MR. DERVISH: You are, of course, familiar with not only the GFD Emergency Plan but with the Territorial Emergency Plan?

THE WITNESS: Yes, sir.

MR. DERVISH: Do you think that the operation went in accordance with those plans?

THE WITNESS: According to those plans, yes, I'd say it did work. It did work out on this -- this -- however, you know, there's room for improvement and corrections and that's being done at this time.

MR. DERVISH: Were you part of the April exercise at the airport?

THE WITNESS: Yes, sir.

MR. DERVISH: And your evaluation of that exercise?

THE WITNESS: It was a well organized exercise. It was -- it was -- I have no complaints for that exercise. And it did turn out well for --according to the Guam Airport Authority's EmergencyPlan and it went right down from number one to 10 without any problem.

MR. DERVISH: Do you have anything else you want to add about improving the reaction time and the reaction capabilities?

THE WITNESS: No, sir. It's just that we are making corrections at this time. We had met -- made some corrections already, and we're -- we are improving the system.

MR. DERVISH: That's all I have. I want to thank you for today's testimony and thank you for your work at the rescue site.

THE WITNESS: Thank you.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: Just a couple clarifying things.

Early in your testimony you had referenced something called a REC Center or --

THE WITNESS: A RAC unit.

MR. FEITH: What is that?

THE WITNESS: That's our Response Activity Coordinators located over at the Civil Defense. When this unit is activated we've got the rep centers from various agencies that you need to actually perform what you have to perform on this type of disaster. They've got the resources that we need on the site.

MR. FEITH: In the fire dispatch log at 0324, and you don't need to turn to it. I'll just read it to you. It says, "Rescue 1 reported large explosion at crash site." Can you tell me what that large explosion was?

THE WITNESS: We had no idea what that explosion was. We were right there, and I thank God that nobody got hurt from that explosion. But it did threw two of my rescuers about 20 feet away from the site. And --

MR. FEITH: Was it a fire-type explosion or maybe an oxygen bottle-type explosion?

THE WITNESS: It sounded more like an oxygen-type explosion.

MR. FEITH: Anything that may have prevented that? Any -- any particular equipment that -- I mean were you aware of anything volatile in -- in the wreckage that may have caused that? Did you do any investigation afterward to find out what that may have been?

THE WITNESS: No, sir. We didn't do any investigation on the cause of the fire.

MR. FEITH: Okay. One last question. You said that when you were answering a question for Mr. Dervish about the problems that you had going into theaccident site and then you tripled those problems trying to come out with victims and that kind of thing. Given the nature of those problems, that is, the -- the steep inclines and given that Guam does have a lot of those steep inclines in their mountainous terrain, have you or the government bought equipment now to equip your -- people for future operations like this given what you experienced on this accident?

THE WITNESS: Yes, we -- we do have an agreement now with other agencies that should we need to activate those agreements that we need it -- again, that falls right into our RAC unit, the Guam Emergency Planning Center.

MR. FEITH: I think what I'm getting at is do you carry equipment now on your truck so that when you're there first on the sign -- first on the scene doing the rescue operation do you --

THE WITNESS: Yes, we have added on our rescue vehicles also portable generators and floodlights.

MR. FEITH: About -- how about for climbing, such as ropes and --

THE WITNESS: Yes. Well, our rescue units were --

MR. FEITH: -- setting up a rappelling-type --

THE WITNESS: Yes. They are equipped now.

MR. FEITH: Okay. That's all the questions I have. Thank you.

CHAIRMAN FRANCIS: Pat?

MR. CARISEO: No questions, Mr. Chairman.

MR. M. MONTGOMERY: No questions.

CHAIRMAN FRANCIS: Mr. Schleede?

MR. SCHLEEDE: Just a couple areas here. Similar question I asked Mr. Rosario regarding the command and control of the accident site. There was a discussion and some media coverage about the switch-over from the Gov Guam to the Navy. Do you -- did you encounter any difficulties? Do you think that caused any difficulties regarding the command and control because the Navy took over?

THE WITNESS: No, I never had problems down there on the site with the rescuers. For whatever I need I would speak directly to the admiral, and from there they'll provide me resources. And the truth is the problem was up on the top. We -- the rescuers never had problems on the bottom. The only problems we had down there was getting the right equipment to do the job, but as far as everybody working together, Navy, Federal, Air Force, crash crew from the airport,everybody was just working together, and there wasn't any problem whatsoever that I encountered with that.

MR. SCHLEEDE: Do you believe the outcome of the -- of the accident was changed in any way or would have been any different if Gov Guam had remained in charge?

THE WITNESS: It -- it -- it's beginning to head that way where there's some -- there's going to be changes.

MR. SCHLEEDE: I'm -- I'm sorry?

THE WITNESS: It's -- there's been a negotiation already for those type of changes.

MR. SCHLEEDE: I'm sorry. You may have --I'm -- I'm -- may have not have asked that question correctly. Regarding the outcome of the accident and the rescue, do you believe that the outcome would have been any different if there had not been a change in the command to the Navy?

THE WITNESS: No, I honestly believe it wouldn't be any -- there wouldn't be any changes of the -- as of this time if really there was no accident.

MR. SCHLEEDE: So you don't have any opinion about whether there was a problem with the switch-over to the Navy command?

THE WITNESS: It was -- it -- it wasdifficult there as far as switch-over to command because the truth is no one at that moment really had the faintest idea on whose property was this plane on. So we just went ahead and did what we had to do, and we worried about whose property later on.

So as far as switching command, there needs to be an improvement on that part, the switch-over of command, because it didn't quite work out the way it should be done.

MR. SCHLEEDE: Okay. I just wanted to touch on another area, when Mr. Dervish asked you about the airport fire-fighting equipment leaving the airport. I wasn't sure how your answer went. I believe he said that the airport would have to shut down if the fire trucks left the airport? Is that your understanding?

THE WITNESS: Well, if for some reason the aircraft fire-fighting crew decides to have their vehicle respond to that site, there wouldn't be any fire-fighting protection for aircraft incoming or outgoing. So, that would have eventually closed the airport.

MR. SCHLEEDE: Okay. Eventually.

THE WITNESS: Yes.

MR. SCHLEEDE: I -- I just wanted to make sure. I think the -- Mr. Dervish in asking thequestion said the airport would have to close down, and I'm not sure that's correct so we'll -- we'll sort that out and look at the regulations later. I didn't want it to be implied that you said that was a fact. Thank you.

CHAIRMAN FRANCIS: Let me -- I -- I just want to make sure that one of Mr. Schleede's questions, his first question was do you believe that had the command not changed that would have made any difference in the prosecution in the -- in the final outcome of what happened out there on the accident site. On the issue of what's happening now or -- or the legal sort of surveyors getting out there is not of concern to us right at the moment, but the issue of whether the change of command affected the outcome from your point of view is -- is an important question for us.

THE WITNESS: No, the chain of command -- the -- no, it didn't really affect the outcome of the accident.

CHAIRMAN FRANCIS: Thank you. Thank you very much for your -- for your testimony. We appreciate it.

THE WITNESS: Thank you.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: It's my intention to have -- we'll see how we do here -- but at least onemore witness and perhaps try to finish with Captain Humphreys-Sprague. I'm not particularly comfortable with letting this go into tomorrow.

I would say to all concerned, the parties and the technical panel particularly, to try to be cognizant. We're getting a lot of questions about things that are in the record and we're getting a certain amount of redundancy, so please before you ask a question think about whether this is adding to the record. The purpose of a hearing is to add to the factual record, not to go back over things which we already have in the record.

So, the next witness is Joseph Mafnas, a deputy chief of police in the Guam Police Department.

Whereupon,

JOSEPH MAFNAS

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF JOSEPH MAFNAS DEPUTY CHIEF OF POLICE GUAM POLICE DEPARTMENT AGANA, GUAM

MR. SCHLEEDE: Please state your full name and address for our business record -- for our record.

THE WITNESS: My name is Joseph Mafnas. I reside in Bargadais (ph), Guam.

MR. SCHLEEDE: And would you give us a brief summary of your experience and education that qualifies you for your present position in the police department?

THE WITNESS: I have 30 years of police experience with the Guam Police Department. I have a bachelor's degree in Public Administration, specialization in Law Enforcement from the University of Guam and the University of Southern California.

MR. SCHLEEDE: Thank you. Mr. Hammack?

MR. HAMMACK: Good evening, Chief.

THE WITNESS: Good evening.

MR. HAMMACK: Can you briefly describe your duties and responsibilities as deputy police chief?

THE WITNESS: At this time -- during this incident I was the acting chief, just for the record. And my duties and responsibility at that time is the management and control of the men and women of the Guam Police Department, also directing, coordinating, and management, all function of related law enforcement, protection of life and property, maintaining accurate law and order.

MR. HAMMACK: Thank you, Chief. Now, if I could, first of all, I'd like to ask you to slow down alittle bit to help our interpreters.

THE WITNESS: Sure.

MR. HAMMACK: Can you please describe the police department's response activities relating to this accident?

THE WITNESS: During this particular time and day in question here, I got a phone call from my tactical command section that a possible down aircraft, and the time that I received the call was about 2:00 in the morning.

MR. HAMMACK: After you were notified of the accident, what did you do?

THE WITNESS: After I got the message I notified my shift leader from the tactical operation command to dispatch police officers to the scene where it's possible that the -- the aircraft went down and then to give me a feedback as to actually whether it's a down aircraft or what. About 20 minutes later I got a phone call again from my command that it is confirmed that it's aircraft crashed, and my two police officers that were assigned to the southern district was the ones that confirmed the -- the aircraft crash. They were the first one at the scene of the crime -- I mean, excuse me, of the crash.

And immediately after that, I -- I notifiedthe -- the command that I should be proceeding at the scene. I didn't really know what time I arrived at the scene, but when I arrived at the scene the fire -- the other rescue -- were already at the scene. Prior to that, though, I instructed the two officers to make sure that -- notify the tactical command to contact all the responsible agencies that handle emergency crises such as this one and to take direction upon whoever is designated to be the incident commander at that time and -- and give assistance whatever is needed at that point in time.

MR. HAMMACK: Who was in charge of police services at the site?

THE WITNESS: There was a sergeant. I -- I think it's Sergeant Rivu, who was the first supervisor at the scene. So at that point in time I designate him as the incident commander pending the arrival of the rescue team which at this point would be the fire or the Civil Defense, whoever comes first. So he takes control of the incident.

MR. HAMMACK: Were there any problems that you're aware of with cooperation among your police department and any other agencies?

THE WITNESS: I -- I don't have any problem with the other agencies.

MR. HAMMACK: Okay. Did you have any communications problems with any of the other agencies?

THE WITNESS: Yes, that's one of the biggest problem that we have, and that's being rectified at this point in time. The biggest problem during this incident was the communication. Although we're very close to each other we cannot communicate by radio because they're not in our net. We have our separate net from the rest of the fire and the -- and the other agencies.

MR. HAMMACK: That's being addressed, is it?

THE WITNESS: Yes. At this point in time we -- we have -- let me look at my -- let me look at my notes here.

Rectifying the communication problem we have purchased new equipment worth $700,000 that will rectify all these communication problem that we can communicate with all other agencies within the Government of Guam, to include the military emergency agencies also. We also recondition some Air Force radio equipment that we will be using at this point in time as soon as it's completed reconditioning. And Chief Sanchez mentioned about the Smart-Net. We will be having a new repeater side up and with additional channel that would accommodate both the other agenciesfor -- for this particular whatever emergency that do come. And -- and one of the forthcoming is the building of a three-story building that will compose of all communications center of all Government of Guam.

And also, I'd just like to mention that the governor has ordered a 911 system task force to come up with this building of the communications center for all Government of Guam agencies to be actually -- I mean to be in that one general location.

MR. HAMMACK: Thank you. One more item. I want to get back to those police cars that were parked up by the severed pipe. I'm -- I'm still unclear about what, if any, problem, they may have caused with vehicular access to the -- to the wreckage. Can you address that?

THE WITNESS: When my officers first arrived for the scene, they -- the -- there wasn't any problem other than it was muddy and it was rough getting inside to -- to the site. And like what Chief Sanchez mentioned, even the shoulder is -- is too rough to travel. It's just enough for a vehicle to move around the pipe that was bent towards the main road. So in other word, the two vehicle would have passed that pipe that was broken by the airline with just barely enough room to move towards the other side, which is the VORside.

But the place was -- was really in bad condition. It's like a clay -- if you want to compare it, you know. When -- when the clay gets that muddy and always slippery and -- and everything else.

MR. HAMMACK: My question is, I guess, once that piece of pipe was moved and those cars remained, was there any problem with getting vehicles into that --

THE WITNESS: There is no problem when the pipe was removed or bent inward. There wasn't any problem for a vehicle to move in and out to one point to another point.

MR. HAMMACK: Would you classify that road as a one-lane road, two-lane road?

THE WITNESS: I would classify it as a one-lane road. Heavy equipment that goes in there, that's the only equipment that can go in there. There is no other vehicle that can go on either side because of the embankment of both sides.

MR. HAMMACK: Mr. Chairman, that's all the questions I have.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions.

CHAIRMAN FRANCIS: Barton?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: No questions, sir.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: Mr. Feith?

(No response)

CHAIRMAN FRANCIS: Mr. Cariseo?

(No response)

CHAIRMAN FRANCIS: All right. Thank you very much for your testimony.

THE WITNESS: Thank you.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: I would like to take a 10-minute break. It is now 6:49. We will reconvene in 11 minutes here for the Navy testimony. You've got the time on the clock, Mr. Feith? You can -- you can setyour watch by my watch for the next two days. After that you can set it back.

(Whereupon, a brief recess was taken.)

CHAIRMAN FRANCIS: We're going to have -- if we could sit down, Mr. Donner. Trying to get recognition? You haven't been saying much recently.

(Pause)

CHAIRMAN FRANCIS: All right. Our next witness is Captain Mary Humphreys-Sprague. She's currently the inspector general of the U.S. Navy, Southern Command.

Whereupon,

MARY HUMPHREYS-SPRAGUE

was called as a witness, and first having been duly sworn, was examined and testified as follows:

TESTIMONY OF CAPTAIN MARY HUMPHREYS-SPRAGUE INSPECTOR GENERAL U.S. NAVY SOUTHERN COMMAND MIAMI, FLORIDA

CHAIRMAN FRANCIS: And you've sworn her in?

MR. SCHLEEDE: Yes, she's been sworn. I just want to ask a few questions about your -- please give us a description of your education, training, andexperience that qualifies you for the position that you held at Guam at the time of the accident?

THE WITNESS: Well, I have 28 years of experience with the Navy. And I also have all the leadership tours that lead up to that. I've had command several times. And I've also had the last 10 years of experience I've had in humanitarian assistance and disaster relief. And the chief of staff position, I've occupied the chief of staff position there, and it basically was chief of staff of all the Naval forces on Marianas.

MR. SCHLEEDE: Thank you. Mr. Hammack, and we might need to speak a little slower.

MR. HAMMACK: Good evening, Captain Sprague. Thank you for being with us.

At the time of this accident where were you stationed?

THE WITNESS: I was stationed at Clannard Naval Forces, Marianas. I was the chief of staff there. I was also functioning in this event as the DCO, which is the Defense Coordinating Officer. The main role of the DCO is to work with civilian authorities in responding to crises there, and we had responded to quite a few typhoons and earthquakes, fire-fighting, and such. And one small aircraftaccident earlier in the year. A Cessna had gone into a swamp.

MR. HAMMACK: Thank you. Can you please describe your experiences and observations regarding the response to this accident?

THE WITNESS: Well, my first contact with the crash was when my husband Jay Sprague was called. He was the executive manager of the Guam International Airport Authority, and he received a call from Airport Ramp Control at 2:16 in the morning, and the subject was that a 747 Korean Airliner was missing over -- over the Nimitz Hill area.

Since the crash hadn't been confirmed at that time he asked the people to call the Guam Fire Department, okay, to see if they knew where the crash might be at.

We also lived on Nimitz Hill, and what I did was I went outside and walked around the house to see if I could see any signs of the crash. And in the back of the house if you looked off to the southeast you could see a -- a bright orange glow in the sky. It was very dark out and the -- and the glow lit up almost like a sunset. And it took up a substantial portion of the sky, probably because of the clouds.

I then went into the house and I called ourNavy Security Office and I called my command duty officer. And I asked the command duty officer to activate our first responders, our search and rescue assets, and the auxiliary security force, and by that I mean our fire, our security, our helos, and our hospital mass casualty forces.

At about that same time after I hung up Jay received a call saying that the crash had happened on Nimitz Hill, and he went to the airport. That call was about 2:26 in the morning.

On his way to the airport he did locate the crash site. As he was going down Sprewins -- Sprewins (ph) Road to Marine Boulevard, he could see the crash below Building 200, which was the ComNav Marianas Headquarters at that time. And it was a large fire, he said, that covered a substantial part of the valley.

Immediately after receiving that call I called the commanding officer at the Naval Hospital to discuss a strategy for a medical response. The hospital always assists in mass casualty situations on the island. There are two hospitals on the island, and we help whenever we can.

The CO's line was busy, so I contacted the officer of the day and asked him to start the mass casualty response system and activate the EMTs, and hedid do that. And the EMTs were sent out of the Naval Hospital at 0240 in Mercy 1 up the hill to the accident scene.

MR. HAMMACK: Excuse me. What is Mercy 1?

THE WITNESS: Mercy 1 is the -- one of the ambulances that's stationed at the Naval Hospital. They're all labeled. Ours are all Mercys.

Okay. At the same time that I was speaking to the hospital I could hear some of the sirens on Sprewins Road from some of the emergency vehicles going towards the crash site. I couldn't tell you whether they were ambulances or fire engines, but they were emergency sirens.

At around 2:40 my command duty officer called back saying he had made all the appropriate notifications to the Navy's first responder. I then called Admiral Jansack at his house and told him we had a 747 down on Nimitz Hill.

He thought this was the exercise that we were going to be doing that day. We had a planned exercise, a no-notice exercise for a plane -- off-site plane crash and a explosion in a oil -- above-ground oil container that was -- and -- and also we were going to practice some -- some environmental work and response to a off-site crash. It was going to be a militaryplane off-site crash at 10:00 that morning. So he thought I was calling him on that, and I assured him I wasn't.

So, he proceeded over to the crash site, and I went down to the headquarters to coordinate the response from the Navy side.

When I got down there, which was around 3:00, the CDO briefed me on the situation on the hill and he also asked me if we needed volunteers. And I did say yes to the volunteers, and I asked him to have them all go to the Naval Hospital because I didn't want too many people responding on the hill because we had notified every command by that time for response for the auxiliary security force so we knew that the word was getting out.

I also asked him for a brief on what was happening on the hill because the admiral was there on the hill at the VOR site, and he told me that there were -- 25 to 30 survivors at the crash site; the conditions at the crash site was that it was in a isolated valley, in the Fonte Valley; the area was covered with a light jungle canopy, which means it's tall sword grass, sword brush, small trees; and they had very steep hills and a rugged terrain leading down to the crash site. It was really dark and extremelymuddy, and there was a light rain falling.

Okay. He also said there was quite a bit of smoke and that some small fires continued to burn in the main cabin and around the wings. The only route into the valley was the narrow road that leads to the VOR site. We also used it maintain the pipeline that was running along through the Fonte Valley.

The VOR and pipeline access road didn't go all the way to the crash site. They went alongside, so you had to go down hills that were 45 to 65 degree inclines, depending on where you were on the hill. It looks in general about a 45-degree, but there were hills that jutted out and then there were 65-degree angles down into the crash site.

The VOR site, as you saw in I think it's 16I, page number five, was above the crash site, and that was where they made the first entries from.

I was also told at that point that the plane had broken into four parts and they were -- they couldn't see where everything was in the site because it was across a little bit of an area but the tall sword grass kept their vision low and it was really dark.

I was kind of concerned about the rescue workers that we were sending up there because inprevious accidents of this sort I knew there'd be a lot of jagged metal, broken glass, and some potential health and safety hazards to our workers.

MR. HAMMACK: Captain Sprague, excuse me. That exhibit you referred to is on the screen behind you --

THE WITNESS: Okay.

MR. HAMMACK: -- if you need it.

THE WITNESS: Yeah, let me show you where --the first --

MR. HAMMACK: Can you bring that microphone around with you, please?

THE WITNESS: Okay. The first entry point was from here down to the site, and this was not --this was a build-in later. So they did come back to this entry point and try to come in this way, which was less steep, but it was still a 45-degree angle. It's also about 750 feet, 700, 800 feet from this road to the site and from this angle almost 1000 feet.

They were telling me on the phone when I was talking to them that they were basically sliding down the hill on their buttocks and they were falling into holes along the way that were filled with water and sometimes they were sinking up to their knees in the mud. It was so muddy and so messy there.

About that time I tried to call down to the Civil Defense bunker and tried to see what kind of assets Civil Defense would need but nobody answered yet at the Civil Defense bunker at that time. It was around 3:00.

At 3:30 -- well, I take that back. At 3:05 the admiral called and confirmed the situation on the hill.

At 3:30 he called me back and he was requesting helicopter support. The helicopters were already en route to the site, but I expressed some concern to him about them having the landing site in the area. And he said, "Well, we'll put 'em at the VOR landing site. We'll land 'em in that concrete area at the top of the hill there."

But my concern was also how were we going to get the people out, and I think the chief talked about that before, trying to bring 'em up the hill. They strung some ropes and stuff and tried to hoist them out, and that wasn't working and it was taking way too long, so they eventually cleared a landing site that the helicopter could land in.

They also -- it was extremely dark when they first started this maneuver. Helicopter pilots were wearing night vision goggles but the sword grass wasswaying back and forth and they couldn't really tell from the depth of the grass how far it was to the -- to the ground, so they hovered quite off, and it was causing a lot of the smoke and stuff to move around on the site.

We were trying to get ambulances to the site, and he had requested ambulance and lighting. I called the Navy OOD around 3:35, and they said -- I asked 'em to send an ambulance bus up. And about 15 minutes later I checked on the bus and it hadn't gotten there yet, so we tried to figure out what was wrong. And we called down to the dispatch center at the hospital, and they told us they couldn't get past a pipeline that had been dragged across the road and that there was also congestion in that area.

But the real problem was that the road is so narrow. It's 10 feet wide and each shoulder was around seven to seven and a half feet wide, and they were pretty muddy. And so, if I can show you on 16I, page two, I think it is, the one where we have the pipeline.

(Pause)

THE WITNESS: The pipeline came across here. Actually, the break measured about 21 feet, and so if you consider seven feet on that side and 10 foot, and then it still came across into that extra muddyshoulder -- shoulder on this side. There was a lot of congestion here, but these cars were parked along the edge from what I understand and they may have had, maybe, one wheel on the pavement. But they were pulled off to the side. It -- a small car had pulled up next to the fire engine to try to help maneuver the fire engine, which when it tried to pass over this way, that's Fire Engine #7, got stuck in its -- up to its axles in mud. So, effectively there was no getting by there except for get out of your vehicle and walk up the hill.

Now, eventually we sent a dozer up. Let me get the times.

(Pause)

THE WITNESS: I was -- I was told that the dozer was en route around 4:10, and the dozer got in. And there wasn't any problem getting to the pipeline and helped with the -- with the other people who were trying to do that, to move the pipeline. They told me that the pipeline had been secured at 4:47, and there was no impediment to traffic after that time.

Let me go back a little bit. We weren't able to reach Mr. Rosario for this whole time so we were just sending assets that we thought he might need at the site, which was basically fire security, helos, andmedical care. He also -- we knew he would be or somebody would be at the controlling entrance into the site and they would only take the types of emergency care that they wanted because we always function in an assistant role to the civil authorities. We -- even though there was some discussion about us taking over, our role is to assist the civil authorities.

Anyway, around 3:15 we talked to the command center at Anderson and they were sending down their fire chief to the accident site, and he was going to try to bring some phone capability with him. But it still seemed like it was going to be pretty tough because there was no access into that crash site, and what access we had was through steep inclines.

Communications was a little tough, but it was -- it was easily workable if you knew how to call the dispatcher and ask the dispatcher to talk to the person in the emergency vehicle or the -- another person on the radio to figure out what's -- what was going on. The problem is that our dispatchers -- I could talk to the Navy dispatchers but I couldn't talk at all times to the -- the Guam dispatchers. But our dispatchers were feeding back information from the hill from our people, and I was also receiving calls from Admiral Jansack and another person, Commander Laner.

When this pipeline broke, it spilled about 1000 gallons of crude oil, and so we were also concerned about the environmental and the Fonte River. And -- and there was also fuel spilling from the plane, and so we were concerned about that 'cause it was basically covering fuel over the entire site. And I was concerned about our rescue workers and the possibility of the fire catching there since that was jet fuel. We were real lucky that didn't happen. There were some small fires. I got a call about a -- a explosion that made a lot of people nervous, but then they called me back and said nothing -- nobody was injured, it just shook up a bunch of people but they were working.

Then around 7:00 Admiral Jansack called and said that they had found the black boxes and he gave 'em to the ATF person and they were sent off.

We took out 19 people by helicopter, and the rest went out by ambulance from the site. And the last survivors were taken from the aircraft at 7:20. They were in the tail section, and they were lifted out of the crash site by helicopter at 7:42.

The first helicopters arrived at the hospital around 5:00 in the morning at the Naval Hospital, and the final two survivors arrived there just before 8:00at the Naval Hospital.

We -- we did continue to search 'cause we took the auxiliary security force and asked them to do a grid search of the area to make sure that none of the survivors had wandered off or gone into the -- or fallen in the valley or anything. We also had EOD and SEALs working on stopping the environmental contamination to the Fonte River, and they were using rappelling ropes to put down oil blooms but they were also looking to see if any survivors had wandered over the side of the hill or anything so that we could make sure that we had everybody.

We continued that grid search until about 16:45 in the afternoon of the 6th, and we found no survivors after the 7:20 survivors were found in the tail.

MR. HAMMACK: Thank you.

THE WITNESS: Okay.

MR. HAMMACK: But you're -- you're no longer at Guam. Everybody's mentioned some communications problem. Is it your understanding as well that they're being taken care of on the Navy's side?

THE WITNESS: Actually, before I left we had talked to the Air Force about using a 400 megahertz capability because they had not used their fullcapability but helping us work out an emergency communications system on the island between the Government of Guam and the Federal agencies so that we could all talk in these types of emergencies.

And I believe that the Air Force -- as a matter of fact, before I left the Air Force gave us a commitment that they would let us use that excess capacity. I don't know if the Navy's bought the equip -- proper equipment yet. I know that we had asked for a study to be done before I left and to get the right kind of equipment so that we could talk with Guam on the same channels in these -- in these situations.

MR. HAMMACK: One more item for clarification, and I'd like to hear it from you because you're sort of an independent voice. I've heard discussion that those police cars you referred to out by the severed pipeline caused some sort of access problem. Am I correct in understanding you that once -- even with those cars there, once that pipeline was moved access was not a problem at that point?

THE WITNESS: When the pipeline was moved and secured to the side, which was around 4:45, the access was wide open. There was not -- there was not an issue. The congestion prior to that -- prior to thebeing -- pipeline being removed was caused by the pipeline being completely across the road.

MR. HAMMACK: Mr. Chairman, that's all I have.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: No questions. Thank you.

CHAIRMAN FRANCIS: Barton?

MR. E. MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: No questions, Mr. Chairman. Thank you.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Thank you. No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Mr. Donner?

MR. DONNER: No questions, sir. Thank you.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: No questions, sir.

MR. SCHLEEDE: Yes, Captain Sprague, I just wanted to ask a similar question to a -- that I hadasked of the other witnesses regarding the search and rescue, and that has to do with the issue of command and control transfer from the Gov Guam to the Navy and whether, from your perspective, that created a problem or any -- affected the outcome of the overall disaster response?

THE WITNESS: It did not affect the outcome of the overall disaster response. As a matter of fact, the admiral was working with the people at the crash site. He was at the VOR site and he was working with the people at the actual crash site and trying to convey the -- via cell phone to the Navy side what assets were needed on the hill. So there was an integral mix before the change of command on the hill, and he called me about 8:04 and said that -- that they were going to start the process of turnover, and I don't think they finalized that process till about 11:00. But the last survivor had already been found and transported before that took effect.

MR. SCHLEEDE: This issue of change of control, was that addressed in your after-action report as something that needed to be improved?

THE WITNESS: Well, yes, sir. There was some -- probably some misunderstandings at the time, but military can never be in command of an -- of a civilianaccident site unless the site has already been turned over to the NTSB and we're augmenting and supporting the NTSB. So in all practicality the civilians have command and control of the site and we assist them, and then when the NTSB comes to the site then we assist the NTSB. And the only time we would be in command and control of -- of the military would be if it was on a military air space.

MR. SCHLEEDE: Thank you very much.

THE WITNESS: Okay.

CHAIRMAN FRANCIS: Thank you very much for coming from your new job. I hope that wasn't an inconvenience or --

THE WITNESS: No, sir --

CHAIRMAN FRANCIS: -- hardship for you to have to come to Hawaii, but we -- we appreciate your contribution.

THE WITNESS: Yes, sir.

CHAIRMAN FRANCIS: Well, thank you very much.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: All right. We'll -- we'll reconvene tomorrow morning at 8:00. 8:00. By Mr. Feith's watch that will be 7:58.

(Whereupon, the proceedings were adjourned, to reconvene at 8:00 a.m., Thursday, March 26, 1998.)

Thursday March 26, 1998[edit]

http://www.ntsb.gov/events/kal801/trans_980326.htm

NATIONAL TRANSPORTATION SAFETY BOARD

THE INVESTIGATION OF KOREAN AIR FLIGHT 801, B-747-300, AGANA, GUAM AUGUST 6, 1997

Ballroom A and B Hawaii Convention Center 1833 Kalakaua Avenue Honolulu, Hawaii 96815 Thursday, March 26th, 1998 8:00 a.m.

NTSB Board of Inquiry Members

HONORABLE ROBERT T. FRANCIS, Chairman RONALD L. SCHLEEDE BEN BERMAN MONTY MONTGOMERY PAT CARISEO

Technical Panel Members

GREGORY FEITH PAUL MISENCIK MALCOLM BRENNER GARY HAMMACK GREGORY PHILLIPS CHARLES PEREIRA RICHARD WENTWORTH SCOTT DUNHAM

Public Information Officer

PAUL SCHLAMM

General Counsel

DAVID BASS, ESQ.

Parties to the Hearing

FEDERAL AVIATION ADMINISTRATION AAI-100 800 Independence Avenue, SW Washington, D.C. 20591

BOEING COMMERCIAL AIRPLANE GROUP MS 67-PR 535 Garden Avenue, North Renton, Washington 98055

KOREAN AIR COMPANY LTD. Kang seo Ku Kong hng Dong #351 Korean Air Building Seoul, Korea

NATIONAL AIR TRAFFIC CONTROLLERS ASSOCIATION 1341 North Camino De Juan Tucson, Arizona 85745

BARTON ATC INTERNATIONAL INC. Barton/Serco Management Services, Inc. 20 East Clementon Road Gibbsboro, New Jersey 08026

GOVERNMENT OF GUAM Governor's Office P.O. Box 2950 Agana, Guam 96932 A G E N D A AGENDA ITEM

Testimony of Nelson Spohnheimer National Resource Engineer for Navigation Federal Aviation Administration Renton, Washington

Testimony of Captain Paul Woodburn British Airways Chairman, ICAO, CFIT Steering Committee London, England

Testimony of Donald Bateman Chief Engineer, Flight Safety Systems Allied Signal, Inc. Redmond, Washington

Testimony of William Henderson Manager Western Flight Procedures Development Branch FAA Western Pacific Regional Office Los Angeles, California

Testimony of James Terpstra Senior Corporate Vice President Flight Information Technology and External Affair Jeppesen Sanderson, Inc. Englewood, Colorado

Testimony of Captain Wallace Roberts Former Chairman, ALPA CHIPS Committee Air Line Pilots Association (ALPA) Herndon, Virginia Conclusion

P R O C E E D I N G S 8:00 a.m.

CHAIRMAN FRANCIS: Mr. Feith's watch indicates that it's now 8:00. So, I think we'll get started, and hopefully with an eye on making certain that we do our usual comprehensive job. If we can move along, maybe we won't still be here at late in the day this afternoon.

Our first witness is Nelson Spohnheimer, National Resource Engineer for Navigation at the FAA in Renton, Washington.

Whereupon,

NELSON SPOHNHEIMER

having been first duly sworn, was called as a witness herein and was examined and testified as follows:

TESTIMONY OF NELSON SPOHNHEIMER NATIONAL RESOURCE ENGINEER FOR NAVIGATION FEDERAL AVIATION ADMINISTRATION RENTON, WASHINGTON

MR. SCHLEEDE: Please give us your full name and business address for the record.

THE WITNESS: Yes. Good morning. My name is Levi Nelson Spohnheimer. I work for the FAA at the Northwest Mountain Region Headquarters in Seattle, 1601 Lind Avenue, SW, Renton, Washington 98055.

MR. SCHLEEDE: Thank you. And what is your position at the FAA?

THE WITNESS: Well, my title is National Resource Engineer for Navigation, which -- which means that I work on a wide variety of technical topics related to all kinds of ground-based navigational aids and their flight testing.

MR. SCHLEEDE: Would you give us a brief summary of your education, training and experience that qualifies you for this position?

THE WITNESS: Surely. I have an electrical engineering degree from Iowa State University. I worked for about six years in industry for Texas Instruments and Motorola as a radio frequency design engineer. During that time, I became system engineer on an instrument landing systems contract, and as a result, I joined the FAA. I've been working on ground-based nav aids of all types for about 24 years.

MR. SCHLEEDE: Thank you very much.

Mr. Phillips will proceed.

MR. PHILLIPS: Good morning, Mr. Spohnheimer.

THE WITNESS: Good morning.

MR. PHILLIPS: Have you had any accident investigation experience in your career?

THE WITNESS: Well, yes, I have. I'm -- I'm the Northwest Mountain Region accident representative for airway facilities, and I work on various national accidents, typically those having navigation issues.

I've worked on the litigation of a number of cases, and I've served on the Air Force Board for the Bosnia accident.

MR. PHILLIPS: Okay. Most of your experience then has dealt with the ground-based side of the equipment?

THE WITNESS: In general, that's correct. I -- I spent a lot of time with the airborne flight testing organization, but most of my work is on the ground equipment.

MR. PHILLIPS: Could you describe a typical work day for yourself?

THE WITNESS: Well, fortunately, it varies quite a lot. I travel extensively, about 40 weeks a year. So, each week is different. But in a given month or two period, I might teach a technical class or seminar, do some trouble-shooting work on signal and space problems with ground-based nav aids, visit two or three companies who have applied for FAA approval for their nav aids equipment, write some technical papers.

I serve on a couple international civil aviation organization committees that deal with standards and testing of ground-based nav aids.

MR. PHILLIPS: Okay. Have you been present the last two days during the testimony in the hearing, and are you familiar with the issues in this hearing?

THE WITNESS: Yes, I have, and I am.

MR. PHILLIPS: Okay. And specifically, I realize that your expertise covers a lot of areas, I'd like to address my questioning today in the areas of the instrument landing systems, and along those lines, I'd like to ask you just a few questions about what is an ILS. Let's lay a little foundation for what is an instrument landing system, how does it work. Go ahead.

THE WITNESS: Okay. An instrument landing system is a ground-based electronics system composed of about six subsystems that provide lateral and vertical guidance and fixes or rough knowledge of position to the pilot along the approach path to an airport.

MR. PHILLIPS: Would you -- would we like to go ahead and put up Page 6 of Exhibit 9-E, Teddy? Would this help in your discussion?

THE WITNESS: Well, yes, thank you. This is the simplified but sufficient diagram of the nature of the needle indications that are provided to a pilot while flying an instrument landing system approach.

The needle, as you can see in the bottom right-hand corner of the -- of the picture or the indicator, rather, consists of two needles, a fly right/fly left and a fly up/fly down, and the antenna system on the ground is arranged in such a way that these needles deflect proportionately more and more as the aircraft departs more and more from the desired course or glide path.

The system operates by transmitting two tones, much like two notes on the piano, and these tones are arranged to be equal in signal strength on the desired path, and -- and as the airplane moves from the desired path, the two tones become unequal in magnitude, and -- and it is that inequality that moves the needles on the cockpit indicator.

MR. PHILLIPS: Is this -- is this the standard ILS system used around the world? Are there any differences in the design?

THE WITNESS: No. This -- this basic character is -- has been standardized worldwide for nearly 50 years.

MR. PHILLIPS: Okay. Speaking of standards, are there technical standards that dictate the design requirements for ILS components?

THE WITNESS: Yes, there are a number. Internationally, the signal and space is defined by the International Civil Aviation Organization in a document called "Annex 10". The standards -- the standards are listed in the manner that define very fully the signal and space characteristics.

Receivers, which must use that signal and space, have their characteristics defined by, in general, two organizations, RTCA in the U.S., which is the Radio Technical Commission for Aeronautics, and a European equivalent called Eurocae, E-U-R-O-C-A-E. These bodies are -- are consortiums of manufacturers in general and regulatory agencies, and their standards define how the receiver will react to the signal and space that's defined by ICAO.

MR. PHILLIPS: Okay. Do the FAA requirements require these standards to be met before they're installed on airplane or ground-based equipment?

THE WITNESS: Yes. For -- for most operations, certainly air carrier operations, the -- the receivers must meet what's called a technical standard order, a TSO, which FAA publishes. It provides a regulatory trail to the RTCA standards in most cases. So that an approved installation on an airplane of an instrument landing system receiver must meet the applicable RTCA document.

MR. PHILLIPS: How long have instrument landing systems been in use?

THE WITNESS: Difficult to say precisely, but the early development occurred roughly at the beginning of World War II, and the system that we know today was pretty well standardized by the end of World War II.

MR. PHILLIPS: Okay. Have there been enhancements or improvements over the years into that system?

THE WITNESS: Well, yes, on the ground side. Although the basic signal generation system has been pretty much standard, the antenna systems that attempt to keep the signal of high quality, straight, with no variations along the approach path, have had to get more and more advanced due to the encroachment of hangars and other reflecting sources on or near airports.

So, in -- in the main, the science of instrument landing systems is the science of antenna systems on the ground side.

On the airborne side, of course, as we went from tubes to transistors to integrated circuits and now software-based or receivers that contain software, there's a continual advancement in the performance, but the general description and the general way in which all ground and airborne systems behave has remained unchanged.

MR. PHILLIPS: In regards to some of the RTCA standards that control the design or specify the design for this equipment, specifically DO-131, 132, 192 and 195, can you elaborate on -- on your opinion or assessment of the differences in these standards over the years?

THE WITNESS: Surely. Two of those were published in 1978 and defined how localizer and glide scope receivers should behave, and the other two were published in the mid-'80s, I think 1986, and were updates to address the changing environment in which aircraft operate.

For example, the occasion of other transmitters, paging systems, cellular radio systems, tv systems and so on has meant that receivers have to be able to operate in more and more demanding environments. As these installations encroach around airports, the frequency congestion gets higher.

So, one of the areas about receiver design that has received a lot of attention in the last four or five years is increased immunity to such out-of-band signals, and, of course, the software is a new -- relatively new change in airborne equipment, and one of the more recent updates deals with software quality assurance.

MR. PHILLIPS: Okay. Are you aware of any accidents or incidents where ILS system components, ground-based side, because of your experience, have been an issue?

THE WITNESS: No, I'm not. I have worked on a number of lawsuit cases as a witness, and to my knowledge, no instrument landing system has been found causative for an accident.

MR. PHILLIPS: You heard the testimony, I believe, in the beginning day of the hearing, the crew of Korean Air Flight 801 commented several times about a glide scope signal or at least the glide scope flag, glide scope operation, when the -- we know -- we know that the glide scope equipment wasn't present at the time, the transmitter.

Would you like to comment on that in general terms?

THE WITNESS: Well, yes. As you say, the -- the intended glide scope signal had been removed for service to replace its shelter and was out of service for about a month prior to and after the accident.

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, and one has to assume that these remarks had to do with the presence or absence of flags.

There are enough remarks in the record that I have to conclude that there must have been some sort of flag activity coming into view, disappearing from view, some time during the approach.

MR. PHILLIPS: Is that unusual in lieu of the fact that we know no transmitter was present?

THE WITNESS: Well, no. When we have an empty channel, many of these potential external sources of noise and unintended signals, which are normally too weak to be heard, can be heard, and it's fairly common when we test airborne flight tests, instrument landing systems, and we turn off the localizer or the glide scope that -- that we record on our instrumentation intermittent indications of flag and needle activity, and as a result, the aviation community relies on notices to airmen as a procedural means to advise everyone that the channel is empty.

MR. PHILLIPS: Would you expect these -- this flag movement to cover a time period that would indicate to a crew that the signal may be valid?

THE WITNESS: Well, no. The typical case of finding some sort of activity on instrumentation is very short duration, intermittent, and -- and pilots usually refer to these brief movements of the flag as flag pops.

For a crew or a pilot to conclude that a signal is on the air and flyable would probably require the flag to remain in a static condition for 10 or more seconds perhaps.

MR. PHILLIPS: Is there any indication in your mind in the transcript, the CVR transcript, to indicate that the length of time these flags may or may not have been in view?

THE WITNESS: Well, the -- the individual comments, of course, do not convey much information about the duration of any flag activity, but I would conclude that there must have been enough absence of flag for the crew to occasionally decide that the system was on the air when in fact it wasn't.

MR. PHILLIPS: If the flag moved out of view, would you have expected to see a needle deflection of any sort, a fly-up or fly-down positional command?

THE WITNESS: Well, on an empty channel, that's very statistically hard to determine. The nature of the various interference or noises, electrical noises, that might cause the flag to move is pretty random, and, so, some of those will cause a quick deflection of the needle, returning it to zero. Others might deflect a needle for a short time. It is quite random in the general case.

We have many recordings from our flight test organization that shows what most people would call erratic needle movement.

MR. PHILLIPS: Can you elaborate a little on the flight test of an ILS system? What's done, and the frequency, and --

THE WITNESS: Yes. In the U.S., instrument landing systems are flight-inspected on a periodic basis. The -- the period ranges from a few months to about 10 months at the maximum.

During each of these flight tests, the alignment of the localizer and the glide path, the amount of needle deflections when the aircraft is off the path, and the actions of the ground-based monitoring system that removes the signal from service when it exceeds certain standards, are all tested and recordings are made. Every other flight inspection is a brief one, might take 30 to 45 minutes. The alternative flight inspections typically take several hours.

MR. PHILLIPS: These flight inspections are conducted with specially-instrumented aircraft or ground-based or --

THE WITNESS: That's correct. I'm speaking about the airborne testing. The aircraft are equipped with quite a lot of unusual avionics and recording capability that provide engineering quality measurements of the signal characteristics.

MR. PHILLIPS: Okay. Could you address flight testing at the Guam Airport; specifically, the post-accident testing that may have been conducted on the system?

THE WITNESS: Yes. We -- we, of course, have a policy that after accidents, any ground-based navigational aids that may have been involved are -- are flight tested as quickly as feasible after the accident, and, so, of course, there was a flight test of those components of the ILS that were in service at the time of the accident, and everything was found normal.

MR. PHILLIPS: Okay. Back to an earlier discussion of the ILS system, we didn't talk about the marker beacons. Would you give us a general description of what a marker beacon is, and what it is to an instrument approach?

THE WITNESS: Surely. A marker beacon is a small and fairly simple ground-based transmitter system that transmits an upward-directed antenna pattern through which the airplane flies on the approach. It causes a separate receiver in the aircraft to light a particular light, different-colored lights, for the different markers that are usually installed on an approach.

The outer marker, inner marker, and middle marker would be the full complement for a high-precision landing system. Each one has a separate light on the instrument panel. So, for about five to 15 seconds, as the aircraft flies through the antenna pattern of each marker station, the associated light will illuminate.

MR. PHILLIPS: Testing of the marker beacons is a part of the flight check?

THE WITNESS: That's correct. The -- the lineal distance along the flight path, the time for which the light is illuminated, is tested and set to a specific value.

MR. PHILLIPS: Is there anything to alert the ground control tower or ATC specialist that a marker beacon system is inoperative?

THE WITNESS: That varies with the installation. In the general case, in the U.S., we do remotely monitor the status, on-air/off-air status of -- of all the components of an instrument landing system.

Certainly for Category 2 and Category 3 higher-precision systems, that is a requirement. For Category 1 systems, such as at Guam, it's not uncommon for the outer marker and sometimes the middle marker to not have remote monitoring because the absence of -- because of the absence of communications lines, phone lines, being available to remote this indication to air traffic control.

So, at Guam, the outer marker is not monitored. The remote status is not monitored.

MR. PHILLIPS: Would -- would you consider an inoperative marker beacon -- would the ILS be operational with an inoperative marker beacon?

THE WITNESS: Yes, in most all cases. It depends upon the design of the instrument approach procedure, but in the general case, the outer marker absence can be substituted with DME or radar vectoring or a compass locator.

So, it's fairly uncommon that the absence of the outer marker eliminates an instrument approach, an ILS approach.

MR. PHILLIPS: Okay. Backtracking just a little bit on your comments about flag pops, do you -- in your view, in your opinion, do you believe that there's -- there's appropriate FAA guidance regarding flag movement on empty channels, I guess specifically in regards to the airman's information manual and flight training practices?

THE WITNESS: Well, I think so. The -- the airman information manual, of course, describes the situation of navigational aids that are off the air. For example, in the U.S., we have perhaps in round numbers 100 instrument landing system approaches which are based on a localizer-only installation. No glide scope has ever been installed.

So, it is common that pilots have to deal with either a glide scope that's been installed being temporarily out of service, or a glide scope that was never installed presenting an empty channel to every -- every airplane on approach, and therefore the aviation community again, as I said earlier, relies on procedural methods, such as notices to airmen and ATIS announcements, to advise pilots that -- that a particular navigational aid is out of service.

MR. PHILLIPS: If a crew was advised that the glide scope was unusable, do you believe that there's any duration of signal long enough to decide that the approach to the glide scope would be flyable?

THE WITNESS: I'm sorry. Would you perhaps restate that?

MR. PHILLIPS: In your understanding of -- of the instructions to the flight crews in the airmen's information manual, is there any period of time -- if

-- if the approach was -- the glide scope was inoperative or unusable, would there be any duration of flag out of view that would be considered enough to consider the -- the source valid?

THE WITNESS: I guess I'll have to assume that you mean if there's a -- if it's announced that the system is --

MR. PHILLIPS: Yes.

THE WITNESS: -- unusable?

MR. PHILLIPS: Yes.

THE WITNESS: Well, if it's announced, and a notice to airmen has been issued, then I think it's quite clear that no period of flag activity, present or absent, warrants use of the navigation signal.

One reason this must be the case is that even though a glide scope or a localizer may be radiating during periods of ground maintenance, we're required to issue a notice to airmen, and during a period that may last for several hours, the system may radiate signals that appear normal, signals that may be flawed.

The various sorts of testing that must be done on a routine basis for ground maintenance result in signals which, from the pilot's point of view, may appear to be valid. A flag would be out of view. A needle would be deflecting in either normal or abnormal methods or manners, however, and therefore the -- the procedural method of advising the pilot not to use the indications is -- is critical.

CHAIRMAN FRANCIS: Greg, could I interject a question here?

MR. PHILLIPS: Sure.

CHAIRMAN FRANCIS: In a situation where you have a glide scope, a fully-operative ILS system, I assume that the glide scope is subjected to remote maintenance monitoring of some sort that you've got the --

THE WITNESS: That's correct. I think you're perhaps referring to what we call integrity monitoring.

CHAIRMAN FRANCIS: I'm dated.

THE WITNESS: There are -- there are three types of monitoring. One is physically present at the transmitter site, and that integrity monitor will turn the transmitter off any time the signals exceed the international standards.

CHAIRMAN FRANCIS: And when that happens, how does the FAA deal with notification of the pilot community?

THE WITNESS: Well, we issue a NOTAM, a notice to airmen, as soon as we're aware that the system is off the air.

CHAIRMAN FRANCIS: And then ATIS and ATC will --

THE WITNESS: That's correct. Depending on the airport, within a short time, -- well, air traffic control will verbally announce to every arriving pilot until such time as the NOTAM or the ATIS recording has been made accurate.

CHAIRMAN FRANCIS: I think that Mr. Phillips' questioning on this, how do you -- how do you make certain that pilots are sensitive to the fact that when they're getting the NOTAM, the controller clearance or whatever it is, that they must ignore any flag activity in the cockpit is -- is one that it certainly would be interesting for the FAA and the international community to pursue, how in training, in the AIM or wherever it is, that -- that we -- we emphasize that enough so that you at least minimize the distraction factor.

THE WITNESS: Certainly. The airmen's information manual and -- and ground school in the general case addresses these issues, although I don't have any oversight knowledge about how -- how thorough that is.

CHAIRMAN FRANCIS: Okay.

MR. PHILLIPS: As part of this flight testing and ground testing of the equipment, are the FAA technicians who perform these tests and review them specially trained or certified?

THE WITNESS: Yes. The ground technicians who maintain an instrument landing system must earn certification credentials by attending a theory class or -- or taking a bypass examination, receiving some on-the-job training, and demonstrating proficiency in a performance examination administered by someone who is already certified, and once the credentials are earned and an assignment to maintain a facility is made, then the national ILS maintenance handbook defines the types of tests, the periods for the tests, the frequency, in general provides the guidance necessary for the technician to periodically test and make a judgment that the system is safe to leave in operation.

MR. PHILLIPS: I'd like to go back to the area of needle movements and flag pops and the potential for those kinds of activities.

Can you describe some of the signals that would potentially cause the flag to move or the needle to deflect, the source of the signal?

THE WITNESS: Okay. Certainly. I mentioned that the -- that the ILS operates by transmitting two tones, and the difference in the signal strength of those tones is what deflects the, in the case of a glide scope, the fly-up and fly-down needle.

So, that means that the receiver has some circuits in it which are looking for those two particular tones, filters that --

MR. PHILLIPS: Would this be a good point to put up Exhibit 9-G?

THE WITNESS: Perhaps, --

MR. PHILLIPS: This was --

THE WITNESS: -- if that's the --

MR. PHILLIPS: Yeah. That's the --

THE WITNESS: -- diagram.

MR. PHILLIPS: -- schematic. For the benefit of the tables, this exhibit was added this morning. It's a one-page aid.

THE WITNESS: Yes. This is a diagram of -- at the most basic level of an ILS receiver on the top half of the -- of the view there.

The filters in the top center labeled 90 and 150 are those filters that are looking for these two particular tones that deflect the needle, and the large circle labeled CDI, course deviation indicator, in the case of a glide scope, for example, is the needle that -- is the meter that the pilots look at, the fly-up and fly-down indication.

So, the fly-up/fly-down needle is an indication of the difference in strength of those two tones, and the difference will be zero, and the needle will be centered when the two tones are equal, and as I mentioned earlier, we -- we go to great lengths to arrange the antenna system on the ground so that those signals are equal at the three-degree glide path.

Now the flag circuit, the other indication that the pilot sees, is driven by a signal which is the sum of the two circuits or the two signals. As long as the 90 and 150 signals are both present at sufficient strength, the flag will remain out of view.

So, the pilot looks at a different signal, which is the fly-up/fly-down, and at a sum signal, although he probably is not aware that it's a sum signal, that activates the flag.

MR. PHILLIPS: Now I -- the localizer works in the same manner as the glide scope, just turned off axis?

THE WITNESS: That's correct. On a different channel, we transmit the same two tones with an antenna system that assures that the tones are equal in signal strength on the runway extended center line, and that drives another needle which has fly-right and fly-left movement, and that needle stays centered again when the two tones are equal in strength, and a separate flag for the localizer is driven by the sum of those two circuits or two signals.

MR. PHILLIPS: So, then when a flight crew dials in a frequency for the instrument approach, they're actually tuning two frequencies?

THE WITNESS: That's correct. The -- the published frequency of the instrument landing system, for example, 110.3, is that of the localizer. The glide scope is paired in a pre-defined way so that the pilot need not also specify this second frequency, but two receivers are being set up on two different channels by that one action of setting 110.3.

MR. PHILLIPS: I see on the bottom of your chart, you have two -- two peaks there that say filter response versus frequency. Would you like to discuss that?

THE WITNESS: Well, yes. Because you asked earlier about what sort of signals could cause the flag in particular to move, we have to know a little bit about the filters that drive that flag circuit.

The bottom figure shows in a general sense how the output of the filters varies for a constant input signal of differing frequencies. To use my two notes on a piano analogy, if you were to play five or six notes on the piano centered around the 90 hertz frequency, only the one that corresponded to 90 would produce, say, a one-volt output of the filter, and as you played other notes at the same level of volume, because they're not at 90 hertz, not at the center of that frequency response for the filter, less and less of the equal -- equal amplitude input signal would be output.

So, as long as the ground station transmits only 90 and only 150 signals, these filters, the 90 and 150 filters that feed the fly-up and fly-down needle and the flag circuits, output equal amplitude signals when the airplane is on course and on path.

If the channel were empty, no ground station transmitting, no intended ground station, and some other signal, for example, a two-way radio with someone speaking on it, should somehow get through the frequency-determining circuits, then those portions of the signal that contain 90 and 150 tones, those portions of the voice, for example, or a music program would still get through those filters and could cause the -- the two needles, the sum and difference needles, to deflect in brief ways.

My voice, for example, contains 90 and 150 hertz components. Music contains frequencies in those ranges. So, depending on the shape of the filters response, which varies from receiver to receiver and from manufacturer to manufacturer, the flag and cross-blender circuits would see varying amounts of intermittent deflections, depending on the content of this spurious signal. As long as it contains 90 and 150 components or frequencies close to them, there's a potential that the needles will deflect.

MR. PHILLIPS: So, then would the -- using that discussion, would the most effective filter be one that had the steepest slope about 90 and 150 hertz points?

THE WITNESS: Yes. When -- when -- when you build the filter for any purpose, you want it to be as selective as possible or as reasonable. The two general curves that I've drawn there are somewhat typical. As -- as technology improves and costs of circuits get lower, it's more common to see narrower and narrower response curves. So that only frequencies very close to 90 and very close to 150 get through to the sum and difference indicators.

MR. PHILLIPS: Then would the effect of this be fewer erratic needle movements and flag movements?

THE WITNESS: That's -- that's correct. In the general sense, the -- the newer the receiver, the sharper the filters, the less often a pilot would see short duration flag pops and needle movements from an empty channel.

MR. PHILLIPS: Assuming we had an empty channel, if we had an intermittent flag, what would the needle be doing or what -- what would you expect it to be doing?

THE WITNESS: Well, for the flag to move, that means that the sum of the output of the two filters has to exceed some threshold that's been previously set.

The flag, of course, cannot tell whether the output from the 90 filter or the 150 filter or both are contributing to the signal that moves the flag. So, it's not possible to say in the general case whether the CDI will stay centered in the case of equal amounts of 90 and 150 or deflect up or down or right or left.

If the external undesired signal was composed of music, for example, the base notes in the music would vary. They wouldn't always be 90 or 150, and therefore if there were enough signal getting through the filters to move the flag, sometimes the needle would deflect up or right, sometimes it would deflect down or left. It's just very difficult to say.

But in the general case, it's random because voice and music and most signals that are transmitted by radio systems do not have 90 and 150 as an intended information source, and therefore those components that happen to be at 90 and 150 are time-variant.

CHAIRMAN FRANCIS: Could I interject a question here? If it's possible, could you characterize the relative sophistication or modern -- how modern the -- the receiver in KAL-801 was in terms of the narrowness of peaks?

THE WITNESS: Yes. I would -- I believe -- I would say that the KAL receiver was fairly typical for recent receivers. There are newer and sharper filtered receivers available, but it is -- the filter response characteristics of that receiver are pretty common. Quite a few other models from various manufacturers have similar characteristics.

The shape of those filters is defined by something called Q, a quality factor, and to get a high-quality factor in a very narrow filter shape takes some more components or some software in the general case. Most of the manufacturers use pretty similar techniques.

As the receiver model generations change over time, the filters typically get narrower, just because it's convenient and cost-effective to make them so, but there are many receivers in service, like the KAL receivers.

MR. PHILLIPS: Okay. One step back here in your description of the deflection without an intended signal, would we need a fairly constant tone then, either a 90 or a 150 hertz range, to cause a steady needle deflection in the absence of a normal glide scope.

THE WITNESS: Yes. Whatever type of signal gets through those filters, it would have to have -- the amount that got through the 90 filter and the amount that got through the 150 filter would have to be fairly constant, so that the difference between the two is constant, and the needle would deflect to a consistent value.

MR. PHILLIPS: In looking at your example of filter response versus frequency on the bottom of the chart, it would appear that approximately halfway in between the 90 and 150 hertz frequencies, at about 120 hertz, the filters would be the least selective, is that true?

THE WITNESS: Yes, that's correct. Where those two responses cross, which can be 120 or 122, it varies a little with the model number, but it's approximately 120, a single tone of that fixed value would get through the filters equally well and would result in, if it were strong enough, a centered needle.

MR. PHILLIPS: Okay. That leads us to a discussion regarding some post-accident testing conducted by Korean Air Lines.

Have you been briefed, and are you aware of those tests and results?

THE WITNESS: Yes, I have.

MR. PHILLIPS: Okay. Would you like to summarize those or would you like me to?

THE WITNESS: I'll take a crack at it.

MR. PHILLIPS: Okay.

THE WITNESS: The Korean Air Lines test basically said what -- what type of signal could cause the flag to disappear from view and cause the CDI to remain basically centered, and -- and since all of us in the business are aware of these filter shapes, as you pointed out, if you had a signal on channel that had in this case 120 hertz modulation, a single tone, it wasn't an ILS signal but it was some other signal, and if that tone were strong enough, you notice that the response of the filters at 120 is rather low, but if the strength of the 120 signal were strong enough, the music were strong enough, the voice were strong enough, for example, then the signal that gets through both filters and is summed in the flag circuit might be sufficient to cause the flag to move.

So, they bench tested such a scenario, a signal generator with modulation of a 120 hertz, quite strong, roughly twice as strong as the typical glide scope 90 and 150 tones, and -- and found that on a variety of receivers, they were able to cause the flag to disappear from view.

Because the filters have a roughly equal response at 120, when the flag disappeared from view, the -- the cross pointer fly-up/fly-down indication was roughly centered, and it would vary from receiver to receiver because the filters are not identical at 120 in every case, but over a wide range of manufacturing choices, most of the receivers have an equal response at approximately 120.

So, -- so, they found out of six different models of receivers from several different manufacturers, four of them, those with the broader filter characteristics, would allow the flag to disappear from view, and two of them with narrower filters left the flag in view.

CHAIRMAN FRANCIS: Any indication of how long that might be -- disappear from view than the -- than the less-precise ones?

THE WITNESS: Well, of course, their tests were static with a continuous signal from a test generator, just to show that the receivers would indeed respond if such a channel -- such a signal were on channel. So, these were -- so far, I've described just bench tests.

CHAIRMAN FRANCIS: I assume we're getting to that.

MR. PHILLIPS: Yeah. Do these results surprise you in any way? Are they what you would expect?

THE WITNESS: They're what I would expect, given the nature of receiver design.

MR. PHILLIPS: Okay. Based on -- on these tests and -- and what you've seen and the testimony this week or what you've heard, do you believe that the warning flags are adequate to protect from interference or -- or spurious movement?

THE WITNESS: Well, no. This -- this type of circuit is intended to warn of failures in the ground ILS station or -- and in the receiver and -- and does not address other types of signals which may have 90 and 150 components.

Obviously any type of signal that's on channel, instead of intended ILS station, if it has the right characteristics in the audio, music and voice and so on, this type of flag circuit, which is used extensively, cannot discern the difference between the intended ILS signal and an extraneous one that has the right characteristics that last long enough.

MR. PHILLIPS: Along those lines, at an instrument landing system location, how do we design or how does the FAA protect the local environment so that those tones and frequencies are predominant?

THE WITNESS: Well, the Federal Communications Commission, which, of course, manages the spectrum in the U.S., has granted to the FAA the management of those bands of spectrum that -- on which the ILS operates.

So, in the general case, of course, we assign instrument landing systems so that any two which are on the same channel are sufficiently far apart that a single aircraft cannot receive two of them at one time.

As far as out-of-band signals go, such as paging transmitters and all sorts of personal communications devices, any time someone is going to construct a station within about four miles of an airport, we have a requirement that they notify us and obtain approval for installation of those stations.

In my region, for example, we see about 30 of these applications a week, and each one is examined for its signal strength, its frequency, its potential to affect radar systems, microwave systems, instrument landing systems, and so on.

So, in that sense, we have a regulatory control over how close and what nature of transmitters are installed close to an airport. So, as long as all of these emitters operate in the way they are intended, the -- the frequency band can be kept clear of non-ILS signals.

MR. PHILLIPS: You noted that in the way they were intended. Does that imply that there's a possibility that an unintended operation could have an effect?

THE WITNESS: Well, surely. Just like any -- anything that we own, like a car or a microwave oven, after some time, transmitters may degrade or fail in ways that cause them to transmit on incorrect frequencies or have incorrect characteristics, and when that occurs, there is a potential in -- in any radio-type system for other systems to be affected.

So, the protection of the navigation frequencies for this condition is basically a reactive one. There's no way to predict when to continue picking on the paging folks, for example. There's no way to predict when a given transmitter is going to fail in such a way that it may transmit incorrectly on frequencies other than is intended, and when we get reports from pilots or from our flight test folks of such occurrences, then we send out folks specially equipped to locate those ground stations and get them corrected.

MR. PHILLIPS: So, you're very dependent on the way the system is structured today to find the faults with the system?

THE WITNESS: That's correct. Changes in the electromagnetic environment, changes in the spectrum, changes in non-navigation systems on or near an airport are detected in general by the users. There's no present way to monitor throughout an approach, for example, the -- the cleanliness of the ILS spectrum.

MR. PHILLIPS: Does the Guam Airport area present any unique characteristics as far as ILS system approaches go?

THE WITNESS: Well, I think not. It's certainly got a lot of terrain, but we have many airports with terrain. We have -- when you have high terrain, you have hilltops and mountains which are very advantageous for other transmitting systems. People like to get their transmitters up at a high location.

So, it's fairly common that we will have AM and FM broadcast stations and various personal radio systems in and around airports and on high locations.

MR. PHILLIPS: There's a military base on the other end of the island at Guam, which operates an ILS system that's approximately aligned with the Runway 6 Left system at Agana.

Would you expect that to have any effect on the Agana, Guam, approach?

THE WITNESS: No. The -- the two ILSs that you speak of, the one at International and the one at the Air Force base, are, of course, on different channels because of the spectrum management activity that I spoke of earlier.

One of the components of assigning frequencies for ILSs is to assure that nearby ILSs are sufficiently apart on the radio dials, sufficiently apart in frequency, that common receivers can easily separate the two.

MR. PHILLIPS: Does the FAA maintain any kind of a database relative to interference or spurious signal cause and effect?

THE WITNESS: Yes. I'm a little hesitant about database. We have a logging system and a reporting system for interference cases, which may appear in some cases to look like a database, yes.

MR. PHILLIPS: Okay. Just a few closing comments here. I would be interested in your comments about future avionic systems designs relative to ILS systems, and in particular, the proliferation of electronic cockpit displays and the potential effects on the ILS systems navigation units.

Do you see a trend toward improving the margin of safety with the newer avionics versus the older designs?

THE WITNESS: Well, yes. As I mentioned earlier, it is increasingly easier and less expensive to produce better and better receivers. We've all seen how electronic systems continue to get cheaper in cost and generally have better and better performance.

So, receivers in general aboard aircraft are increasingly capable, and -- and now we are seeing a single box that has microwave landing system, instrument landing system, and global positioning system receivers all in the same space that a single receiver used to occupy.

Increasingly, with more and more software-based systems, the amount of hardware required is less. This means that the receiver itself has less complexity, less potential for failure and so on.

On the other hand, the software has the potential for failure, and, so, software quality assurance is becoming a very large component of receiver design.

The displays in aircraft are becoming more and more cathode ray tube and flat panel-based. These displays have a lot of electronics to drive them, and any electronics has a potential for generating signals. So, there's a corresponding increase in the amount of testing to ensure that on-board systems don't affect on-board receivers.

So, the standards bodies have been adding more and more tests for -- to ensure compliance that the signals emitted by circuits aboard the aircraft are not affecting aircraft receivers.

MR. PHILLIPS: And as a final question, are there active working groups in the aviation community looking at the issues of interference, spurious signals, and ILS system improvements?

THE WITNESS: Yes. Most aviation authorities have their own. For example, FAA has several, and I serve on a couple international committees which are editing and improving, updating ICAO and X-10, the document used worldwide for ground and airborne testing of nav aids and so on.

In general, to keep up with the changing environment that receivers operate in, higher and higher power broadcast stations and so on have resulted in a requirement, for example, starting very soon, that aircraft operating in international environments have to have a new receiver that's more immune to these off-channel signals.

MR. PHILLIPS: Do you expect in the future to see ILS systems replaced with another precision landing system?

THE WITNESS: Great question.

MR. PHILLIPS: My last one.

THE WITNESS: Certainly that is the general goal of most aviation authorities, is to migrate to satellite-based systems. However, there's a large portion of the avionics community that feels that at least as a back-up system, some small portion of the existing instrument landing system installation should be kept. So, I believe the technology will support moving to satellite systems.

MR. PHILLIPS: Thank you. That's all I have.

THE WITNESS: You're welcome.

CHAIRMAN FRANCIS: That's interesting. It's possible we'll get through the whole morning without talking about MLS.

I'd like to just make a comment and an observation here for those in the audience, and that is both at the NTSB and the FAA, we have what are called national resource specialists, and -- and these are people who, because of exceptional qualifications and international reputations, are designated to operate in certain areas.

It turns out that both Mr. Spohnheimer and Mr. Phillips are national resource specialists, and I think that the exchange that we've just witnessed is evidence of why they are. That really was extraordinarily interesting and informative.

Thanks to both of you.

I would now say to all of us here concerned that we would -- we would like to keep things moving along. So, let us all of us keep in mind that which has been said and try to avoid redundancy in our questions or going on longer than is necessary.

KCAB?

MR. LEE: Thank you, Chairman.

Mr. Phillips put special technical questions, and Mr. Spohnheimer gave us excellent answers, and I'd like to take this opportunity to appreciate both of you gentlemen.

Just one thing. Let me just double check. The KAL accident, the location was, as you know, --

CHAIRMAN FRANCIS: I thought he was so good that he'd be able to operate without one. Go ahead.

MR. LEE: The location of the KAL accident is Nimitt Hill, as you know. There are antennas and many other radio facilities located also in that area.

Given that, do you think in your personal view from the vantage point of a specialist, do you think all those radio facilities had any effect on the accident?

THE WITNESS: Statistically, I think it is unlikely, but it is very difficult to say with any certainty without some testing, and -- and even so, the nature of spurious signals and the failure modes that produce them means that as antenna systems change and deteriorate, the conditions change.

Certainly we have -- most airports are challenged with the same sorts of problems. I would offer in general that -- that I probably am aware of five or 10 cases in a given year of interference to an instrument landing system in the case of several hundred ILSs.

So, the occurrence is not rare, but it's perhaps in the one to five percent range.

MR. LEE: Thank you very much. That's all.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCEY: We have no questions, Mr. Chairman.

CHAIRMAN FRANCIS: Barton?

MR. EDWARD MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: Yes, sir. We do have a question.

Not to delay the process, but would you please tell us if FAA ran any kind of testing on the localizer signal, interruptions or deviations, as well as the Korean Air-run glide scope testing, bench testing of similar nature to the localizers?

THE WITNESS: I'm not aware of any bench testing on localizer receivers associated with this accident. As I did mention, we -- we flight tested the localizer in the day or two following the accident.

CAPTAIN KIM: Right. The question is referring not to flight testing but bench testing with similar set-up to verify the results as Korean Air did.

THE WITNESS: No, I'm not aware of any testing. I would expect the results to be similar, however, that -- that one could inject signals that would cause the flag to move.

CAPTAIN KIM: Okay. Thank you very much.

May I ask you one more question? So, are there any plans underway to continue testing at Guam, in specific to find out if there are any more things to be discovered regarding this accident?

THE WITNESS: I'm not aware of explicit plans, but there has -- I have been a participant in some discussions about the nature of ways we might test the Guam environment more fully.

I did request an extra airborne test just recently to make some recordings of the ILS with the glide scope off the air. That was done within the past week. It took perhaps 45 minutes. So, it is only a very short look at the nature of the spectrum at Guam with the glide scope off the air. Nothing was found on that particular check, although it was a very short one.

CHAIRMAN FRANCIS: I think Mr. Phillips might supplement that answer.

MR. PHILLIPS: Yes. I'd like to comment on that. The systems group has had discussions concerning plans, potential plans for additional site testing at Guam in an attempt to identify potential signal sources.

One of the issues you may be aware of is that after the accident, there was a typhoon passed through the island that did considerable damage to the antennas and transmitting system there.

So, we believe that the environment at Guam today is different than at the time of the accident, but nevertheless we intend to -- to set up a plan to go take a look for -- for potential spurious signals. So, that's an activity that we'll be discussing in the systems group over the next couple of months.

CAPTAIN KIM: I'm sorry to delay, but we have one more question, and we have about 30 seconds before we ask this question, Mr. Chairman.

CHAIRMAN FRANCIS: Why don't we go to the other parties, and then we'll come back to you.

CAPTAIN KIM: I apologize. Thank you.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. Just a very brief question.

Sir, do you have any opinion as to the -- any particular technical difficulties, and just in very general terms, the cost of co-locating DME facilities with the ILS transmitters?

THE WITNESS: Yes. The cost of installation is quite minor, perhaps $10,000, if there's an existing building with enough room. The equipment, DME equipment, would be perhaps $100,000.

MR. MOTE: And are there any particular technical considerations regarding such an installation?

THE WITNESS: Well, there are many, but none particularly challenging. We have many installations with localizer and DME co-located.

MR. MOTE: Thank you very much, sir. No further questions.

CHAIRMAN FRANCIS: Steve, you ready?

CAPTAIN KIM: Yes, sir. We're prepared at this time. I understand there's not conclusive evidence to continue further testing of the equipment.

In particular to the Model 51RV-5B, are there any plans underway to improve the safety performance of this equipment in particular?

THE WITNESS: I'm not aware of any, but I haven't spoken to the manufacturer recently either.

CAPTAIN KIM: But nothing will be initiated from the FAA's part to mandate any kind of further improvements on that model?

THE WITNESS: I don't know how to answer that. I -- the avionics group, which happens to be located in Seattle but a different part of the agency than myself, would -- would have to initiate some dialogue to -- to promote such a change.

I take it you mean about the flag circuits?

CAPTAIN KIM: Yes, sir. You just described the process you would -- that's how you would go about it, but are there -- do you have specific plans at this point to initiate or mandate specific improvements to that model by the FAA?

THE WITNESS: I know of none.

CAPTAIN KIM: Thank you very much.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Mr. Donner?

MR. DONNER: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: No questions, sir.

CHAIRMAN FRANCIS: Mr. Montgomery?

MR. MONTY MONTGOMERY: Thank you, Mr. Chairman. I have just a couple short ones.

Mr. Spohnheimer, for the benefit of those of us who are not as technical as our national resource specialists, when we talk about injecting signals into the -- the device to see its response to a 120 hertz, I -- I -- I hear you say things like you just somehow squirt base band information in the system, and it responds in a way that's -- that's unsatisfactory.

However, in reading the report here, I find that they actually put this on top of an 88. -- 83.75 megahertz carrier in one instance and a 355 megahertz carrier in another instance. In other words, it takes a special way of doing this in order to get those base band frequencies in there, is that correct?

THE WITNESS: That's correct. The base band frequencies, the tones that we've been speaking about, are -- are called the modulation, and the carrier is the VHF or UHF signal that a pilot would tune a control head to.

So, in all cases, when I spoke of a signal generator, that was referring to a piece of laboratory equipment that could both generate the very high frequency signal, the numbers you're referring to, and add the tones to that signal.

MR. MONTY MONTGOMERY: So, if I walked up to this piece of equipment and played my radio real loud at a 120 hertz, it's not going to have any effect?

THE WITNESS: That's correct. I'm sorry if I left you that impression. The circuits that are sensitive to audio tones, of course, there's no microphone connected. They listen to those frequency-determining circuits that I had in the block diagram, and those circuits are the ones that limit the incoming signal to radio signals in the desired band.

MR. MONTY MONTGOMERY: And the modulation type, is it FM or AM?

THE WITNESS: This is amplitude modulation.

MR. MONTY MONTGOMERY: AM. So, if I flew over an FM station playing at 10 kazillion megawatts, what effect might that have?

THE WITNESS: Well, unfortunately, it probably would, even though the receiver is intended to respond only to amplitude modulation.

When -- when an FM signal is strong enough, it can actually affect the operation of the circuits and add amplitude modulation to the signal. So, a somewhat common occurrence among the interference cases is an aircraft operating close to a mountaintop-located FM transmitter.

So, the AM receiver is not immune to FM and vice versa.

MR. MONTY MONTGOMERY: Okay. Thank you very much. Thank you, Mr. Chairman.

MR. SCHLEEDE: Yes, Mr. Spohnheimer, I just wanted to follow up on one area you mentioned about the possibility of doing some testing at Guam to look for some problems.

Do you have any recommendations for us regarding our investigation whether we should be doing additional testing or the FAA should be doing additional testing at Guam?

THE WITNESS: Well, my view is that the FAA should be involved and perhaps has an incumbent responsibility to do something out of the ordinary to assure that there are no -- no extraneous signals affecting ILS.

The difficulty with all of this testing is that if -- if an extraneous signal is due to another user or to a degraded transmitter of some sort, they're seldom continuous. They're usually intermittent, and sometimes it takes a very long time to locate something that's clearly been reported.

It's like proving a negative. You can -- you can flight test it for a week or two weeks, and if you haven't found anything, you can't say that it didn't exist. Obviously if you find something right away, then you're done, and you can go fix it.

So, I think it would be reasonable to -- to define a -- a short test program that had a definite end to it that made a diligent effort to confirm that the spectrum is clear in the area of the approach.

MR. SCHLEEDE: And would the -- would the pilots that fly in there certainly play a factor in reporting outages or -- I'm sorry, not outages, spurious signals?

THE WITNESS: Yes, they would. The sort of thing that an engineer would probably do is -- is haul some test equipment out to the area and set it up with a computer so that it logs the conditions automatically every so many minutes for -- for some hours or days, so that we have actual measurements using lab-type equipment as opposed to user complaints.

But if there were approaches being flown at the time, it would be easy to add that sort of information certainly.

MR. SCHLEEDE: Thank you very much.

CHAIRMAN FRANCIS: Mr. Berman?

MR. BERMAN: No questions.

CHAIRMAN FRANCIS: Mr. Cariseo?

MR. CARISEO: No questions.

CHAIRMAN FRANCIS: Thank you very much, sir.

THE WITNESS: You're welcome.

CHAIRMAN FRANCIS: That was a very helpful and impressive performance, and those of us that travel a bit have -- are particularly impressed by anyone who travels 40 weeks of the year, and I won't ask you about your family status.

THE WITNESS: Thank you.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: We have five witnesses left. Three of the five, including Captain Woodburn, who is the next witness, are, I think, a little unusual for an NTSB hearing, but I thought that it was interesting to -- to perhaps have a little wider perspective on some of the issues that we consider important here.

So, Captain Woodburn is a captain with British Airways. He and I worked together on a number of committees, many of which are -- are involved with the CFIT issue, and I think that he can give us a contribution in terms of the overall worldwide implications of this kind of accident, and the same will apply to Don Bateman and to Jim Terpstra.

Mr. Schleede?

MR. SCHLEEDE: Thank you, sir.

Whereupon,

CAPTAIN PAUL WOODBURN

having been first duly sworn, was called as a witness herein and was examined and testified as follows:

TESTIMONY OF CAPTAIN PAUL WOODBURN BRITISH AIRWAYS CHAIRMAN, ICAO, CFIT STEERING COMMITTEE LONDON, ENGLAND

MR. SCHLEEDE: Captain Woodburn, please give us your full name and business address for our record?

THE WITNESS: It's Captain Paul Woodburn of British Airways PLC, The Compass Center, Heathrow Airport, London, England.

MR. SCHLEEDE: And would you please, because you're called here as an expert in this field, give us a summary of your experience and training and education that qualifies you for your current position and status?

THE WITNESS: Yes, sir, I will. I've been 34 years of flying with British Airways, 25 years as a captain and currently a captain on the Boeing 777.

I also have 23 years of flight management experience, the past 12 in senior management positions.

I also have 20 years of other industry experience having served on a number of industry committees and various projects. One in particular concerns this inquiry, and that is the Flight Safety Foundation initiative commenced in 1992 into Controlled Flight Into Terrain, CFIT.

I was a founding member of the original steering team. I have served as a member of the CFIT equipment team, and I'm now currently the chairman of the steering team for the past 18 months and a member of the implementation team for both CFIT and approach and landing accident reduction.

I'm also a Fellow of the Royal Aeronautical Society and a liveryman of the Guild of Air Pilots and Air Navigators.

MR. SCHLEEDE: Thank you very much.

Dr. Brenner and Captain Misencik will question.

DR. BRENNER: Mr. Chairman, we've asked Captain Woodburn to prepare a presentation about the industry efforts. With your permission, we'd like to have him present that.

CHAIRMAN FRANCIS: Go ahead.

THE WITNESS: Mr. Chairman, ladies and gentlemen, as you are expecting, I have a short presentation here to explain, I think, the problem of CFIT so that we can all understand it and, of course, to explain the Flight Safety Foundation initiative and to discuss some of the recommendations.

CHAIRMAN FRANCIS: Paul, could I just sort of reiterate the reminder that the interpreters are trying to follow you. So, I suspect that you're going to be more easily understood by them seeing as you're speaking real English, but -- but if you could sort of modulate your speed, I think they'd appreciate it.

THE WITNESS: Okay, Mr. Chairman.

I start with a definition of CFIT. There is no internationally-agreed definition, and the one on the screen in front of you reflects the one we chose for our work in the Flight Safety Foundation.

CFIT is when a perfectly-serviceable airplane is inadvertently flown into the terrain or water.

Can I have the next slide, please? Here you can see some statistics on controlled flight into terrain, and this reflects worldwide experience. On the bottom axis are years from 1968 through to 1997, and the vertical axis are the number of accidents predominantly to jet aircraft.

Over on the left-hand side, you can see where GPWS was introduced alongside the highest peak.

CHAIRMAN FRANCIS: Could we turn the lights down a little in here so we can perhaps get a little more better look at this presentation?

THE WITNESS: And you'll see the relatively dramatic reduction thereafter.

Over on the right half of this particular visual, you can see highlighted blocks, and I would draw your attention to the two peaks that stand up there, and they reflect the years of 1988 through to 1991, and then, of course, in 1992, there is a second peak, and this appears to be a regular characteristic of CFIT data.

There is a cyclical action here. Over three to four years, there is a rise to a peak, and then it diminishes. We don't necessarily know the answer for it, but we believe it's related to industry awareness.

When it reaches a peak, there is so much media attention and awareness that there is a natural, I think, reaction to it and therefore could explain the reduction.

It was that peak in 1992, the second of those two peaks, which led to the Flight Safety Foundation starting its initiative into CFIT and approach and landing accidents.

Next slide, please. Here you can see which sort of airplanes CFIT is attached, and you can see over on the bottom left side there, there are approximately five large commercial jet accidents on average per year worldwide, and this was the data that we had in 1992.

Interestingly, you can see the impact on large turbo-prop, regional commuter turbo-prop, business jet, and business turbo-prop aircraft, and over on the right-hand side there, the business turbo-prop have an average of 23 losses per year.

Next slide, please. This particular slide just shows from 1992 in top left there the initiation of the Flight Safety Foundation initiative. That led to a commitment and then formation of teams. I was involved from that very early stage, and then, of course, the teams worked for several years, and the final working group reports were delivered towards the end of 1995.

A further year was taken refining what we now know as the CFIT Education and Training Aid, and that became available towards the end of 1996, being distributed to industry in early 1997.

So, the bottom two lines there are concerned with Flight Safety Foundation implementation team activity which continues and the application of the associated products.

Next slide, please. Why did we concentrate our attention on CFIT particularly? This is worldwide and U.S. airline fatalities classified by type of accident over a 10-year period. The highest peak on the left-hand side there are the fatalities due to CFIT.

The next highest peak is the loss of control in flight, and that's another story, and it's because this particular peak of CFIT there that there has been so much industry activity.

Next slide. Where does CFIT occur? The simple answer is worldwide. This particular slide shows western-built commercial jet transports again up through to 1997. This is just a five-year period, and this is the latest data and not the data that we saw when we started our work. But let me talk you through this.

First and foremost, in the middle, in Eastern Europe and the Middle East, the figures of zero are not really zero. They are areas where we have insufficient data.

If I can turn now to North America, and you will see an accident rate there of .03. That has been pretty stable over a long period of time at that value. But over there adjacent to it, you can see Europe at .10. In other words, three times worse than North America.

Coming down to Latin America, you can see the figure there at 1.12, and that is a figure of 37 times worse than North America. These are CFIT accident rates.

Moving across to Africa alongside, that figure there is 18 times worse, and then moving across to Asia Pacific, these figures are 23 times worse or down in Oceana, 11 times worse than North America.

They sound terrible figures, but I have to say that since we started this initiative, the worst figures that we saw before were in Africa, which were 70 times worse. So, there has been a significant improvement from 70 times to 18 times, whereas in Latin America, there has been no improvement whatsoever. That figure is still 30 times -- 37 times as bad as North America. So, this gives you a measure of the size of the worldwide problem.

Next slide, please. If we can concentrate over on that right-hand bottom corner, where it gets into 1997, if we can just move it slightly, you'll see here the same block diagram that we looked before, but what I'd like to concentrate on is that for 1996 and '97, those black boxes, they are three CFIT accidents per year for '96 and '97. All of those black boxes were non-precision approaches. In other words, five out of six accidents in those two years were on non-precision approaches.

Indeed, the accident data shows that the risk on non-precision approaches is five times greater than for conducting precision approaches.

Next slide, please. Here, we're looking at commercial jet aircraft, again a 10-year period, from '88 to '97, and this is where these accidents occur on what type of approach, and there's 38 accidents here worldwide. The very large blue block there, which is roughly half of the cheese, half of the number, were on step-down approaches.

The interesting thing is most of those had DME available. There are only three accidents there which are over at the 8:00 to 9:00 position on precision approaches, and they relate to probable glide scope receiver failure, probable failure of a flight director to capture, and also a possible autopilot not being coupled. But they're a relatively small proportion of the whole, and the interesting thing is that 70 percent of CFIT accidents occur on final approach.

Non-precision approaches generally are much more complex than precision approaches. For many pilots, they are less familiar. They are more error-prone. They require more comprehensive briefing. They need particularly careful and accurate monitoring, and it is possible for complex step-down procedures for steps to be missed or to be taken out of step. In other words, to get one step ahead of the airplane could be fatal.

Such approaches also need much more carefully-managed airplane crew and checklist management, and it is a characteristic of many CFIT accidents that they occur when the crew is pre-occupied or distracted by other tasks.

Next slide, please. Where do they occur? As I mentioned, 70 percent on final approach, and that solid red line in the middle is where most of these accidents impact the ground. They're all in line with the runway, and, fortunately, as we shall see for the next slide, you can see here an idealized three-degree glide scope in orange, red, and then these are the flight paths of many accident aircraft underneath the three-degree glide scope. In other words, following paralleling a three-degree glide scope but impacting the ground on extended center line but short of the runway.

The parallel to Agana, Guam, is obvious.

Next slide, please. The Flight Safety Foundation overall goals were to reduce the CFIT accident rate by 50 percent in five years and that's this year.

The latest data that we have available shows that this goal has actually been achieved, albeit the data is still being assembled, and I have not got it to show you today.

The second goal here was much more challenging, and if you remember those worldwide accident rates I showed you, the worst in 1992 being 70 times worse than North America, under this basis, we would be looking for a rate no worse than twice North America.

So, we've made some improvement but certainly not to the extent of this particular goal that we set ourselves.

Next paragraph. So, who was involved on this industry participation? With the Flight Safety Foundation, we brought operators, manufacturers, to some extent regulatory authorities, although I have to say that the degree of participation by regulatory authorities has been disappointing. There was very little direct involvement in any of the working groups by any of the regulatory authorities worldwide.

However, they were kept informed of what we were doing either through the Flight Safety Foundation or by direct contact. Flight Safety Foundation also represents training organizations, and we had good participation there.

Wherever the Flight Safety Foundation found another initiative already going, we combined resources, and then everything was put under the Flight Safety Foundation banner, and that brought in ICAO, IATA, IFALPA, ALPA, the ATA, and again the ATC authorities.

Like the regulatory authorities, the ATC authorities were reluctant participants, too. The interesting thing for all of this industry activity, it's not just organizations but represents hundreds of individuals who have worked with us, some of whom still work with us on this particular initiative.

ICAO is normally recognized as a body that takes five to seven years to do anything, yet it has been remarkably supportive and productive to this process. Since 1994, there's a lot that they've done as we shall see.

Next slide. So, let me just recap on CFIT. It is this inadvertent flight into terrain or water. It does cause the greatest number of fatalities. The risks on non-precision approaches are greater, and they almost always involve the breakdown of crew coordination and monitoring.

Another factor which became very strongly evident in the analysis of all of this work was that there is no single measure that we can take to prevent CFIT. It needs a range of measures suited to a particular operator and the operating environment.

There is no new single piece of equipment that can be fitted to aircraft that will make CFIT go away. Yes, it may help, but in isolation, it is not the sole cure.

Remember also that any new equipment requirement takes many years to implement across the entire industry, and in many ways, it's the areas of the world that have the least problem that will fit the equipment first, and it's those other areas of the world where the greatest problem exists that will fit it last.

Industry must therefore take action now because we can't afford to let this risk go on unaddressed.

Next slide. This ICAO requirement becomes effective on January 1st, 1999, and if you remember the earlier slide in terms of small aircraft CFIT exposure, this was aimed at applying GPWS-fitted to the smaller airplanes.

You still have to remember that there are up to 200 heavy jet aircraft flying in the world today that have no GWPS-fitted at all, even after 20+ years of requirement.

Next slide. The GPWS warning functions described here are in effect the characteristics of a Mark-2 or subsequent model of GPWS, and the effect of this rather more stringent set of requirements for ICAO is that the early Mark-1 GPWS installations will need to be replaced by Mark-2 or better.

Next slide. There are a number of other changes that are being pursued in terms of instructions and training requirement for the avoidance of CFIT. There is also the requirement being framed for a company policy on the use of GPWS. Proposals in this direction being very detailed, which is why I'm not going through them here today, were being presented to the ICAO Council only last week. We await progress reports.

Next slide. This is a whole series of future ICAO actions, and I will only mention briefly some of the things associated with these headings.

Under the licensing and training, Annex 1, the proposed changes there are mainly to do with air traffic control language, skills and proficiency with requirements for improvement by 2001.

The next one down, charting, is concerned mainly with the adoption of colored terrain all minimum safe altitude contour presentation on charts to improve their readability and understanding by flight crew, particularly in the cockpit environment at night.

Operation of aircraft, the third bullet down there, there are a whole range of things, whether they be equipment and procedures, but typical things being discussed there are prohibition of the old altimeters, things like three-pointer designs or fixed drum-pointer design of altimeters which can easily be misread. There are still many in the industry in use today.

Under equipment, there is a requirement, an extension of requirement for ACAS, pressure altitude encoding transponders, forward-looking wind shear warning systems, and others.

Under procedures, there are new requirements and new emphasis on standard operating procedures, altitude awareness procedures, including the use of standard or automated call-outs, guidance on the use of autopilot, the incorporation of stabilized approach procedures concepts, etc.

The next one down, instrument approach procedure design, under PANS-OPS, there are particular changes there applicable to non-precision approaches concerning the optimum angle, and, of course, growing interest in the application of vertical navigation, VNAV, or FMC approaches.

Under air traffic services, there are new requirements regarding radar vectoring to avoid GPWS alerts as well as emphasizing and encouraging the implementation of MSAW of which we've heard a lot on this inquiry.

The last bullet there in terms of publishing a manual on CFIT avoidance is still under consideration. Further activity with ICAO concerns the translation of the Flight Safety Foundation education and training aid into ICAO languages, the other five beyond English. We're still awaiting a time scale for that availability.

Next slide, please. So, in summary, these are the ICAO sorts of changes. There is a need to train to ensure pilot response to CFIT ground proximity warning systems and so on.

Now there are two different ways of doing this. Many operators use a technique of during normal proficiency checks, inserting what some call an imaginary or glass mountain which generates a GPWS pull-up alert unexpectedly.

The problem with that is that the pilots may have been operating perfectly normally, safely, under their proficiency check, and they then have what is a rogue warning that seems to come at them with surprise. That can be considered negative training because it causes them to mistrust their basic normal procedures.

Another way of doing it is to still show how ground proximity warning systems work but in a more creative way. I'll describe a way that I know well particularly, and I know a number of other operators use it.

Modern simulator systems have good visual displays. When operating to an airport in the simulator database, under VFR good visual conditions, in mountainous terrain, it is very easy to take a vector that puts the airplane flying towards a potential conflict with the terrain. The briefing to the crew is let it happen, see what it looks like, and don't do anything until the ground proximity warning pull-up occurs.

The pilots are then left with this situation of watching the ground approaching, eventually filling the windshield in the visual display, and still the pull-up does not occur, remembering that 15 seconds or so to impact is typical of the characteristics of such systems. It could be less or marginally more.

So, when they get to the pull-up point, they're on the edge of their seats, can't stand the sight of it, and then, of course, pull up, they do the pull-up maneuver, and hopefully, if they've done the right technique, having watched the ground approaching, they will follow the required escape maneuver. They then have this visual image of what it looks like to be that close to terrain.

The next part of the exercise is to repeat it all in a different area, different bit of terrain, but they're now IMC. They don't see the terrain at all. For you pilots out there, I can guarantee you've got that visual image with you for several years after the event of having done that exercise, and when you fly in IMC to the pull-up point, you remember what it looked like visually. You don't waste any time. You get out there very quickly indeed, and it is an aggressive maneuver needed. Gentle ones or time taken to say is this real or false is not a luxury that we can afford.

Now that type of pilot teaching, I think, is very powerful and much more meaningful to them.

So, moving on to the second bullet there in terms of updating early ground proximity warning system installations, I've covered that in terms of Mark-1s being replaced by Mark-2 or better.

The third bullet is in terms of encouraging development and application of enhanced GPWS. We also need to provide precision approach glide scope guidance whether that comes from GPS, GNSS, RNAV, and so on.

I think we all recognize the need to eliminate the step-down non-precision approaches because the accident data says we should. We also need to encourage the expansion of approach radar coverage with MSAW on a worldwide basis, not just in the few countries that presently use it, and, of course, as we saw earlier, we're fostering the equipment of smaller transports with GPWS.

Now set against that, what actions have the regulatory authorities taken? Relatively little.

Now let's turn to the next slide, and here what I've tried to do, rather than go through a detailed presentation of all of the recommendations which would be beyond, I think, the scope of this inquiry, what I've tried to do is to show some of the applicable recommendations, and then I'll talk a little bit about them.

Chart supply and presentation. One of the recommendations was that looking at the worldwide data, a factor in some of the accidents was that not all crew members have charts. If they don't have charts, how can they effectively monitor what's going on?

So, there is a requirement that all crew members should have appropriate charts, and then, of course, the charts themselves in terms of presentation should have clear depiction of terrain and be easy to read in the cockpit environment. Hence the recommendation of colored contours.

The second bullet down in terms of approach and departure briefings, again the accident record shows that many of them have a failure to conduct adequate either departure or approach briefings. The more complex the approach, the more briefing and careful rehearsal of what is needed on that approach becomes necessary.

The third bullet down, allocation of flight crew duties and the use of the monitored or, as some call it, the shared approach procedure. An analysis of the accident data shows quite conclusively over hundreds of whole losses that they occur mainly in terms of IMC or at night, and on four out of five occasions, they occur when the handling pilot is the captain.

Another piece of data is that where crew coordination and monitoring is shown to be a causal factor for the accident, then it is four or five to one more likely to occur when it's the co-pilot monitoring the captain rather than the captain monitoring the co-pilot flying the approach.

That accident data therefore led to a recommendation that suggested that for IMC and night approaches, then the co-pilot should be flying the approach and the captain should be monitoring, and the captain takes over when visual reference has been achieved for the landing.

Now we all accept this question of the monitoring of the captain by co-pilots and so on is, I think, a worldwide cultural issue. The human factors experts have coined the phrase "the authority gradient". It applies to all nationalities, not just one particular nationality. All of us, I think, have a respect for rank, authority, experience, but in addition to that, there are some cultural issues, too.

It is more difficult for some cultures to be critical of the man in charge, the captain, or woman in charge than for some other cultures, and it doesn't matter how much training or whatever the company policies and procedures are, that has to be worked out continuously to achieve the correct, I think, crew integration and team effort. But all of that is part of this allocation of flight crew duties.

One other factor, a related recommendation, but I've not done it separately, is the use of the autopilot. Even for non-precision approaches, and probably particularly there, we've already discussed that it's a more difficult sort of approach. Why not use the autopilot? Because it reduces the workload. The handling pilot even operating the autopilot has more capacity to monitor what's going on and, I believe, will lead to a safer conclusion of that approach.

It does keep the workload well down, and I think improves this crew integration and monitoring enormously.

The last bullet is the non-precision approach procedures, including the design. This is where most CFIT accidents occur, and, of course, it led to the recommendations to try and make precision approaches more like -- or to make non-precision approaches more like precision approaches, where the accident rate is lower. It is the one most flight crews are performing most of the time. So, let's make non-precision approaches as similar as possible to precision approach.

The accident record of decades shows that jet aircraft have crashed for failure to follow stabilized approach concepts. So, let's incorporate stabilized approach into non-precision, which means continuous descent powers rather than step-down approaches which are inherently unstable.

It is also, as I mentioned earlier, very easy to get out of step with those -- those particular vertical descents flying level going to another one and so on.

There's a recommendation, too, that the construction of such approaches should be around the three-degree point provided all obstacle clearance can be achieved, and that one should have a final descent power of at least eight to 10 miles to allow stabilized conditions to be established more easily than trying to do it from the final approach fix at four miles in-bound.

I'd like to just look at a chart at the moment, and this just shows a particular instrument approach chart. It's an ILS or a VOR to Runway 8 in Gabaroon or in Africa, and this is a particular approach with similar characteristics to Guam. This has a VOR DME at the final approach fix.

Down there in the bottom right-hand corner, if we can zoom in, bottom right, that's it, just there, you'll see DME distance with an altitude table, and this is the sort of information that a company I know which produces its own charts provides to pilots which gives additional DME guidance beyond that final approach fix to determine an optimum descent angle, and that actually computes to a 3.1 degree angle.

If we now go back to the profile, and we can see there in the middle the GBV VOR DME at the final approach fix, crossing altitude of 4,800 feet, there's nothing whatever to stop anybody commencing a final descent path instead of 5,300 shown some distance out. It only needs to be less than two miles outside that VOR DME to do a continuous descent path.

Indeed, you could run right around the whole procedure at 5,500 and face finals at 5,500 and commence descent at 2.5 miles before GBV and do a continuous descent all the way in. You've observed all of the limitations, but you have a more effective continuous descent and stabilized approach capability.

Now, this chart is not ideal, but that's the sort of thing that I would like to see us eventually rewrite such procedures using the aids available and to allow the pilot to operate the airplane in the best possible way.

If we now just look at the planned view of the chart itself, that's the upper half, again all I would just draw attention to are the colored areas there in light green, and the figures in there. These are minimum safe altitude contours. In other words, the figure you see there is a safe altitude to fly at.

Now that's one way of depicting contour presentation rather than the terrain itself. This is, after all, what the pilot wants to know. What's the safe altitude I can fly at? Not necessarily read the height of the ground, apply a margin, and then eventually get to the figure. This is prime presentation of information.

Next slide, please. Coming back to these applicable recommendations from the CFIT education and training aid, the next bullet here is altitude awareness, and here, it's important that the flight crew establish the applicable minimum safe altitude for where the airplane is going to be and where it is.

They also have to bear in mind that the minimum operating altitudes, when in low temperature or high winds, needs to be increased, and that, I think, is a correction that is not well understood worldwide for international operators who may occasionally operate to either very low temperature airfields or indeed may experience high winds when operating at low altitude.

Altitude awareness also includes the incorporation of the 500-foot radio altitude call-out, particularly on non-precision approaches. The value of such a call-out, if integrated into normal operations, is that it's in the vicinity of most minimum descent altitudes.

When 500 radio goes off, if you're not close to being visual with the runway, then you should be getting out of there. That's the intent of that particular call-out.

There's also a requirement here that there is rather more positive cross-check of the final approach fix crossing altitude before continuing the descent to the runway.

The next bullet is radio altimetry and call-outs. It is vital, the accident record shows, that we have improved terrain awareness. Most of our aircraft have the radio altimeter on board our aircraft, but many operators don't use it for normal operations and only require its use in Category 2 or 3 conditions.

The significance of that is that in Category 1 or even in VFR conditions, then one should have the radio altimeter as part of the instrument scan when below 2,500 feet and lower commencing the approach. The intent of it is to make pilots aware that they are getting close to terrain and need to be aware of it.

Another feature is that how do you integrate it? Do you have manual pilot call-outs or, better still, have automated call-outs through the ground proximity warning computer? That has a number of menus of call-outs, and many aircraft have them today. The value of automated call-outs is that it doesn't get tired, distracted or anything else. When crews can forget to make the manual call-out, the automation doesn't. But the important thing is to have procedures associated with it, not just to have the call-outs made and then ignored.

The next one down here is measurement and evaluation of system performance. The world's airlines have imperfect systems quite often to measure how their aircraft are being flown, whether the standard policies, procedures and so on are being observed, and to what standard.

Here, what I am recommending and what the Flight Safety Foundation recommends here is the adoption of flight operations quality assurance sorts of programs, the foci as we know in North America, and comparable programs elsewhere.

A growing number of airlines are now using such data which means analysis of either flight data recorders, quick access recorders, enhanced pilot reporting, whatever, to monitor how the aircraft are being flown, and that information can be used for routine engineering purposes or operational purposes.

Sticking with the latter, it is possible to determine if limitations have been exceeded, flat-limiting speeds, for instance, whether the aircraft had a rushed approach. In other words, mismanaged approach by the flight crew.

Another one is a recording of ground proximity warning system alerts. There is too little data being collected by most operators as to how ground proximity warning systems are working on their aircraft.

I think many of us know that accidents show that pilots were ignoring the ground proximity warning shouting at them when the accident occurred, and they were ignoring it.

The big question behind that is why? Now, we know that the false or nuisance activation of ground proximity for some systems can be high, but there are technical solutions to make them much more dependable, and therefore pilots should be encouraged to believe them.

But getting the data is half the problem. When you know the problem, you can then apply solutions. You can also see how flight crew responded to GPWS alerts. That, of course, has benefits in terms of having confidence that this safety system is protecting your aircraft, but also the technique that is being applied by the pilot in the recovery maneuver. Again, that can be fed back into the training program to refine the technique, and then by gathering the data after the change, you can measure the improvement.

Another one is monitoring of go-arounds. We've talked a little bit about that earlier in this inquiry, and we believe it's important to monitor for a variety of reasons. Yes, we must not discourage pilots to perform go-arounds when necessary. Indeed, you must positively encourage them.

However, you need the data for these sorts of reasons. For instance, at congested airports these days, aircraft are being squeezed in to maximize capacity with minimum separation between airplanes. It is possible that by monitoring go-around rates, you may find a problem at one particular airfield. That may need a discussion with air traffic control to refine their procedures.

Another benefit could be not just the numbers of go-arounds but how are they performed. We all know that in the simulator on proficiency checks, pilots perform the required maneuvers well. They have to. They're being assessed on it, and nobody worries about doing aggressive go-around maneuvers in simulators.

However, most pilots change when they've got 400 passengers sitting behind them on an aircraft, and there is almost an unconscious relaxation, an attempt to be somewhat smoother, gentler. The reality is you do a lazy go-around by comparison with an aggressive go-around, and when you are in the vicinity of low minimum descent altitudes or decision heights, getting close to the ground, you cannot afford that luxury.

So, again, if you monitor performance, you can feed this thing, feed the information back into the training and the education of your pilots.

The last one on here is the minimum safe altitude warning system. I won't go into any more detail on this, but there are recommendations about its worldwide application. It is available in many countries, as we've already heard, but it is in limited use worldwide. We need to see more of it.

You can take the slides off now, please. In conclusion, I don't have a slide for this but would just like to make a few remarks.

In spite of the efforts of the Flight Safety Foundation, the many individuals, some of whom are in this room today, and in spite of what we've now discovered about controlled flight into terrain accidents worldwide, they still continue to occur. Just ponder that. They still occur.

I believe that industry needs some degree of compulsion to take more effective action. It's not enough at the moment to have awareness and voluntary action. We need the help and support from the regulatory authorities to maintain the momentum of this Flight Safety Foundation initiative and the work that the industry has completed.

Remember the ICAO proposals that are being worked on now need state approval. State authorities will listen to their regulatory authorities. So, we need the support from the regulatory authority to ensure success of those ICAO proposals.

But that's not all. I believe all public transport operators should be required to have a CFIT avoidance strategy and a program with policies and procedures applicable to that particular operator and its operating environment, but based upon the Flight Safety Foundation education and training aid.

It's then not enough to have policies and procedures. The regulatory authorities must verify that they are in place and being used.

Operator training programs should incorporate the diverse nature and range of instrument approaches that they encounter in the real world in their simulators.

We should also recognize that continued development and application of new technology and equipment, both in the air and on the ground, should be positively encouraged.

Chairman, ladies and gentlemen, thank you for this presentation.

CHAIRMAN FRANCIS: Thank you very much, Paul.

I'd like to preempt perhaps a little bit a question, but -- but I think that this issue that -- that you mentioned several times of participation in the groups that are working on this and particularly participation by regulatory and air traffic authorities is extraordinarily important.

We basically have a situation where as far as I can see, the entire rest of the industry is involved, and yet the people who are essential to -- to moving much of the -- of the equation here that we're talking about are not involved, and I'd be interested in any thoughts you might have as to, Number 1, well, particularly why they may not be involved, and I certainly hope that this hearing and anything that we can do afterward to get them involved, we can all work on.

So, if you have any comments on this. We didn't co-conspire, by the way, on this, but -- but I think we're both coming from the same place.

THE WITNESS: Well, thank you, Chairman. Yes, it has been a difficult area. I think one recognizes that not just operators but regulators have also had difficulties with resources and processes of change and various other internal problems.

It has been difficult for them to resource these sorts of industry activities, but the converse of that is that we found it difficult, too, but felt it important enough to do it.

That, I think, is the -- the message that now needs to get to the regulators, that the work and the progress that has been made will not be maintained unless they join this program.

I know my own regulatory authority in the U.K. I have given presentations to them on this, and they have been reluctant to take it on as a regulatory activity.

Remember when I suggested that some encouragement be given to it. That's one thing, but verification means more work, and that maybe is what they're hesitating over. But I don't think we have the choice. The data shows that this is the biggest cause of fatalities, and we must react to it.

It would be a very powerful, I think, signal to the world if we could persuade, for instance, the FAA, either as a recommendation of this inquiry or beyond it, to come on site and to take a more active role in running with the recommendations that have come out of the Flight Safety Foundation.

There are no axes to grind here. We have a shared common goal, safety.

CHAIRMAN FRANCIS: My apologies to the Tech Panel for that, but I think that's an extraordinarily- important message for us to get across, and proceed.

DR. BRENNER: Thank you, Mr. Chairman.

You mentioned that there's been a -- a major reduction in CFIT accidents since the beginning of this effort. What -- what are some factors, do you think, in helping in that reduction so far?

THE WITNESS: I think the major factor has been the increased awareness within the industry, and certainly since the Flight Safety Foundation commenced this initiative, there has been a lot more media coverage of this activity.

The combination of this, I think, awareness and the growing availability now of products like the CFIT checklist, the various videos in both corporate aviation and that comes with the education and training aid, these are the sorts of things that are now being more widely applied within operators.

But I believe a great deal more needs to be done to maintain the limited improvement that we've seen thus far. We'd dearly like to see this problem eliminated.

DR. BRENNER: You mentioned the checklists, the CFIT checklist. How is that used?

THE WITNESS: The CFIT checklist, for those of you that may have seen it, is a fairly complicated list of factors which enables airline management, not operating flight crew members, but airline managements to assess the nature of their operation and to come out with a risk-degree factor at the end of it which may cause them to select appropriate measures that reduce that risk, various policies.

I mean, for instance, how one flies non-precision approaches or the use of the monitored or shared approach, those sorts of things. They are mitigating factors against a risk of a particular type.

So, yes, it's a management tool, not an operational tool.

DR. BRENNER: Would -- would pilots use it as well?

THE WITNESS: I don't believe they would find it very user-friendly, no. I think most pilots want things much shorter, sharper, punchier, whatever, and we already have difficulty with long checklists in airplanes now.

The CFIT checklist is quite complex and really is not a factor for them because most flight crew are not the determinants of operating policies and procedures. That's the airline management's.

CHAIRMAN FRANCIS: Excuse me, Malcolm. This is aimed -- the CFIT checklist is aimed at the issue that we're all talking more and more about, and that is that safety is not just the pilot ran the airplane into the water or into the mountain. Safety is ultimately the responsibility of corporate management in whatever company it is, and that this starts at the top of the management.

So, this checklist, while complex, is aimed at what the entire spectrum of the company is doing in terms of its policies in order to prevent CFIT. It's aimed at the company and not just at the operations people, but in the -- at the entire company.

THE WITNESS: If I might diverge very slightly, Chairman, there is some work going on in another country, which is trying to enhance what I would call awareness of safety management systems, and there, they have already discovered that the most important factor on the safety performance of any organization is its management culture.

Have the right management culture, safety in terms of both culture and performance will result. So, it's just really emphasizing the point that you made that safety starts from the top, doesn't stop there. It runs right down through the organization from top to bottom and all the way back up again. It has to be, you know, staffed. It has to be resourced. It has to have an organizational commitment to safety in everything that that management organization does.

DR. BRENNER: Captain, in the case of the accident flight, would the checklist have highlighted certain areas of risk that might have developed more attention?

THE WITNESS: I believe that the use of the checklist will highlight to management, yes, that certain types of operation do have higher risks and that there are policies and procedures that could reduce that risk when applied. But as I say, it is for managements and not the operating crew.

DR. BRENNER: The -- you mentioned that the CFIT training aid was sent out last year. How has the response been from the international community?

THE WITNESS: That is an interesting subject. We know that more than 2,000 copies of the education and training aid have been distributed worldwide through the manufacturers principally and through some training organizations and other industry bodies.

The difficult thing is we now have to gather data as to what airlines have done with it. We have no established communication at the present to measure that implementation progress.

So, the Flight Safety Foundation is considering sending out some form of small questionnaire, quite deliberately not aimed at where the CFIT education and training aid was sent. If it went to the VP, Flight Operations, and he did nothing with it, then it's no good sending the questionnaire to that particular individual.

What we'd like to do is to send the questionnaire to some lower point in the organization, for instance, into the training management arena, and also to the flight crew community themselves through the pilot associations.

We then have a measure of how effective changes might have been within the organization and the degree of communication on CFIT that's going on from top to bottom.

Now that data-gathering is due to commence later this year, and we will be eventually reporting on what we find to the Flight Safety Foundation, and we hope that that information can be used to both encourage the airlines that have started doing something and, I hope, to prompt those airlines that have done very little so far to start doing something quickly.

DR. BRENNER: How many airlines are using monitored approaches?

THE WITNESS: I don't have an exact number. All I can say is that there are a large number and a growing number now using the monitored approach, if not for all of their operations, at least for part of their operations.

The name of it may vary from one airline to another. I've already used the term "shared approach". Some airlines use the term "low-visibility procedures approach". So, they may have a different set of procedures for Category 2 and 3 that may be different to the procedures used for Category 1 or VFR flying.

There are also a number of military forces in the world that use it, too, particularly in the transport arena. So, yes, it's being more recognized and steadily growing.

DR. BRENNER: Among airlines that have hesitated to use this approach or decided not to or are considering it, what are some of the concerns that are raised?

THE WITNESS: There is a difficulty when an airline has an established operation that may have existed for many years, and pilots are resistant to change. It's remarkable how pilots can adapt to new concepts with a new airplane that they're required to fly but are remarkably resistant to changes of policies and procedures because they defend that which they know best.

So, airline managements who wish to make a change have a fairly uphill education task as well as a redefinition of policies and procedures to support the change.

It then doesn't happen overnight. I know from my own personal experience that it can take many years before these sorts of changes of concept can be fully accepted. But you only have to look at that accident data, and it's difficult to refute it.

There is a better way of flying airplanes. We know that. The data supports it.

DR. BRENNER: How many airlines have training for aggressive response to a GPWS warning?

THE WITNESS: Well, all airlines would claim to have it. I think only those airlines that have some form of system to measure performance in the way I was describing earlier know whether their pilots are actually doing it.

Simulator performance is not enough. You have to see what they're doing on the real airplane. I don't have figures of how many airlines are doing aggressive. I just know that that is the general policy, but few airlines have the means to ensure that it's being done.

DR. BRENNER: Yesterday, we spoke about considerations of tracking missed approach data. Do you have any -- any thoughts on that, on any value towards this type of effort?

THE WITNESS: I'm sorry. Could you redefine that question a little?

DR. BRENNER: I believe keeping airline records on go-arounds.

THE WITNESS: Oh, yes. We -- we keep the records. We feed the information back, and I think operators generally in being encouraged to keep the record should do that.

As I indicated, it does identify problem airfields with other causes for go-arounds, but the important thing is that we use it for beneficial purposes in terms of encouragement and also the correct performance of the go-around itself.

It is essential that the aggressive maneuver for a go-around is performed when at or near the minimum descent altitude or decision height, but when you are well away from it and commencing a go-around from more than a thousand feet away from such low altitudes, could be more gentle, and that may be an airline policy choice, but again have the data, use it, refine it, and then have confidence in how your pilots will perform.

DR. BRENNER: And we spoke yesterday about MSAW. Are there international standards or requirements?

THE WITNESS: There are none yet, and that is the work I referred to earlier in terms of ICAO. Have a proposal to mandate it at some point in the future.

However, we know that for recent radar equipment installed worldwide, most of them have the MSAW capability. Other than a few states, like North America, like Israel or Turkey or one or two other places in the world, most do not have them commissioned. They do not have them tailored to the installation.

Air traffic controllers are not trained in its use, and indeed there is some degree of air traffic resistance because, remember, MSAW, an alert, could indicate that the air traffic controller made a mistake, and there are some therefore cultural or punishment issues associated with that alert, which are natural inhibitors to adoption.

But all of those issues have to be worked through to make sure that we do have the safety benefit that is available but being unused. In other words, the cost of actually putting it in place is minimal.

Let's use it.

DR. BRENNER: Is there CFIT prevention training for air traffic controllers?

THE WITNESS: There isn't, but there should be, and that was one of the recommendations that came out of the air traffic control procedures and ground equipment working group report, and the sort of things that need to be done are training to understand the capabilities and requirements of aircraft.

I think many of us take that for granted, but I believe air traffic controllers need to have more knowledge in that area. They need to understand the stabilized approach procedure and what it means to us as pilots when they ask us to fly at certain speeds to certain short distances from touchdown.

They need to improve their awareness of GPWS performance and radar vectoring in the vicinity of terrain. They also, I think, need to have education in terms of operation at low temperatures or high winds when operating at low altitude in the vicinity of terrain.

Many states have no procedures for such -- for such conditions. Others have procedures where air traffic control will modify clearances. Other states have procedures where they expect pilots to make the corrections and then notify air traffic of such corrections. There is no uniform standard, but there should be.

Those are the sorts of areas that I would see education needed.

DR. BRENNER: The NTSB has recommended to the FAA to make CFIT training mandatory for airline pilots, like wind shear -- training in wind shear avoidance. Is this a positive step?

THE WITNESS: That's a positive step, but as we have seen, and I -- as I have tried to reiterate, there is no single step that stops CFIT. It is a collection of measures.

CFIT education and mandating of it is just one element of those measures. Another piece of equipment on the airplane is not the only measure needed. It is a step in the right direction.

DR. BRENNER: Are there some measures that can be implemented immediately?

THE WITNESS: Well, interestingly, most of those things I talked about in terms of applicable areas of the Flight Safety Foundation education and training aid report, most of those areas could be applied at little or no cost.

What it requires is management will to do it, and then, of course, a resource and effort to support it. So, there is a small cost, but it's not a big one. We've already covered, I think, the crew education and awareness as being one step, but the most important thing is to make better use of the available equipment that we have on our aircraft. Some operators do that already, but many could make better use.

There needs to be a management review of policies and procedures. That takes time and effort, but it's well worth it. There needs to be appropriate and more effective training.

We also need to encourage, I think, the new equipment development and the application of new technology, and most important of all, we need to move in this area of performance monitoring so that we know how the aircraft and how the flight crew are performing when they're out in the airplane, not just in the simulator.

DR. BRENNER: Thank you, Captain Woodburn. That completes our questioning, Mr. Chairman.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Thank you, Mr. Chairman. We have no questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: Thank you. No questions.

CHAIRMAN FRANCIS: Branson? Barton. I'm sorry.

MR. EDWARD MONTGOMERY: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCEY: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: No questions. Thank you, Chairman.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: Just several questions, follow-up questions, and the first one is probably tell-tale on ourselves.

You had spoken of the reluctance of regulatory authorities to become involved in this -- in this program, and you had spoken specifically of your regulatory authority.

Have you had any feedback as to the reluctance or a perceived reluctance on the part of the FAA or any other worldwide regulatory authority what their concerns are?

THE WITNESS: I've had no specific feedback to me personally at all. I have good contacts with my own regulatory authority, and they in principle support what's going on.

The problem is manpower to commit to doing it, bearing in mind all of the other tasks that they're supposed to be doing. That, I think, is more the heart of the problem, not an objection in principle, to what we're trying to achieve here, and it's a question, I think, of just changing priorities and recognizing that this is a valuable initiative that must be supported and continued to achieve the desired improvement.

MR. FEITH: I'll take that one step further and go beyond the regulatory authorities. I may be telling tale on ourselves, but has the NTSB or the AAIB or any other safety organization around the world been involved in this program?

THE WITNESS: Yes. I have to say that whereas CFIT may not have been supported as well as we would have liked, what I didn't describe to everyone here today was that the Flight Safety Foundation initiative concentrated on CFIT initially because of the fatality data that I showed you.

We also recognized that CFIT and approach and landing accidents are very closely related. Indeed, it's sometimes difficult to separate the two. It's really two sides of the same coin in some respects.

There are a number of working groups still running with the Flight Safety Foundation on the approach and landing accident reduction element of this initiative, and that has now involved both regulatory authorities and safety organizations, and I have to say I think that is after the event and the degree of success that CFIT activity showed. So, yes, we've got them involved at last.

MR. FEITH: And just to make sure that I have a correct perception, were the ATC authorities involved in the -- in this program, also?

THE WITNESS: They were invited to participate, and indeed the air traffic control and ground equipment working groups started off under an FAA chairman several years ago, but within a year, he took early retirement, and that was the end of FAA participation of any sort, unfortunately.

Subsequently, when the group was reconvened and then completed its report some 18 months or so ago, there were few representatives, if any representatives, from air traffic managements, but we actually had air traffic controller participation. So, it was the -- like the pilot, we had the man on the spot there.

MR. FEITH: So, that's worldwide air traffic control, --

THE WITNESS: Yes.

MR. FEITH: -- not just the FAA or --

THE WITNESS: Yes.

MR. FEITH: -- just --

THE WITNESS: That's correct.

MR. FEITH: -- that kind of organization?

THE WITNESS: Yes.

MR. FEITH: Just for a clarification, you had spoken in one of your presentations about stabilized approach velocity. I think just for the benefit, could you give us the nutshell or Reader's Digest version of what you mean by stabilized approach criteria for the approach segment because I think you related it to the three-degree approach?

THE WITNESS: I don't have the benefit of a diagram here, but if we can visualize a final approach segment around the three-degree descent path, and ideally one should have somewhere between eight to 10 miles of in-line approach, constant descent from what may be 2 to 3,000 feet, in a landing configuration established early enough such that the landing check-list can be completed and out of the way, to allow the flight crew to then perform the remainder of the final approach and the transition of the final approach fix without having distracting and conflicting tasks.

You then need to set gates at various points on the approach, and many operators choose, for instance, 1,000 feet above the field as a particular point when the airplane must be in the landing configuration, must be at the right speed at no more than maybe 20 knots past the target speed with the approach pass and landing checklist complete and so on, and that is the target for all approaches.

Then operators may have another point down the approach, and 500 feet is common, at which point there is a tighter gate still in terms of speed and associated conditions being on the vertical profile in the right position to complete the landing, and if the tighter set of conditions are not met, then there should be a mandatory go-around requirement from the 500-foot point.

The target at 1,000 feet, if not met, is one which has consideration given to go-around, yes or no; 500 feet mandatory go-around if the conditions are not met, and the final check is at 100 feet, and particularly on limiting runways, this target is where the aircraft has to be at the right point above the threshold, at the right rate of descent, and not exceeding a speed of, say, 15 or 20 as the maximum condition for landing.

On a limiting runway, if that particular gate is not met, then again mandatory go-around. So, I would liken it a bit like if you can imagine at 1,000, 500 and at 100 feet, three eyes of a needle. It's a slightly bigger hole at 1,000, a smaller home at 500 feet, and a very small hole at 100 feet, and you thread the aircraft through the needles, and you get it right.

MR. FEITH: Thank you, Captain, for that explanation. Appreciate it.

You had made a statement regarding providing all crew members with charts, so that they could basically all be up to speed on the approach. Would that include non-flying crew members; that is FEs or international relief pilots that may be in the cockpit but not actually performing a flying duty?

THE WITNESS: You added a caveat on the end there, not performing a flying duty. There are some two-crew aircraft designed for two-crew operations which have third crew members which do not have assigned duties, and that is one category, and I would say in that case, it's the operating crew members that have to have the charts.

However, there are many three-crew aircraft operating in the world today with either flight engineers as pilot or engineer in the third seat who are forward-facing for take-off and landing and who do have assigned duties of monitoring the pilots.

If they are to monitor effectively, they have to have the chart to be able to do that. It's very difficult in night-time conditions to be looking over a pilot's shoulder trying to reach his chart when you're supposed to be doing other things as well, or during briefing to try and extract and write down relevant bits of information to enable the monitoring to take place. That -- that procedure, I think, is unsatisfactory.

MR. FEITH: And with regard to one of the charts that you showed depicting minimum safe altitudes and your explanation that pilots would rather see what the minimum safe altitude is than to try to figure it out, ball park it and then make sure that they hit the right altitude, the chart that you showed is produced by an independent organization over in your side of the world. Jeppesen, of course, is typically a world standard for charting.

Do you have any comparison because Jeppesen doesn't show that on their charts? Do you have any particular opinion about the differences in charting?

THE WITNESS: Yes, I do. I mean I'm not being critical of any particular company. I believe that the industry recognizes that terrain or minimum safe altitude are better presented in contours rather than in tabular or spot height form.

One gets a much better impression. I actually have two charts here to show a comparison of the two different techniques which I could show, if you would allow me.

MR. FEITH: Please.

THE WITNESS: And you can see therefore the difference of presentation that one should, I -- I emphasize, not be critical of either. They are satisfying two different purposes, and the rationale behind it is to make it easy to read and use.

Now both are better than the ways that used to be the norm, and I would encourage developments in this direction. The problem, of course, with minimum safe altitude compared with presentation of terrain is that you may need some degree of skill and cartographic application to, as it were, draw the right minimum safe altitudes versus terrain which is fixed to the ground or topographical charts. You may simplify those, but they're easier to draw.

So, let me just show you, and you can see what they look like.

MR. FEITH: And just for the benefit of us, we're going to give Jim Terpstra an opportunity to defend his position when -- when he testifies regarding Jep charting.

THE WITNESS: What you've got here are two real charts.

MR. FEITH: Excuse me one second. Can we just lower the lights a little bit so we get a better picture, please?

THE WITNESS: Is it possible to focus that slightly differently? Okay.

Here on the left-hand chart, this is minimum safe altitude presentation of the safe altitudes to fly at, and you can see, I think, pretty quickly that it's very easy to pick the appropriate figures here. They're in hundreds. The large digit is the thousands, the smaller digit being hundreds, and it's very easy to then -- this -- these are the mountains to the southeast of Geneva.

If we look at the -- the chart on the right-hand side, here we're seeing -- if we go to the same area, the bottom right, one has to be a little bit more careful in terms of reading the figures on here and remember this is terrain. So, you've got to get the right figure, then apply the right margin of either 1,000 or 2,000 feet obstacle clearance, and remember you've got to do this in night-time cockpit conditions with the airplane flying at various speeds.

Now both of these presentations, this one is in a brown tint which shows the ground, the other chart is showing minimum safe altitude, which is in green, these conform with the ICAO Annex 4 requirements for charting, which says that the ground shall be in either black or brown, and that minimum safe altitude shall be in green.

Now, obviously one can see the basic similarity of terrain is evident on both, but you have to ask yourselves which is the easier one to use and apply flying an instrument approach.

We, in my particular company, started off using the terrain contour presentation some 35 years ago, and we then found some difficulties of interpretation in the night-time configurations of those aircraft.

We started to experiment with this type of minimum safe altitude display, and in the 1960s ran a test with our pilots, and we had a more than 90 percent in favor of presentation of minimum safe altitude rather than the terrain itself, and for the past 30 years or so, we have maintained this style of presentation.

Either of these, as I continue to reiterate, is much better than those earlier charts which did not have the contour presentation on at all. So, the fact that the industry is now moving in this direction is, I think, enormously important.

MR. FEITH: Thank you, Captain.

Lights up, please. One last question. You had talked about trying to collect, I guess, real world data from line operations, so that you could feed that back into the training arena, and I think you as a line pilot know, and I think the industry knows, that a lot of times, the collection of such data is feared by pilots, that management will use that for other purposes other than for training or education but more for punitive action.

Given that we are trying to collect real world data, we're using crew performance data as an educational tool or that's the intent of it, how do you change that mindset in the crew, in the cockpit, that this won't be used as a punitive tool, it's used as an educational tool because that fear goes very far back, especially with the use of the CVR or the flight data recorder information, things like that?

THE WITNESS: That is a complex issue. You really need to have an agreed set of procedures between an airline management and its flight crew community. It also needs the positive support of the associated regulatory authority, such that punishment doesn't follow from such data. That should not be the intent.

I think all pilot associations know of the various schemes in existence whereby such data is collected on an anonymous basis. It is not associated with a particular pilot, and some operators have procedures whereby only the union representative can be given information from engineering, not flight crew management, to eventually contact an individual to seek further information.

Airline managements do not have access or should not have access to the individual themselves, except through pre-arranged procedures that the pilot associations are comfortable with.

I know of many operators who've moved in this direction, and, yes, it is a learning process, an education process, and it's not enough for managements to say certain things. They actually have to do certain things. They have to prove and support the agreements, and they must not hound the pilot to punish him because they prejudice the whole system and the value of the system.

So, it can be done, but it needs positive education, support, appropriate procedures, and then the support of the regulatory authority to make it work.

MR. FEITH: Captain, thank you very much for your testimony. Appreciate it.

CHAIRMAN FRANCIS: This last issue is -- is a question of establishment and maintenance of trust and confidence.

Pat? Mr. Berman?

MR. BERMAN: Captain, we heard testimony yesterday from Korean Air about their procedures for responding to a GPWS alert. We heard that there is not a mandatory go-around for a sink rate or terrain -- terrain warning in IMC.

Can you please evaluate that procedure?

THE WITNESS: There are, I think, two levels of alert from ground proximity. There is, as we all know, the pull-up alert associated for most airplanes with red warnings and that is and must be a mandatory go-around.

However, there are other what we would call secondary alerts, which many operators allow their pilots to correct the condition without necessarily associating it with a mandatory go-around, unless they are at a low altitude, and the secondary alert is continuous, and the best course of action is therefore to get out of there.

Many of the secondary alert features of ground proximity warning with -- if they exist for a period of time, get translated into a primary alert of a pull-up anyway. You'll get there.

MR. BERMAN: Could you give me an estimate of the number of air carriers that you are aware of that

-- that do not have that procedure? In other words, that require a mandatory pull-up for a secondary alert, such as that.

THE WITNESS: I -- to be honest, I have no data on that. I know what a number of airlines do, which is what I've described. I know what manufacturers and the -- both of the airplane and the equipment generally recommend that we do, but beyond that, I have no figures on it.

MR. BERMAN: Okay. Thank you. What has been the usage worldwide as far as you know of the Flight Safety Foundation CFIT training aid?

THE WITNESS: I believe the use has been extremely limited worldwide. I think a number of airlines are still in the process of translating what is a fairly large package of material into something that suits their particular operation.

For those of you that have not seen the education and training aid, it is two very large volumes of paper with an associated video of some -- some 30 minutes' duration, and it is not an effective package to give to pilots.

You have to, I think, take appropriate elements out of that, repackage it in a form that is then suitable for individual flight crew communities. That takes time, and my belief is a number of operators are in that phase of adapting it. Many others, however, I believe, are still in the phase of it got parked on a shelf somewhere gathering dust, and it has not yet received serious consideration within those operators, and that's why I feel that the efforts made by the Flight Safety Foundation to find out what happened to this distribution of the aid will be valuable because it will be another reminder to that package that came last year how we should have done something with it, and it will spur them into action, I hope.

MR. BERMAN: Thank you. Could you please characterize the workload involved in executing a constant rate descent procedure on a non-precision approach without an electronic glide scope and without pre-calculated descent starting point or -- or pre-calculated check points along the way that are on the chart?

THE WITNESS: If you have no means of establishing additional data points on the final approach, the constant descent without other than just a final approach fix requires the calculation of an estimated rate of descent based upon ground speed for the final approach segment, and associated with the constant angle approach is also the need to be stabilized at an early enough point such that landing checklist is out of the way early enough, flight crew can positively then monitor the conduct of final approach.

The workload of such a procedure, I think, is considerably less than attempting to fly level, for instance, a descent to an MDA in a jet aircraft that's 3 or 400 feet above the field typically in a landing configuration requires fine judgment to then seek visual reference over a nose pointing in the air and then complete an approach at the right descent path to the runway, all of that in limiting conditions.

The constant angle descent, I believe, also should be associated with a philosophy of not flying level and on reaching an MDA, whatever that value is, if visual reference is not secured for landing, then the aircraft should conduct a missed approach at that point.

MR. BERMAN: Captain, if pilots were executing a constant rate descent-type approach, would you expect them to set into the altitude selector the intervening step-down altitudes?

THE WITNESS: I would believe that that is one way of doing it, yes. My particular aircraft is well-endowed with flight management system constraints, so we can achieve that, and those restrictions will be observed.

For a more basic aircraft, yes, that can be done. It can also -- one needs to be careful of observing limitations without setting those in. If you've got effective pilot monitoring, that can be done, but it is safer to put those intervening altitudes in so you have the protection that the airplane should level off, particularly if operating under autopilot.

Even when operating with flight director, there are commands on the flight director bars that if the pilot inadvertently continued descent when he should not have done, then he gets the protection of those intervening altitudes being set, yes.

MR. BERMAN: Okay. Thank you. No further questions.

CHAIRMAN FRANCIS: Mr. Schleede?

MR. SCHLEEDE: Yes, just one short question about your comments about the need for both flying pilots or two pilots having sets of charts.

Do your comments apply also for smaller aircraft, like twin -- small commuter airplanes?

THE WITNESS: Yes. In fact, it's less of a problem with the bigger operators, and it's much more of a problem with the smaller operators where, for a variety of reasons, probably cost, one set of charts tends to be supplied, and where two pilots are carried, they share charts. That's commonly the case.

MR. SCHLEEDE: Thank you.

CHAIRMAN FRANCIS: Thank you very much, Captain Woodburn. That was very, very helpful for us.

THE WITNESS: Thank you, Chairman, and ladies and gentlemen.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: We'll now take a break. It is, according to my watch, seven seconds before 11:00. We'll come back at 20 after 11.

(Whereupon, a recess was taken.)

CHAIRMAN FRANCIS: We are ready to go. Our next witness is Mr. Don Bateman, who is Chief Engineer, Flight Safety Systems for Allied Signal, also a participant in the CFIT activities of the Flight Safety Foundation, and I believe he's been sworn in by Mr. Schleede, and Mr. Schleede has the floor.

Whereupon,

DON BATEMAN

having been first duly sworn, was called as a witness herein and was examined and testified as follows:

TESTIMONY OF DON BATEMAN CHIEF ENGINEER, FLIGHT SAFETY SYSTEMS ALLIED SIGNAL, INC. REDMOND, WASHINGTON

MR. SCHLEEDE: Thank you. Mr. Bateman, give us your full name and business address for the record.

THE WITNESS: My full name is Charles Donald Bateman. I'm known by my friends as Don. And my address is in Redmond, Washington, the State of Washington, at Allied Signal Company.

MR. SCHLEEDE: Thank you. Would you give us a brief summary of your education and experience that qualifies you for your current position?

THE WITNESS: Well, I like flying. I was -- I graduated from the University of Saskatchewan as an engineer, electrical engineer, and then I worked back East for a heavy radar company, and then I went to work for a very informative two years at Boeing on the 707 and left there, and I've been with the same firm, even though we've been bought twice, since, and our kind of business was -- was avionics, designing equipment for aircraft.

MR. SCHLEEDE: Thank you very much.

Mr. Pereira will begin.

MR. PEREIRA: Good morning, Mr. Bateman. How long have you been working on CFIT prevention, and in what capacity?

THE WITNESS: Well, in about 1966, I was a Caravelle flown in short at night, drizzle, in Ankara, Turkey, and it was operated by SAS, and -- and everyone had lost their lives in that accident, and it was a lot of concern about maybe this could happen again, and Scandinavian Airlines wrote sort of a problem statement that it shared with the industry.

What they really wanted was basically a system that would be like a fire-warning bell that would inform the pilot that something was wrong, and that's how we started out in the evolution of -- of a warning system that we call Ground Proximity Warning System today. So, that's 31 years.

MR. PEREIRA: Okay. There's been a great deal of discussion about GPWS and enhanced GPWS at this hearing. As one of the primary manufacturers of these systems, would you please describe what GPWS and enhanced GPWS are, taking time to explain any of their relative advantages and disadvantages?

THE WITNESS: All right. I'll try to do that, and I'll try to keep it short. I brought some view foils or overheads that perhaps will make the points I'd like to make.

The purpose of what we call ground proximity warning systems or GPWS, as the acronym, is to provide the pilot with a timely alert, visually and orally, of possibly flying into the ground or water, and at that time in '67, in 1967, we really wanted to use what's on the airplane. We -- at that time, our Category 2 equipment was being installed, and as part of that equipment was the radio altimeter that looks down below the airplane to see the terrain.

We also had air data signals, and we also had glide scope deviation which exists on just about all the airplanes. So, that's basically the purpose, was to provide an early alert, if possible, something could be wrong.

Next slide, please. Since that time, we've accumulated in the 31 years a tremendous amount of experience. Today's commercial jet airfleet is about 12,500 aircraft, and, unfortunately, we still have airplanes being flown with no ground proximity warning system nor -- in many of them nor radio altimeter. But, nevertheless, it's a very high proportion of the airplanes are equipped and flying with some form of ground proximity warning system. Some are very old and ancient and some are pretty new.

We've accumulated over 230 million departures probably worldwide. So, there's a lot of experience with this equipment, and in conjunction with minimum safe altitude warning system in the United States, because that really is very, very effective technology -- pieces of technology can reduce the risk, and we've lowered it from about .85 to .03 per million. That's a 28 times reduction in risk, which is paid in terms of airplanes that have been prevented from flying into the ground.

Unfortunately, in FAR 129, it still remains high, and -- and the previous speaker, I think, made some very good points about why we must continue with training and so on.

Next slide. What the GPWS uses is the existing radio altimeter, and looking at the radio altitude, the height above the field, we look at the descent rate. We also can use air speed sometimes to try to advance the alert, if a high-speed descent or flight is involved.

We try to look at the landing gear, not to determine really that it's down or up, but just to determine that you wouldn't be where you are with, say, 500 foot of terrain clearance with the landing gear still up. Something's got to be wrong. So, we try to alert the pilot.

The same with landing flap. Most pilots try to land with the landing flap as part of the procedures. If it's not down, the terrain clearance may be as low as 200 feet, something's wrong.

We also normally don't fly the airplane below the glide scope. So, we use that in conjunction with relating that to the ground to alert the pilot to the fact that something may be wrong with the glide scope or his position with the respective glide scope.

In some installations, we use a radio altitude setting, whatever the pilot has put in, to use it as an advisory or an alert for the pilot.

Next slide. The outputs we get from the GPWS are soft alerts, sink rate, and I believe in this particular -- at Guam, we heard one sink rate. Down sink would be at take-off when the airplane may be in the dark accelerating back into the ground. We also get too low terrain, glide scope, that sort of thing.

A hard warning is when we've got to a point where we're running out of time to recover the airplane. Typically, we say terrain, pull-up, and the pull-up -- at first, when we start out with GPWS, it was a warning tone because we couldn't -- technology was such that we couldn't generate a voice, but we've been able to generate many voices now. Maybe we've got too many of them.

Advisories. We'd like to also from the radio altitude altimeter create a list of advisories. The flight operations people usually select these. I believe on the Guam -- Guam -- particular Guam airplane involved at Guam, we heard a call-out at 1,000 feet, at 500 feet, and a hundred, so on, as we approach over the runway.

GPWS, like anything in this world, has got its limitations, and it has -- the limitations have been rather illuminated for us, and in this particular accident, they're illuminated again. It can give very short warnings for flight into precipitous terrain. That's what happened, I'd say, in some of the recent accidents, like Cali. There just wasn't enough sufficient time for the pilot to recover the aircraft.

We -- we may not give an alert or warning for a stabilized approach or stable flight into the terrain when you're configured for full landing. GPWS has no way of knowing where the end of the field is or the end of the -- the runway, and if there's no glide scope signal, there would be no glide scope alert, and another limitation, the last one I put there, is the altitude calls are referenced to altitude above ground, not runway, and we have some differences sometimes.

GPWS is required -- I think that's the wrong one. Sorry. Let me just read from this anyway. A misplaced slide here. Could you excuse me just for a moment?

(Pause)

THE WITNESS: Sorry. I -- my slides got misplaced. In the United States, GPWS is required on all U.S. airplanes with 10 passenger seats or more, and that -- and these -- these aircraft operate under Part 121, 125 and 135.

GPWS is not required for foreign aircraft in -- flying in or out of the United States under Part 129. However, under ICAO, Annex 6, most states are recommended -- recommended to carry an operating GPWS, and most states, including South Korea, do comply.

In the last 12 years in the United States and for operations in and out of the United States possessions, I put a list on here. There's 12 airplanes, and as the previous speaker and other speakers have said, this is an on-going problem. Agana is only one of these 12, and -- and the operator is -- is not specifically isolated. There are many, many operators involved with these losses. Many countries. It's a worldwide problem.

The Agana fits in the -- in the situation where the airplane's configured for a landing, and there's no warning. There were advisories, and I don't understand why the crew flew through those advisories.

Lima, Peru, was an American airplane, a cargo airplane, a non-precision approach in 1996. Cali, we've mentioned. You can go through each one of these, and, unfortunately, most of them involve a loss of life.

In San Salvador, we lost two ambassadors, the ambassador from Holland, from the Netherlands, the ambassador from Brazil, and in La Paz, Bolivia, which is at the very bottom there, an Eastern Airline airplane, we lost the ambassador to Paraguay's wife and the director of the Peace Corps. These are very painful to the people involved.

Next one. Last year, just to show that it's a worldwide problem, we lost three airplanes. Agana we're talking about today. Madan, Indonesia, was a radar vector for an ILS and a miscommunication between the crews, between the controller and the pilots. At Bangladesh, we had an F-28 that went in in landing configuration into a rice field in the dark. Unfortunately, the airplane was destroyed. Amazingly, nobody was killed.

Next one. This one right there. All right. If you take these 12 accidents, you can put them down here in a -- sort of a breakdown. In many cases, not in the U.S. but we have had worldwide no GPWS installed. A very small minority of airplanes is where the greatest risk is in the losses, and then we've had the 28 percent shown there with no warning. This is a case where the airplane -- aircraft is configured to land and no warning.

These late warnings or improper pilot response for the 41 percent would be what I would classify like Cali, there just is not enough time by looking down to try to see ahead.

Let me go to this one here. Put this up. So, we've tried to improve the GPWS by providing increased situation awareness, if we can, of significant terrain or obstacles with relationship to the aircraft.

If a pilot can really perceive where he or she is with the relationship to the runway or the terrain, we've got a much better chance of never ever having an alert or a warning in the first place. We'd like to by looking ahead into that terrain database, if possible, provide a timely alert that is more in the nature of about a minute or half a minute compared to the 15, 10, 12 seconds we get now with the conventional GPWS.

Again, we also want to keep the system practical by using existing sensors, such as the FMS, IRS or INS, GPS, scope of positioning system; that is, in -- it's on the existing airplanes. We also want to use an existing weather radar or EFIS map display to show the terrain.

We use the same signals as GPWS. We use position data that's already in most of the airplanes, that's already wired to the GPWS. We have track and heading and ground speed from those signals. We use altitude MSL because quite often -- I mean in the databases which I'll talk about this morning. They're measured -- they're referenced to mean sea level.

A new signal, though, we do need is the display range, and the output as shown at the bottom is -- we want to drive the EFIS or weather radar with terrain pictures.

And we want to add -- to make this thing work, we need to add the worldwide database, which would be airport terrain, airport runway ends, the terrain data and manmade obstacles.

A wonderful thing happened during the end of the Cold War between the Western powers and the Soviet Union, was that both -- enlightened people on both sides decided to use the digitized terrain that was developed for military purposes for cruise missiles and so on be made available for the civil sector, and that's been very, very good. It is something I didn't think would happen in my lifetime.

The second thing I didn't think would happen is we would be able to develop flash memory, memory on the consumer side, very low cost but very small size, that we could store this data on, and typically we can put that -- all that data on the size of this credit card, and this -- this is -- this has all been happening in the last five years. Something that we dreamed of but never realized it would really happen so quickly, all of a sudden.

We need also, though -- one point I want to make out, is that some of the countries in the world still consider their terrain data as military, classified, and -- and Korea is one of those, unfortunately. We need Korea and many, many countries to share that data with the world, and it doesn't have to be down to military quality data, but it can be down to about what we call 30 r seconds or half nautical mile cells. This is good enough for what we need for commercial transport purposes.

And I should skip this slide, but this looks awful busy, but the portion that's shown in green, those all exist in most airplanes. All production airplanes don't have all those signals that go to the GPWS. So, we're adding the bottom there, which is a blue section, which is basically the terrain databases and airport data, and then we want to drive a display that -- that we share with either showing weather radar or terrain.

A quick view, next slide, please, shows -- this is typically like the size of a chocolate box. It's -- and -- and from the front, we can load data which we don't have to do. Terrain doesn't change very much in our lifetime. So, it's a very reasonable thing to do.

But the idea is to use what is available in the airplane and replace -- simply replace the existing GPWS computer with the enhanced one.

Next view foil. This is a picture of my colleague, Hans Mueller, and we're looking at a terrain in a -- on the right there of -- we're at Juneau. We're in a 747-400 airplane which is rather unlikely to be at Juneau, Alaska, but, anyway, we can see the plan of departure's down that canal, and we should always have a black area where we're flying.

To make the display intuitive, next view foil, we use a scheme of the terrain that's referenced to the airplane. This is not a map of terrain. This is a -- is terrain that's referenced to the airplane. You're flying at 30,000 feet. It will be all dark shown on the very bottom there. If you get within 2,000 of the -- of the terrain, we start to have a slight color of green, and as we approach up to the altitude, it should be still a little bit green. It will start to go yellow and above there, more yellow, and finally we get to a dotted density of red.

How that looks in the next view foil. Attorneys won't like this, but I picked Cali. This -- if you were -- the airport is -- is at the top of the screen there, SKLC, and we're at Tulo, which is a sort of initial approach fix.

At this point, this is what a normal approach you would see. You'd see all the dark. It's all dark, and the terrain is red, at least 2,000 feet above you or more, and the yellow's a thousand feet above you, less yellow is at your altitude or higher, and you can get a good picture, sort of a situation awareness, that everything's okay here, and the planned flight path as shown on the display is correct.

We want to also look ahead into the terrain database and to give an alert, and this looks rather complex, but it's -- it's -- it's below the airplane. There's two envelopes. One is a cautionary alert, one's a warning. They vary automatically with your speed and your relationship to the airport, and we also want to make sure that we can out-climb the terrain. So, we also look up six degrees. As one of the witnesses told you that day in MSAW, it was five degrees.

Next slide. And this is sort of a crude picture, but you can see the airplane flying towards these terrain cells, and these terrain cells are about a half a nautical mile each, and when the elevation is stored above sea level.

The -- also, we want to surround the airport with a terrain clearance floor. The bottom of this bow is the airport, and we store in terms of information the ends of the runway, and then we slowly build a floor up that progressively grows with distance from the runway to try to protect against landing short. As the previous speaker said, half of our losses are on the non-precision approach.

This is a picture of what would -- of the track that you've seen that the NTSB has displayed as shown. The airport is at the extreme right, in the upper corner, right corner. This is a ground track picture.

These are the terrain cells, and in each of those cells, you will see an elevation stored digitally on some flash memory.

Please change.

MR. PEREIRA: Mr. Bateman, before we go too much further on to the Korean accident, could you touch back again on the database, the terrain database? You mentioned that Korea hasn't provided it. Is there a significant lack of worldwide coverage or could you summarize that briefly?

THE WITNESS: The -- the -- some countries still consider it a military secret. Basically in South America is a prime example of that.

The United States is in the position of releasing much more data, but we're very, very sensitive to political and military agreements with some of these countries. So, we've had to work as a company trying to acquire data any way we could, and the Russians have been very supportive in trying to do that for us because they're willing to -- they need money, and -- but some places still missing are the bulls in Brazil, the upper latitudes agreement.

But essentially we have most train data today, but not to the accuracies we'd like to have.

MR. PEREIRA: Do you have a map of the world that shows that coverage or --

THE WITNESS: Well, I apologize to everyone in this room that I did that terrible, terrible thing. I didn't match my view foils to the -- I thought we were.

Yes, as shown in blue areas what we're still missing, and you can see little bits of every country except the United States and Canada is very thorough, but most of the airports of the world that we're operating in, too, like Agana, is -- was covered.

Agana wasn't an original -- what we call a digital or a DMA release from the U.S. Government, but we -- we generate it ourselves before the accident and had it in place. So, we have some work to do in the blue areas there.

Korea is not shown as blue but it's basically very crude data, and -- and as I said, Russians have helped with -- helped us with some data for -- I see North Korea is filled in.

MR. PEREIRA: The large South American area, what's preventing us from getting that data?

THE WITNESS: Well, as I said, these governments, like Brazil, have border disputes with -- with Peru, Ecuador, not so much with Ecuador, but certainly with Colombia and Venezuela and -- and -- and Bolivia, and -- and it's difficult to get military to release anything less than 500,000.

In the United States, we have much -- we can -- our military probably has much of this data, but they certainly don't want to offend any particular country. So, we've had to assemble this.

In the Brazilian area there, you'll see some areas that are not covered. We've added those ourselves at great expense from satellites to be able to put terrain around key airports.

MR. PEREIRA: Have you exhausted all -- all of the possibilities with the U.S. Department of Defense on obtaining these data?

THE WITNESS: No. After the accident, after Brovnik and the White House, I think, we became very interested in -- in controlled flight into terrain. They've been slowly applying pressure on the -- on the military and the State Department to try to work out something reasonable with the different states involved, and I'm hoping, I'm very optimistic that more and more data will be released.

This isn't just data for our particular kind of instrument, but it's very important. It can be very, very useful for people who design instrument procedures, engine-out procedures, things like that. It's a great safety tool for us.

MR. PEREIRA: Is there anything in particular that you think the Safety Board could do to assist in getting these data?

THE WITNESS: I think just be supportive of efforts by FAA and NOAA and our military, too, and -- and -- and -- and with the State Department the best we can to try to get the individual countries involved to help.

MR. PEREIRA: For enhanced ground blocks, are there any future regulatory plans that are in the works?

THE WITNESS: I understand there's a notice of proposed rulemaking that has -- that I was briefed last week on this by an FAA person publicly, that will be called a notice of proposed rulemaking, has been generated requiring upgrading GPWS to enhanced GPWS, also lowering it down from 10 seats to six seats in the United States. This has been signed by the FAA Administrator Jane Garvey and has gone to the Department of Transportation for review and hopefully soon being published for the public to comment on.

CHAIRMAN FRANCIS: Can I ask a question here, Don? Is -- is there, in addition to the number of seats, also a -- a requirement that would affect large cargo aircraft?

THE WITNESS: I think the NPRM, as I understand it, will cover all Part 121 operations, and -- but -- and, so, it would cover the cargo aircraft.

MR. PEREIRA: Did they mention any proposed dates for implementation of the requirements?

THE WITNESS: Well, I think their target is something like 2003 to have all aircraft fitted. An interesting thing has happened, is that all the airlines, major airlines in the United States, through their collective industry representative called Air Transport Association, has made the announcement that they were going to equip these things voluntarily with no rule, and they will all be completed by 2003.

We've already sold -- I'm not a sales person, but as an engineer, I've been really baffled. We have orders for over 4,600 aircraft in hand, and by the end of this year, we will have delivered a thousand or over a -- we've delivered over a thousand this year. There will be over a thousand airplanes fitted in basically the United States by the end of this year out of about 4,300, I think it is.

MR. PEREIRA: Okay. Why don't we get back to the Korean Air 801? What kind of GPWS was it equipped with?

THE WITNESS: Well, that's going -- I'll show that in a couple of view foils. Let me finish this one picture of enhanced, and then we'll go back and look at the --

MR. PEREIRA: Okay.

THE WITNESS: The next one we have here. This is a profile as you show on the wall, and this is the terrain along the flight path as shown in these individual terrain cells, and you can see that we would have given an alert or warning or the first alert much like the MSAW system, is about almost a minute. In this case, it's about 50 seconds.

What it would tell the crew, it would show a picture, bright yellow, something's wrong. I'll show what that looks like, and it would say orally on an automated voice call-out, Caution, Terrain, and Caution, Terrain, and then it would repeat itself.

In this case, it would have heard Caution, Terrain, Caution, Terrain, and then seven seconds later, we would have heard Caution, Terrain, Caution, Terrain again. That would have been followed by a red set of cells which I'll show you with the oral voice saying Terrain, Terrain, Pull Up, and the pull up would have continued for 43 seconds or so to impact.

MR. PEREIRA: Don, where did you get the data for that graph?

THE WITNESS: From yourself.

MR. PEREIRA: Okay. And it's based on FDR data and the terrain data off the Agana map, is that correct?

THE WITNESS: Yes, sir. The cells along the bottom are what -- from the ground track that you had portrayed.

MR. PEREIRA: And you said the two warning times are -- are what, again?

THE WITNESS: They're 52 seconds is the caution before impact, which is considerably better than we could ever do with most ground proximity warning system times, and then 43 seconds, hard warning, until impact.

MR. PEREIRA: And --

THE WITNESS: Hard warning being Terrain, Terrain, Pull Up.

MR. PEREIRA: And what would the automated call-outs have been at those points?

THE WITNESS: Automated call-outs?

MR. PEREIRA: Or the oral alerts. What -- could you describe those at those points?

THE WITNESS: Yes. The oral alert is Caution, Terrain, Caution, Terrain, and then the hard warning is -- what we call hard warning is Terrain, Terrain, Pull Up, much like the existing GPWS.

MR. PEREIRA: Thank you.

THE WITNESS: The picture I can show you from existing terrain data would look something like this, and I'm sorry, in the projection system, it really doesn't show that well, but the screen is black, except for the colored area, the high ground of Guam, and you see a touch of yellow in the left-hand corner, and as the airplane's progressing down, the green would be -- indicate it's relatively safe, it's be careful, though, because the terrain is being shown.

Most airports, there would be very little shown here that the terrain is not -- the terrain is not a significant factor.

Next view. Next one. The next view foil is about -- as the -- as a profile or the aircraft descends further and further and further. We still don't see very much change.

The next one, please. At the 53 seconds from impact, we would hear this oral Caution, Terrain, and the screen would go a solid yellow indicating that something's wrong with the flight path. It's too low, there's terrain, something is wrong. This is something we would normally ever see in normal operation, and as we continue on, the next -- with the -- we continue our descent further and further.

Next one. We actually get the red -- solid red alert, which is Terrain, Pull Up, Terrain, Pull Up, and as you can see for both the Cali and this particular incident, if you had actually seen a display, and the display is up and operating, you probably wouldn't have done -- you would have probably, even before you got the alert, avoided the situation developing.

MR. PEREIRA: Don, is this the screen that would have showed up at approximately 47 seconds prior to impact?

THE WITNESS: Yes.

MR. PEREIRA: Okay.

THE WITNESS: This screen we're looking at would be like an existing color weather radar screen or an EFIS, which is like a map display in front of each pilot. Those exist in most airplanes today.

MR. PEREIRA: And this would show up on his screen without requiring any pilot action for selecting the system?

THE WITNESS: Most installations, the -- this display pops up automatically and without any pilot input. The pilot can select the terrain at any time, and -- and as I said, one of the new signal goals of EGPWS is the range the pilot has selected. So, the terrain will be automatically scaled correctly for the display involved.

Right now, -- thank you. Right now, this slide is out of date, but this was the beginning of the year. We have over 300 airplanes, jet airplanes now flying worldwide. British Airways was the first one to put it on a 747-400 over three years ago, and -- and every day, the fleets are being rapidly fitted.

American Airlines is one that's got a very, very brisk program followed by United, followed by Delta, followed by just about every airline in the United States.

Foreign operators are Lufthansa, British Airways in itself is going to fit their whole fleet, and the number of certifications, which is probably the most pacing thing we have, the base pacing thing is by the FAA, and they're trying to streamline things, and I hope that they can do, but we're over about 20 now certifications. We need to get to about 250 different airplane types and variations on that, and as I said earlier, the intent by the airlines themselves is to be fitted with -- with no mandate, is to be fitted by the year 2003, and as I said, we have -- we have no trouble getting convincing airlines to put this kind of equipment on their airplane.

MR. PEREIRA: Mr. Bateman, was Enhanced GPWS available for Boeing 747s at the time of this accident?

THE WITNESS: It was available for airplanes that were in production, like the 747-400. As I said, British Airways had one, 757-767, on the retrofit basis, but it was not available as a unit for replacing, directly replacing the 737-300 unit which was a Mark-7, and --

CHAIRMAN FRANCIS: Excuse me. 747-300 you're talking about?

THE WITNESS: Yes. I'm sorry. Did I say 737? I'm sorry.

CHAIRMAN FRANCIS: One of those 7s.

MR. PEREIRA: How about today, Don? Is it available for that type of aircraft today?

THE WITNESS: Yes. In June, we will have a certification for the 747 family, 200 and 300s. Boeing has a program to certify as quickly as possible production airplanes, and this week, I think, or maybe it was the end of last week, their 777s now are certified. So, anything leaving the factory will sooner or later have this kind of a system on it.

MR. PEREIRA: So, then Korean Air's fleet of classic 747s could be retrofitted after that point?

THE WITNESS: After June, yes.

MR. PEREIRA: What would a typical retrofit like that cost for a Korean Air 747?

THE WITNESS: Well, I'd say on the order of about $80,000 kind of thing. Most of the sensors are there, but they have to do -- it's the installation costs. Nothing goes into an airplane that's simple. It has to have some work on it.

MR. PEREIRA: So, that would include -- that would be an approximate number for both the hardware and the labor to install it?

THE WITNESS: That's correct, yes.

MR. PEREIRA: Does that include any rebates for trading in their old?

THE WITNESS: No. If the equipment is relatively new, and I think in this case, it was, there -- I'm quite sure financially, our sales people would make some kind of a trade-in because they're usable units to sell.

You asked me a question about the kind of equipment that was on the airplane, and -- and to -- to Korean Air Lines' credit, they had updated their original Mark-2, replaced it, updated it. It was a little late, but they did it, and they did it in August 1994.

With that, they got additional performance. They got wind shear detection alerting which is on most -- I think it's a requirement on all U.S. airplanes in the United States. They got radio altitude call-outs, and they got better immunity to unwanted warnings.

Do I have one more? Yes, that one right there. And as Captain Woodburn said this morning, if you don't know what you got for unwanted warnings, how can you improve anything?

This is -- with their permission, I show this. This is what it was like in 1993 for amount of unwanted warnings already across their fleet. They were having for that time span down there. This is for an A-320, but British Airways not only complained about unwanted warnings but produced hard data from what we call the focal program, and it was -- they have an excellent relationship with their pilots. So, it was not -- it was not -- it was meant just to try to improve the equipment.

So, progressively down to three years ago, we were quickly reducing the unwanted warnings, and we're still getting further improvement. So, the benefit that the Mark-7 that went into the Korean Air Line did get the -- the benefit of those unwanted alerts.

MR. PEREIRA: Okay.

THE WITNESS: The reduction in their --

MR. PEREIRA: And you did a simulation for us of the performance of the Mark-7 GPWS that was on Korean 801. Can you summarize that simulation in your findings and then advise us whether or not the simulation indicated that it performed as expected?

THE WITNESS: Okay. Go ahead. With -- with the aircraft in landing configuration and the Mark-7 that was installed on the airplane and a relatively stable descent into the terrain that was short of the runway and with no glide scope, there would have been no warning or alerts.

Radio altitude call-outs may have reinforced the pilot's situation perception of the distance to the DME if he was misunderstanding the DME was not -- was -- the DME was looking at was on the runway and unfortunately it was not, and apparently the Smart 500 with procedure was apparently not used, although almost all operators in the world now are using 500-foot call with a procedure that if you do not have the field in sight, as Captain Woodburn said, or see the runway approach lights in sight, you ought to wave off.

I don't know why the pilots flew through the last different altitude call-outs, but on the simulation tests we ran, --

MR. PEREIRA: Don, you mentioned -- just to stop you briefly.

THE WITNESS: Hm-hmm.

MR. PEREIRA: You mentioned that almost all carriers are using the non-precision approach, the 500 missed approach practice?

THE WITNESS: Yes.

MR. PEREIRA: Could you give us an example of some of the airlines that you're aware of?

THE WITNESS: Well, British Airways was one this morning. I think he didn't say that, but that's what he meant. United Airlines and -- and many of the U.S. other airlines, too, are doing that. Hm-hmm.

MR. PEREIRA: Have -- have you as a company disseminated your recommendation for that policy to airlines?

THE WITNESS: Well, we've put this -- all our equipment has this provision, and whether it's -- whether it's used or not depends on the operations people. I feel my company hasn't been strong enough in jumping up and down and maybe advising -- not advising, but asking them to do this, but we have recommended it.

When we put what we call the Mark-6 into the regional 135 operations, the 10 to 20 seats, that was mandated a few years ago, we rigged it so that it had to be disconnected. We built it in so the only way the airline could not have a Smart 500 was to disconnect it deliberately. But I think in this case, we met the provisions, and I think we were responsible in putting the provisions in, but maybe we didn't do a strong enough case in getting to the operations people on doing this.

But the Flight Safety Foundation and the airlines themselves have talked about this, and, so, I don't think it would be a surprise or something an airline, if they really wanted to work it, would know about.

MR. PEREIRA: Okay. Thank you. You can go ahead to the simulation.

THE WITNESS: From the data you gave us, we ran a flight path profile and -- and the radio altitude. The radio altitude had to be derived, which is unfortunate. Unfortunately, I didn't learn until yesterday, but we don't even have glide scope signals on -- on the FDR, which is very, very difficult for you investigators, but we ran that simulation, and we got one single sink rate, which correlated within half a second of the actual recorded time.

The descent rate was momentarily building to maybe something like 1,200 feet a minute, and we're down to less than 200 feet above the ground. So, it was -- it was a legitimate call.

The actual GPWS computer was recovered, as I understand. I know that it was recovered, and it was brought to our facility. It was -- it was significantly damaged. The front panel had been literally ripped off of it, and there was some damage to the IO, but some data was recovered from it which I think is significant.

The flight history for the last flight, which is Flight 1, as we call it, logged in one sink rate, which agreed with what was heard on the CVR. What we didn't understand, there was one mysterious bank angle logged in, but nothing heard on the CVR.

The bank angle was something you don't hear until you get to about 40 degrees of bank angle, but it also, when it gets down to about a 150 feet or less above the ground, it shortens up to about 10 degrees. So, I may -- my feeling and my -- my opinion is that the system was still functioning as the airplane was breaking up, and -- and -- and even though the CVR didn't log it in, there may have been some broken wires or something, but, anyway, it was -- the system was functioning.

I'd like to comment on this phenomena of -- of -- we talk -- we talked about -- I'm an engineer, and I'm a little worried about why radio altitude call-outs didn't break the train of thought. I'm not a human factors person, and as we said, this system worked as it was designed and installed, but why would a crew fly to the DME if that's a possibility?

I mentioned the suggestion is that if they were hearing call-outs, it would -- it would reinforce their thinking process that they really were going to the airport, and maybe that explains some of the initial call-outs but not for the latter ones.

Individually, I pulled out 88 international airports around the Pacific Rim, just to see how many times this occurred, and I also went back to a history, which I collect a lot of history, and I've got over 300 of these things, 300 of these things, and we can go on and on and on, and as the last speaker said, if we don't do something, we're not going to stop it.

It's a spectrum of things we've got to do to -- to beat it, to eliminate this as a loss of life and airplanes.

Out of the 88 airports I looked at, only six percent -- only six, that's about seven percent, had a single DME located off the airport. Yes, we know there's one off in Frankfurt and D.C. and so on, but those airports are typically filled with other nav aids, such as localizer DME or glide scope, and I've listed another two out of this list of 88 were without a glide scope approach aid.

if the glide scope had been operative at Guam, then we probably wouldn't have -- maybe this would not even -- it would not have been considered, but the key thing is here, is a single DME integral to the approach procedure and no glide scope.

Looking at the -- yes, the next one. Looking at the -- the probability of this occurring, it's a rarity. It's a rarity for these airports with an instrument approach procedure to have the only procedural DME located off the airport and with also no operating glide scope, and the crew in this case -- it would be interesting to go back and take a look, but I bet they flew the majority, 99 percent of their time, with no -- during just ILS approaches and no non-precision approaches.

So, the glide scope out at Guam, it became a non-precision approach with this additional hazards as one can identify, the airline can identify, and the CFIT control list. It's at night. It's a non-precision approach. It's over unlit terrain, on and on and on. These all give you assessments of -- of the risk involved.

So, the crew certainly is not perhaps groomed or -- or up to speed on non-precision approaches. That doesn't mean that they're not -- not -- that they don't have the skill factors or not, but they probably may not be expecting it.

An insidious CFIT trap then to my mind is the only DME navigational aid located off the airport and no glide scope data. Well, what does the history show? So, I went and looked at the history, and there were actually two examples of where the same thing almost happened to other airplanes and crews and passengers as what happened at Guam.

One -- the first example is in Lagos, Nigeria, a 747-200, and -- and the second one would be the St. John, British Columbia, in Canada, with a deHavilland-8.

Looking at St. John, the procedure for that, I know you can't read that back there, but maybe you could focus right on that DME in the airport. Can you do that? If you can look at that, and you'll see the airport is to the right of your screen at the bottom -- not the bottom, mid-part of the screen, and you see the VOR DME, which is like at Guam, off the field. It's about 5.3 miles off.

On this particular dark night, rainy and so on, this -8 -- next view foil, please. At Fort St. John was making this approach, a non-precision approach. You can see that the airplane almost hit the tower, the VOR and the tower on there. In fact, the crew believing that the passengers actually saw the tower go by above them, he -- he -- he reported it, as he should have, to his airline.

At the time, I didn't quite understand this because the airline said it was a mis-set VOR radio. I truly believe that they believed, the crew believed, the DME was on the field, and the reason this accident was avoided or potential accident and to keep it an incident was the fact that the airplane was not configured for a landing. It gave a Terrain, Terrain, Too Low, Terrain, and enough sufficient time anyway for the airplane to be -- the flight path changed and the recovery made.

The next -- my thanks to the operator. He's trying to improvise. I show on here two procedures, and the crew on this dark night -- sort of zero in on the right screen -- the right part of the screen or the -- yeah. That one. Just for the moment and sort of zoom in on it.

You see this is an ILS. It's a VOR ILS. It's got a DME that's off the field, and it also has a DME on the localizer, and many of the fields, I mentioned the Pacific Rim, have localizers, and they all have DME. I wish every localizer had a DME on it, but, anyway, this is what the crew expected, and when they arrived, that's the life of the pilot, is the unexpected. Regardless of what was NOTAMed or not NOTAMed or anything else, and that's why pilots have to talk to each other even before they start a trip, -- let's slide it over to the left. The other approach procedure.

This is what -- without any knowledge or clearance from the tower, he suddenly was faced with a VOR DME approach to Runway 1-9. He had no -- he didn't have the luxury of a DME on the localizer and the rest of it, and the localizer was -- the glide scope was flaky. I mean was -- it was moving around with a flag once in awhile, and that's what alerted the crew in the first place, maybe something's wrong, even though it's not NOTAMed or not referenced to them.

The next view foil, please. This is what the flight path profile would look like. They had prematurely descended to the DME, and the co-pilot calling out altitudes and distance to go, and -- and the crew is a vigorous -- I mean the airlines are vigorously enforces or practices CIM and -- and believes in the non-flying pilot speaking up when it's appropriate.

The co-pilot -- the navigator spoke up, the flight engineer, which they apparently ignored because they said, well, he's sitting back further, even though he's spoken up, he can't see -- really see the lights, which we can see, and they could see some lights, but as they got down further and further, they had a thousand-foot call-out, but when they got to the 500-foot call-out, it's what we call a smart call-out, it's normally not heard on the glide scope, with the glide scope working, and you're on the glide scope, the crew remembered that the procedure was to get out of there.

If you don't see the approach lights, you don't see -- you're not stabilized and configured for a landing, you wave off, and that's what Captain Woodburn was saying. It's very, very important that we do this.

I picked two of these just from a selection of a chart I made up which shows a whole bunch of these. These -- this trap of misusing the DME, being misread, misinterpreted or DME -- there's a DME hole in general aviation airplanes, is -- is -- is much more common than I ever thought it was, and let me -- when we worked on the Flight Safety Foundation, we tried to classify many of these into what we called traps, traps that inadvertently will trap the controller or a pilot, and that's my -- what I wanted to comment about anyway at the Guam situation.

MR. PEREIRA: Okay. In the case of an aircraft, an old aircraft, like a 727, for example, that doesn't have an FMS or a GPS, how do you go about completing the installation of Enhanced Ground Proximity?

THE WITNESS: Well, GPS is progressive, rapidly progressing to all the airplanes. It's still expensive, but in many units, we're putting a very low-cost engine, we call it engines, about the size of this credit card. Inside it is the whole GPS receiver, and we -- the cost is less than a thousand dollars to buy and put in there. We obviously want to make a profit on that, but the biggest thing to the airline or the most expensive thing in the airplane is to find room for an antenna on the roof, but it's a minor thing, and many airlines are going to do that, are doing that.

MR. PEREIRA: And if an aircraft doesn't have an EFIS display or weather radar display, is there another display type that can be installed?

THE WITNESS: Well, the minority of airplanes that don't have some kind of color display is -- there are a few. The old 727s and some of the DC-10s, maybe. But ourselves and others are offering very relatively little cost -- nothing's low cost in the aviation business, but very small displays that can be located in a central position or a key position for the pilots, and that's -- a lot of airlines are doing that, too, are thinking about that.

MR. PEREIRA: Similar to some of the small TCAS displays maybe?

THE WITNESS: Yes, it's about -- what do you call it? A 3 ATI. It's -- it's about -- it's about three inches diagonally, and there's a larger one that's a five-inch.

Amazingly, the general aviation corporate planes, they're putting these things, enhanced systems, into their airplanes faster than the airlines are with no mandate. It's wonderful.

MR. PEREIRA: With everything going so fast as far as demand, are there any problems with meeting the demand regarding production or certification?

THE WITNESS: No. As I said earlier, we've shipped -- I mean we've shipped over a thousand units earlier in the year. This year, we'll ship another -- easily another 2 -- 2 to 3,000 units to satisfy the on-going orders, and that's more -- you know, you add that up, that's more than half -- by the end of this year, we will have more than half the American airline fleet fitted, if we can get some help and cooperation from the FAA.

MR. PEREIRA: Do you mean on the STC process?

THE WITNESS: Yes. Certification process is turning out to be the bottleneck, and we -- we need to do more as a country to encourage other countries to -- many of the countries do not have an experienced certification branch. They rely -- whether we like it or not, they look to the United States as a leader. Sometimes we're a rather shabby leader, but we're a leader, and a leader in the aviation business, and we need to make the FAA -- try to help those people. We're not asking for extra work.

As someone said this morning, many of the FAA people are good people. Most of them are good people, and most are over-worked, but we got to find a way of doing it, if we're going to remain the leader in safety.

MR. PEREIRA: Can you describe some of the STC problems, and what you think the FAA can do to --

THE WITNESS: We still have only one person in the Seattle office that's handling these certifications. We need to streamline the process and make it grow. It's easy to throw bricks at the FAA. We are part of the problem, too. We need to be -- we need a memorandum of understanding, an agreement, with the FAA so we can use more informed engineers and so on to get this equipment in.

MR. PEREIRA: You mean like a DER kind of situation?

THE WITNESS: Yes, a designated engineering representative sort of thing, and it's working. It's -- but it's -- I'm -- you know, I'm a very impetuous -- I get -- I want to go and get it done right away, and I think in most cases, our customers, the airlines, want to do that, too. So, I'm hoping that the FAA can help.

The FAA's becoming more and more expensive to get something approved and certified, but I know they're trying, but they need almost -- bad nights or bad days, I go back to saying we need a revolutionary reform going on in the FAA, but I think they're trying to help.

MR. PEREIRA: Could you just briefly explain for some of the audience the reason why an STC is there? If you design this Enhanced GPWS, and it gets certified for one airplane type, why is there a delay in certification for another airplane type?

THE WITNESS: I think it's -- it's unfamiliarity, ignorance, on our part. We should be out training and making more people more aware what the system is, and there's a great conservatism. It's almost like tar or molasses in trying to get some changes made in regulatory bodies.

As the previous speaker spoke, I feel very strongly if we don't get our regulatory bodies involved in the safety process, really working with us at the -- at the start of these things, there's no commitment on their part. It's not going to happen.

Five years ago, the FAA didn't -- they believed there was no CFIT risk. The NTSB didn't. But the FAA didn't think there was any kind of risk. It took Cali, it took -- even the 129 accidents that were going in and out of the United States with FAA people on board, it still didn't get their attention, and, finally, when we had Dubrovnik with a 737 carrying the Secretary of Commerce and a bunch of business people, then it really got started to get the attention, but up to then, -- everybody wants to get out on the bandwagon now, but we need fundamental regulatory involvement right up front, and the Flight Safety Foundation is the place to start with.

As the previous speaker said, we couldn't get one air traffic controller or manager from the FAA to come, and here we had a separate committee on ATC. We couldn't get many of the world body to -- there was -- there was this great wall between air traffic control and flight standards or flight operations, and this shouldn't be.

I'm ashamed. I've tried to phone and get information from the FAA on the MSAW system because MSAW system, and what we're doing are very, very similar, and very, very similar, we have -- we must have similar problems, and we have similar problems, maybe we could collectively work on them, and we've done a lousy job on that.

I was very impressed with the previous witness two days ago that said they're ready to do something about MSAW. I know I've wandered off a little bit, but MSAW has saved a lot of airplanes in the United States, and shame on us for not doing flight inspections on a system that's put in there.

If we were to do that in our equipment, we would be hammered so hard on software, the lack of software and everything else that they did, we would financially pay a terrible price for that and also a moral price for it.

MSAW is something that's here, and I have -- we have no business leverage on this or -- the -- the rules -- air traffic control radar, almost all of it has got the hooks in for the United States MSAW system. Not one country -- okay. There may be an exception, but in my eyes, one country has really vigorously worked this.

The United States has tried to help, I believe, and I believe the FAA could make it even better if they could write the thing simpler about what the system is, but every country in the world should do this. Shame, shame, shame on any country who doesn't utilize the existing MSAW, the equipment's in place.

We're going to -- we're losing lives out there, and MSAW is a wonderful system. It's been bought, it's there, and the radar's been bought and paid for. It could be made to work very easily just with some determination.

I know there's a political problem. The -- you know, in some countries, the controller has no protection against -- if he makes an error, and it results in an airplane being piled in, he can be held -- charged with manslaughter. Pilots can be thrown in jail. We don't have the kind of environment that -- that kind of legal protection that should be worked out for those MSAW people -- I mean the controllers and for the pilots.

We have to work, unfortunately, in a very harsh environment, but MSAW is something that could be done and would save airplanes today.

CHAIRMAN FRANCIS: Let me just make a comment about the STC in a broader sort of look at this issue. I took the opportunity at the last break to -- to talk to the FAA about this. I think that they've gotten the message in terms of the -- the kinds of cooperative efforts that are necessary here, and I don't -- while the FAA certainly has its share, as you pointed out, there are all of us that have conservative people and don't know everything that we can be doing, but I -- I do think that -- that it's particularly incumbent on the regulatory authorities to be -- to be active in this area, and where you have -- where you have a situation with a major effort going on and the activity that is killing the most people in the world and to not have the regulatory authority and the air traffic control authority actively involved is -- is -- is unfortunate at the very weakest way that one could put it.

So, I think that the FAA is getting this message, and I certainly think that the -- the Administrator of the FAA is certainly in everything that she says and does very philosophically and actively involved in -- in these cooperative kinds of efforts that -- that this represents.

So, I'm confident, and I hope, and I certainly personally will -- will be involved in trying to make sure that -- that we all go forward with this, including the STC issue.

THE WITNESS: It's -- the industry really -- the airlines, they're really sincere about improving safety. Well, maybe some aren't, but most are, and you're right, the FAA, the manufacturers of the air frames, they all have a very positive outlook on this, and there's many people in the FAA have a very positive outlook on this, too, and all we need to do is cooperate and get -- and do it. That's all.

CHAIRMAN FRANCIS: Charlie, do you have more questions?

MR. PEREIRA: Yeah. I have a few more. Do you think -- you mentioned that MSAW is very important, and obviously GPWS is very important. Do you think there could be some better coordination on the technical level or a committee level between the people responsible for GPWS and MSAW?

Everyone seems to have taken a separate isolated approach in terms of systems to this point. Do you think perhaps the Flight Safety Steering Committee or some other steering committee could bring those two efforts together to try to see how the -- you mentioned we have a five-degree climb angle for the one warning envelope and 60-degree climb angle for the other envelope.

Do you think that there could be some coordination that could help improve each side?

THE WITNESS: Well, this meeting was very -- this hearing is very informal to me. I didn't realize the MSAW system was not working, actually deliberately almost disconnected, if not that.

I just didn't realize that, and I make a personal vow to myself that I'm going to talk to the FAA about the two systems, try and drag them out together. We -- we can do a lot of good together talking about this. They have the same kind of system as we have, and we just -- it's unfortunate, and I -- and I accept some responsibility for not talking, but I just didn't realize they were restructuring and reformulating the processes for MSAW.

MR. PEREIRA: And then I have one last question. I just wanted to verify. We didn't get to touch on it, but the simulation that you performed for the Korean Mark-7 GPWS, did that indicate that it functioned properly and as expected?

THE WITNESS: Yes. It logged in the fact that there had been a sink rate alert. You had a sink rate alert on -- on the -- on the CVR, and that all correlates for -- well. The system, I hate to say this, worked as designed.

The thing we really didn't know, as I pointed out, we need to know where the end of the runway was, and we're getting that information now, and that enables us to -- to provide something better. But at the time we had, the equipment did its job and functioned as it was designed.

MR. PEREIRA: Okay. Thank you, Mr. Bateman. I have no further questions.

CHAIRMAN FRANCIS: Can I just make another editorial comment here because it's interesting that Don's here. The importance of this hearing and -- and conferences and meetings and having people at -- at these kinds of events. I mean we've all got to make an effort to have our people out in the community talking with other people, and I'll cite a personal instance.

Don, I flew with him in the -- in the King Aire where they demonstrated this, and as we were flying back, I asked him if he knew John McCarthy, who at that point was at the National Center for Atmospheric Research, doing very similar kinds of work. They were working on displays for weather for pilots on glass displays in aircraft, and it turned out that these two people knew of one another but didn't know one another.

So, we ended up because of this generating a meeting between -- between Don and John McCarthy, and I believe they're now working together to have a coordinated effort to display of weather and terrain data on display. So, we've all got to be out talking to people and communicating and being aggressive.

We can't say I can't afford to send somebody to this meeting because he'll be out of the office for two and a half days, and it will cost $300. We can't afford as organizations, whether it's the FAA, the NTSB, or Allied or whoever it is, not to have our people out talking with other people, because this is showing us what we're losing and what we're wasting.

Korean Air?

CAPTAIN KIM: Thank you, Don, for giving us a chance to speak on a few matters.

Mr. Chairman, we've had some difficulties in the translation and live interpretation going on, and for the benefit of the people who will not have access to the recorded transcript, we would like to clarify just a few points. Do we have your permission?

CHAIRMAN FRANCIS: Briefly.

CAPTAIN KIM: Briefly. You used the word "retrofit". Would you please explain that in a few words, what retrofit process involves?

CHAIRMAN FRANCIS: Do you want me to explain it or Mr. Bateman to explain it?

CAPTAIN KIM: Don, would you please explain it for us?

THE WITNESS: Well, retrofit to me is -- is an older -- an airplane that's been delivered by the aircraft manufacturer and is in service, and, so, if you want to put something new on it, that's part of retrofit. You may be retrofitting older equipment that's on -- an older system on the airplane. That's what retrofit in my mind means, is replacing.

CAPTAIN KIM: And I remember, if I may quote, you said it was to Korean Air Lines' credit to -- to have updated the Mark-2 system to the Mark-7 which is the most current model available for the accident airplane, is that correct, sir?

THE WITNESS: That's correct.

CAPTAIN KIM: Thank you. And then just two points on the comments you made. You said about 99 percent of the precision -- the pilots would fly 99 percent precision approach and with no non-precision approach experience. Would you say that's a conjecture on your part?

THE WITNESS: Well, the number of nav aids and the preference by most pilots to fly a glide scope is very high. It may be not 99 percent. It's going to vary, depending on your route and the particular airport you go to. It's amazing how well equipped the international airports are equipped.

CAPTAIN KIM: Right. Would you say that the 99 percent figure that you quoted differs from the facts established on the first day of and the second day of this hearing?

THE WITNESS: What facts was that?

CAPTAIN KIM: About the testimony of our witnesses regarding the exposure to non-precision approaches.

THE WITNESS: Well, I don't want to accuse them of -- of giving erroneous testimony or anything because I think they probably gave what they thought was correct testimony.

I did personally look at 88 airports around the Pacific Rim. So, my observations were based on those.

CAPTAIN KIM: Thank you. And the Smart 500, regarding that, you said almost all carriers use this procedure, is that correct, sir?

THE WITNESS: Yes.

CAPTAIN KIM: And then how many carriers are you aware of throughout the world?

THE WITNESS: I think it's sort of like assume it's been done. We mentioned British Airways, United. I've never paid much attention to this. You can say all the small 10 to 20 seat airplanes, they're all using it, too. It's become a -- it came out of the Flight Safety Foundation.

The first carrier I know that used it was -- was Pan American Airlines.

CAPTAIN KIM: Would you allow me the disagreement with your comment about almost all worldwide carriers have used the Smart 500 procedure? Would you allow me that --

THE WITNESS: Yeah. You can disagree, if you want.

CAPTAIN KIM: Okay. Thank you. No further comments. Thank you.

CHAIRMAN FRANCIS: Barton?

MR. EDWARD MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing?

MR. DARCEY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you. We have no questions.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: No questions.

CHAIRMAN FRANCIS: Mr. Cariseo?

MR. CARISEO: No.

CHAIRMAN FRANCIS: Mr. Berman?

MR. BERMAN: Thank you, Mr. Chairman.

Mr. Bateman, would you please comment on the procedure for GPWS alerts that doesn't mandate a go-around if a sink rate or terrain secondary-type warning is received in instrument conditions? Have you -- are you aware of any air carriers that -- that do have such a mandatory go-around?

THE WITNESS: Well, I can speak my opinion, I guess. When we first started with GPWS, all we had was a whirling tone that something was wrong, and then when Boeing really got started to pursue trying to make this piece of effective safety system, we added in the 747 days the word "pull-up", and a lot of the procedures then were rather dogmatic.

Then we introduced voices, which Mark-2 designs or second-generation designs that are reflected where we had sink rates, glide scope alerts and so on, and -- and these -- depending on the situation, my opinion is anyway you may -- you may mis-correct the flight path if you have -- if you have assessed the situation in the cockpit, everything's all right, you maybe can see outside, it's probably a modest -- it's

-- it's not a significant thing that would call for a go-around or missed approach.

But if you got a sink rate in the dark, and you don't see the ground, you better think twice. You better assess your situation, assess the instrumentation you have to work with, and -- and how far you are in the approach. You may want to get out of there right away, and some of the airlines, I think, are teaching that. I'm not an expert in flight operational matters, though I am a pilot, but I think some of the -- I think all the airlines would -- would like the crews to take deliberate best approach procedures on hearing an alert that they shouldn't have -- should not be hearing at that point in the approach.

Glide scope is heard quite often, but it's -- it's an advisory. There's usually sufficient time, but in most cases, they take corrective action to get back on the glide scope, and that's the end of it.

MR. BERMAN: Thank you, sir. I just wanted to get a clarification of one of the -- one of your statistics from a few minutes ago. I'd like to know of the two airports that you mentioned that had an off-site DME and no glide scope installed in the Pacific Rim, on those two airports, is the off-site DME integral to the non-precision approach that is there at the airport?

In other words, is it used for identifying the final approach fix or a step-down fix?

THE WITNESS: Yes. I brought some notes along, but I don't have them with me, but there is a few of those, yes.

MR. BERMAN: Okay. A few of those approaches but only at those two airports, I guess?

THE WITNESS: Yes.

MR. BERMAN: Okay. Mr. Bateman, I'd like to put up an exhibit which is 9-D, Page 1. I'm sorry you don't have it in your package probably, but you'll see it on your screen momentarily. Okay. 9-D.

If you'll just pan down a little bit, Ted. Yeah. Right there to those two columns. That's the -- that's the results of the post-accident testing of the accident ground proximity warning system unit, and it has a counter of the warnings that had been received by that unit during the preceding, I guess, 5,442 hours of operation.

We note that there are a number of warnings that had been received in the history and -- and clearly understand some of those may have been due to testing conditions and other -- other issues, and I'd like to get your comments on -- on this history as you see it.

THE WITNESS: Well, you -- you put your finger on the first item. I mean the first thing I would respond with is quite often, the airline or the installation time or inspection may deliberately simulate conditions to get the alerts to occur. In this case, sink rates. They're very difficult to run, but where the radar altitude is closing very rapidly, so they had to test that.

So, you know, descent after take-off, those sink warnings, there's three of them shown here, that would be very -- very, very rare, if ever. I would think this is just a test condition that they did.

MR. BERMAN: Okay. I'm sorry. Go ahead.

THE WITNESS: Looking at this information here, it shows that there were 8 -- roughly 860 flights. I assume -- I don't know if this particular computer is the one that was installed at the time of

-- of -- in August 1994, but it probably was. It may have been replaced. There's no indication of -- on -- it's a very crude warning counter.

MR. BERMAN: Are there different modes tested individually or -- or would you expect the mode counter to go up in any particular pattern for a GPWS test as you require them to be tested?

THE WITNESS: Oh, it depends on the test sequence they ran on the ground. Normally, when you do a self-test from the cockpit, it doesn't do anything to this flight history. So, this would -- when I look at this, this has actually been -- these alerts have either been caused in operation, real-flight operation, or in testing, and it's a very crude indication.

We were interested in -- in the flight hours and the hours operating time and the departures to help.

MR. BERMAN: Okay. Thank you very much. I have no further questions.

CHAIRMAN FRANCIS: Mr. Montgomery?

MR. MONTY MONTGOMERY: Thank you, Mr. Chairman.

Mr. Bateman, this looks to -- the -- the enhanced system looks to be a very -- very comforting item for a crew to have. It gives them an excellent sense of where they are relative to -- to dangers and does a lot of the worrying for them.

How does your system respond or -- or, better phrased, how would -- how would a crew know if they're flying into an airport where you do not have the digital terrain data available and the system performance is not as good as it could be?

THE WITNESS: That's a good question. In those areas I showed in blue, you were getting the airplane -- they would be showing what we call a purple haze. It's a light background to indicate the terrain is not there.

But as the airplanes have gone into service, and especially with Enhanced GPWS and especially those airplanes that are in corporate -- where they go to really strange places, they don't like to talk about them, we have discovered a few airports that were not

-- that -- that -- that they're not in an airport database anywhere. So, we had to add them.

Typically they're like inside the area or some places. India was one place, but in schedule operations, it's been a rarity that we're missing airports.

One -- the Russians are opening up more and more civil fields for civil -- military fields for civil use. So, we've been surprised. Perm -- Perm in the Urals was one that Lufthansa ran into. So, we have to make quick update to add the runway ends, and when you -- every time you add a runway, you want to go into more detailed terrain around them, and, so, we've done that.

Does that answer your question?

MR. MONTY MONTGOMERY: Yes. Thank you very much. That's all I have, Mr. Chairman.

CHAIRMAN FRANCIS: Thank you very much, Mr. Bateman.

THE WITNESS: You're welcome.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: I don't think that it's practical to try to finish before lunch. So, we will now break for lunch. It's quarter of 1. We will be back here in an hour, please, quarter to 2.

(Whereupon, at 12:45 p.m., the hearing was recessed, to reconvene this same day, Thursday, March 26th, 1998, at 1:45 p.m.)

A F T E R N O O N S E S S I O N

1:45 p.m.

CHAIRMAN FRANCIS: All right. Our next witness is Mr. William Henderson, Manager, Western Flight Procedures Development Branch, FAA Regional Office, in Los Angeles.

Whereupon,

WILLIAM HENDERSON

having been first duly sworn, was called as a witness herein and was examined and testified as follows:

TESTIMONY OF WILLIAM HENDERSON MANAGER, WESTERN FLIGHT PROCEDURES DEVELOPMENT BRANCH FAA WESTERN PACIFIC REGIONAL OFFICE LOS ANGELES, CALIFORNIA

MR. SCHLEEDE: Mr. Henderson, please give us your full name and business address for the record.

THE WITNESS: My name is William Henderson. I'm the Manager of the Western Flight Procedures Development Branch.

MR. SCHLEEDE: I'm sorry. I missed the -- I didn't quite hear.

THE WITNESS: I'm William Henderson, the Manager of the Western Flight Procedures Development Branch, and the office is in Oklahoma City, with the Mike Moroney Aeronautical Center, at 6400 South McArthur in Oklahoma City.

MR. SCHLEEDE: And what is your position with the FAA?

THE WITNESS: I'm the Manager with the Western Flight Procedures Development Branch. AVN-120 is --

MR. SCHLEEDE: Could you give us a brief summary of your education and experience that qualifies you for your current position?

THE WITNESS: Yes, sir. My formal education was in aviation business management with a semester of graduate work. I am an ATP pilot. I've got 12 years of experience with the procedures specialty in the FAA. I was a flight check pilot in procedures development, a specialty doing both things.

I was in the Southwest Region as an aviation safety inspector in the procedures and a retired Air Force pilot, jet instructor for 10+ years. I was the chief of the Standardization and Evaluation and the evaluation check pilot and the chief of the Instructor Pilot Upgrading.

I was also an Air Force accident investigator. I was a simulator instructor. After retirement, I became a corporate pilot. After that, I was a demo pilot for one of the largest GA distributors in the country, owned my aircraft, sales, and am currently an aircraft owner and an active pilot and have been since 1953.

MR. SCHLEEDE: Thank you. And when you mentioned procedures in the earlier part of your background, what -- in what -- what type of procedures? Could you elaborate?

THE WITNESS: Okay. Instrument approach procedures.

MR. SCHLEEDE: Thank you. Mr. -- Captain Misencik, proceed.

CAPTAIN MISENCIK: Good afternoon, Mr. Henderson. How big of a staff do you have in your office?

THE WITNESS: I have a staff of 35 that is in four different physical locations.

CAPTAIN MISENCIK: How many of those people are rated pilots?

THE WITNESS: I have, including myself, there's 13.

CAPTAIN MISENCIK: I see. Could you briefly describe your duties for us?

THE WITNESS: I manage the resources in those four groups, and in the instrument approach procedures specialty is what we work at, designing the procedure, setting it for flight check, and sending it for charting.

We also do the OE program, which is Obstacle Evaluations, of anything in our areas of responsibility that's to be constructed, and air space analysis, and environmental issues that become with the approach procedures that we don't need or the current environmental study, if we need one, or we can do an exclusion to it.

CAPTAIN MISENCIK: I see. What documents provide guidance for your duties?

THE WITNESS: Well, the two main manuals are the TERPS manual, which is 8263(b) and 8260.19(c), which is an FAA manual, and several other orders of the 86 series for some military or 15(c), 32(c), 34, 36(a) for MLS, 38(a) is for GPS, 37 is for helicopter GPS or MLS for helicopters, and 42, 44 for nav departures, 46 for instrument departures, and several others, but the -- the two main manuals are TERPS, that is for all joint services in the states that use instrument approaches.

CAPTAIN MISENCIK: Could you briefly explain for us the concept of TERPS?

THE WITNESS: TERPS, before I got into it, I believe it was about '68, it was adopted as a standards for all instrument approaches in the national air space system used by all of the users, the FAA, for the civilians, the Army, the U.S. Air Force, the U.S. Navy, and the Coast Guard.

CAPTAIN MISENCIK: And could you also describe the process by which an approach is -- approach procedure is developed and certified?

THE WITNESS: Yes, sir. The approach can originate from any requested source, airport owners, from pilots, air carriers or any other user. We funnel all of those through our flight procedures offices which are located at the regional headquarters to do the initial contact because we always like to -- we want the airport owner-operator to be involved, that he or she would want that approach to their airport. That requires a feasibility study to be done to see if we could possibly do one.

The additional coordination is -- the initial coordination is started there with all of the users at the different services, and the airport owner, air traffic AF airports, flight standards, the -- the user that requested that the owner of the airport, and if they have any pilot inputs at that time to see if we can do them.

They continue that process and gather the data for the airport, so we have a firm good data to use, see if it is feasible. The environmental issues need to be looked at, as I said before, to see if we could have an approach and be friendly with keeping the noise down and environmentally.

As I am responsible for signing an exception to a complete environmental and we can do that if it normally follows the same traffic that flying in there without any increase in traffic as most instrument approaches do not increase it a lot.

After the complete package is -- initial coordination is accepted, and it's feasible, the environmental -- it's then sent to Oklahoma City where our specialists research the -- the procedure, seeing that we do have the good data, the best maps available, the largest -- the best maps, I mean the largest scale that we can use and have available, and design the procedure according to TERPS.

CAPTAIN MISENCIK: Excuse me. Mr. Henderson, could you maybe just get right down to the specifics of how you -- how you -- what -- how you construct a -- an approach procedure? What data?

Like, for example, the -- could you tell us how the 8260 forms fit into the process?

THE WITNESS: The 8260 form is the form that is filled out that has all of the pertinent data from the terminal areas to the missed approach and the final. It's put on that form, sent to flight check, flight check certification, and before it goes to flight check, it goes through our quality assurance staff to see that we're in compliance, and we go to flight check, flight checks, back for my signature, sent to NFDC, put on a transmittal letter, and sent to NOS for publication.

CAPTAIN MISENCIK: Okay. Could you tell us how the obstructions are located, and how their heights are determined for an approach procedure?

THE WITNESS: Map study and our instrument approach procedure's automated base that is updated weekly with all the obstructions that -- in a particular area.

CAPTAIN MISENCIK: How often are these obstruction heights checked?

THE WITNESS: The obstruction heights are verified on our flight inspection, and as you heard earlier, this flight inspection varies on different approaches and time when the reoccurring, and they're verified each time, flight checked, that the obstacle height is still there, and it's the same.

CAPTAIN MISENCIK: Is there any way to check on unauthorized or how -- how -- how is that taken into account, unauthorized construction or -- or tree growth?

THE WITNESS: Well, the OE program I spoke of awhile ago is a requirement that anything built on a 100:1 plain from an airport, there's a federal order requiring it be filed with the FAA, and anything over 200 feet any place is required. Have the specialists in areas that -- of responsibility in, say, the Western Pacific Region that -- put our inputs into that program for every obstruction known.

If it's unauthorized, it's built, it's found on our flight check or if we have the pilot community will call in and say they see something being built, and we will investigate it, and it goes back to our OE program for that.

CAPTAIN MISENCIK: Okay. Thank you. When you develop an approach procedure, what determines the segment altitudes? Is obstruction clearance the only criteria?

THE WITNESS: No, sir. That is the minimum requirement, is obstructions. Then we have air space, environmental as I talked about, air traffic needs, users needs, and it just must fit the puzzle with everything else around it.

CAPTAIN MISENCIK: When -- for example, at Guam, we have an ILS procedure and a localizer procedure. Are the segment altitudes for the protected air space the same for both procedures?

THE WITNESS: No, sir. The altitudes are computed differently. The area is slightly different for the two approaches because the trapezoid or the area of protected air space from the final approach fits in is slightly different, in the missed approach is slightly different.

We use the worse case for both of them, could use the missed approach on -- for the ILS and localizer, but the localizer has a one required obstruction height all the way through it, and the ILS is the best we can do, and it gets down to which we know it was, 200 feet of a height above the airport for the DH.

CAPTAIN MISENCIK: I see. The -- would you say the ILS or the localizer has -- which one would give the -- the greater obstacle protection?

THE WITNESS: Well, the ILS because of the glide scope is a different protection. The localizer would have a standard of 250 feet versus the 200 feet. So, you would have more height above an obstacle with the localizer, but you don't have the glide scope. Glide angle is --

CAPTAIN MISENCIK: I see. Going back to the Guam ILS approach, are you familiar with the origin of the -- the ILS 6 left approach at Guam? Was that originally a military approach turned over?

THE WITNESS: Yes, sir. That approach to my -- best of my knowledge, and I can find out, has been there 20+ years. It was -- the ILS was commissioned in 1972, basically the same approach. The closing of different military bases throughout the world have opened up some of those airports for civil use. That airport also was a joint use civil use for all the time that I can -- back to those 20+ years that I've been able to find out.

But we took over the responsibility to design the procedure, and the closing was in '95. We got the procedure in '96, and it was an agreement that the Navy would keep the procedures in until the FAA could produce them because of the user's needs.

CAPTAIN MISENCIK: Are the TERPS applied differently at military airports, civilian airports, or joint use airports?

THE WITNESS: No, sir. The standard TERPS for all the services that use them, the military and the FAA, are all the same. The difference being a military has an operational advantage to do -- to change something in TERPS, they can do that with their operational advantage, but the approach would be noted as not for the civils to use.

CAPTAIN MISENCIK: Okay. Just to make sure I understand that, you're saying that the military could have a special approach, but that wouldn't be available to -- to the civilians on a regular basis? Is that what you're saying?

THE WITNESS: Yes, sir. That's -- and it would be noted that the civilians would not use that -- could not use that approach.

CAPTAIN MISENCIK: When a military airport becomes a civilian airport, like Guam did, was turned over, what time table do you have to have it flight tested, have the procedures flight tested to make sure they're in compliance with your -- your regulations?

THE WITNESS: We look at the procedure, and if -- we assume that it's -- it's all right until we find there was something different, and we would develop it. If we leave the procedure there, if it was needed, and there is no noted note for not civil use, that they could use it as they were doing it before.

When we developed the procedure, we will design it. If we find any flaws at that time, we would immediately correct them.

CAPTAIN MISENCIK: Has Guam been flight tested since it's been turned over?

THE WITNESS: Yes, sir.

CAPTAIN MISENCIK: Do you recall how many times or the last time that it's been flight tested?

THE WITNESS: I believe the last time at Guam was right after the accident, and that was a special was done, and that is not in my area of expertise of tracking flight inspection, except that it was done and commissioned.

CAPTAIN MISENCIK: Was it done since it was turned over but before the accident?

THE WITNESS: I believe it was. Yes, sir. I don't have those -- those dates.

CAPTAIN MISENCIK: That would be under -- where would we find that? On 8260 forms or --

THE WITNESS: You'd find some on the 8260 forms and would find it in the flight inspection operations that become the state's permanent records.

CAPTAIN MISENCIK: I imagine you've studied the -- the approaches at Guam. Do all the approaches -- are they in compliance with -- with the TERPS regulations?

THE WITNESS: Yes, sir, they are today, and they were when we published them. When we looked at those, there were two that were noted with high descent angles, higher than standard, that we changed the procedure to be the VOR. It was to 6 left, it was a straight-in with a higher-than-standard descent rate, and we changed that to a VOR alpha.

CAPTAIN MISENCIK: The -- the approach plate prior to the one that was in effect during the accident showed a -- a lower VOR crossing altitude than at the time of the accident. What necessitated raising that

-- that altitude?

THE WITNESS: My recall that we had two changes on that approach. We have a requirement for the civil areas to have an air space requirement in the intermediate just prior to the final approach fix of a thousand feet above the ground, and then the obstruction that we discovered when we did the procedure raised the minimum at the VOR.

CAPTAIN MISENCIK: When you're developing or certifying an airport, do you normally solicit user group input into that process?

THE WITNESS: Yes, sir. We do that in the -- two times, basically. The original coordination from my office that's in the regions, and we send out requests at that time from the airport owner and -- and any of the pilot information that they may have.

Before the procedure is published, we send it for coordination with all of the user groups and give them 20 calendar days, and we use a standard 30 days before we would do any action on the procedure to give them a chance to review it and answer to us if they have any questions or recommended changes or --

CAPTAIN MISENCIK: What would be some examples of some of the user groups you solicit input from?

THE WITNESS: We use ALPA, ATA, AOPA, the American Airlines, ANR, whatever their user group of the American, the air traffic folks, the airport operators and the owners.

CAPTAIN MISENCIK: Do you have -- were there any significant comments or criticisms from other user groups when the Guam approach procedures were being turned over from the Navy and being certified by your office?

THE WITNESS: No, sir. We had none, and I checked with the Navy if they had any known users complaints or problems, and they had none.

CAPTAIN MISENCIK: When you're -- when the flight procedures office was transferred from the flight -- FAA Flight Standards to Air Traffic Services, how did that affect the way you did business, Mr. Henderson?

THE WITNESS: It -- it only changed that they were part of Flight Standards, and they did basically the same job that they were doing and fed the information to us to be used in procedures design or development and time frames. When they became our responsibility, they report to me, and then I have just a bigger area that I'm responsible trying to satisfy all the customers out there.

CAPTAIN MISENCIK: Did it affect the input from user groups in the process?

THE WITNESS: I don't think so. No, sir.

CAPTAIN MISENCIK: There's been some comments have come out regarding the Guam approach. They're in the factual -- operational factual report. One pilot said it's an unusual airport approach and takes a local knowledge to fly it. Another pilot said the approach to Runway 6 left has to be well briefed, and the pilots have to pay close attention to the approach to make it successful, and another pilot stated there should be a dedicated non-precision approach plate for the localizer-only approach to Runway 6 to help alert crews.

How would you respond to those user comments?

THE WITNESS: Well, first of all, I respect all those pilots' comments. I personally don't think it's a particularly difficult approach. I think local knowledge from any area in flying is beneficial. It has been my belief that the air carriers do that and have their captains fly it before they fly it as the captain to a place normally.

To the second part of that question was that the other pilots -- the second one was that -- oh, it was well briefed. I believe that is true. I think every mission -- every flight should be well briefed all the way from starting engines to shutdown.

And the third one of a different approach, I have been taught, and I taught as an instructor, when you're flying an ILS, you automatically would start timing at a FAF, which is not necessarily the same as the ILS, for the approach or if any reason, you lost the glide scope in your aircraft or on the ground, you could continue on the localizer approach as long as you hadn't gone below the MDA, and the approach is right in front of you, and you don't have to fumble and try to find another approach to complete it or make a missed approach.

CAPTAIN MISENCIK: Have you given any thought or consideration to making a dedicated localizer approach to the Guam ILS?

THE WITNESS: No, sir, I haven't.

CAPTAIN MISENCIK: Are you aware -- are you aware of any other approaches where a VOR is an integral part of the non-precision approach localizer procedure within the final approach segment and where the VOR is used as a step-down?

THE WITNESS: I can't recall particularly a

-- where there are VOR at that point. However, we have many, many approaches with a different piece of equipment or additional equipment required to fly the approach throughout the NAS. There's over -- there's over 10,000 approaches.

CAPTAIN MISENCIK: TERPS -- the TERPs procedure, 288(c), states in the final segment, "Minimum shall be published both with and without the last step-down fix, except for procedures requiring the DME."

Since the DME is not required in the final segment, why isn't there a 1,440-foot MDA also listed for this approach?

THE WITNESS: If you look at that paragraph, and that's the only thing you would consider, it has some shortcomings, such as a DME fix on -- the order 8260.19(c) states that as one area that you would have two sets of minimums.

All the -- the -- the requirements for second sets of minimums in 19(c) are additional pieces of equipment that the pilot does not need to fly that approach successfully throughout the complete approach.

On the Guam approach, the VOR is absolutely mandatory to have to successfully fly that approach entirely. If we had a second set of minimums for the VOR without the VOR, in my opinion, that would lead the pilot down a path that he would think he did not need the VOR for that approach, and if he got down to the minimums and tried to make a missed approach, the missed approach is required for the VOR and the DME, and we -- if he had a lost column, there's no place to go, and he has no idea where he needs to go.

CAPTAIN MISENCIK: I'm not sure I understand why the VOR is required in its entirety for the -- for the approach if there would be VOR out minimums.

THE WITNESS: The VOR is a -- we use a -- a -- not a vector but a route to get in from the end route in case of lost column. We give the pilots a way to get to shoot the procedure. If you get to the minimums and make the missed approach, you must have a way to go to the missed approach, either holding fixed or the end-route system.

On this system that we have here, the uniqueness of having just one big VOR in this part of the area, that that is part of the missed approach, and the DME is the missed approach holding fix.

CAPTAIN MISENCIK: Could you explain the meaning of the note DME required on the approach plate?

Do we need -- would you like to refer to it on the board? Could we have Exhibit 2-N, please, Ted? On the top of it, there's a note.

(Pause)

THE WITNESS: The missed approach is down here, but if I had -- we had minimums with this -- stopping here, the pilot would continue with this track without the VOR, he would be sort of lost in space and not having a way to get back to the holding fix and especially if you have a lost column, and that's where we take the worst case.

CAPTAIN MISENCIK: I -- can you think of another airport under FAA jurisdiction with an approach that has the note just DME required?

THE WITNESS: Having a note of DME required only? No, sir. But I can think of many approaches that have different equipment required from single -- this one VOR to VOR -- I mean DME to DME or radar or ADF required.

CAPTAIN MISENCIK: Could you explain why, if DME is required, it's not listed in the title, like ILS/DME?

THE WITNESS: Well, to fly a procedure or to be named on a procedure, the procedure name is arrived from what it takes to fly the final approach. On an ILS approach, glide scope intercept is the FAF, and the DH is the missed approach area. So, you don't need DME to fly that final.

CAPTAIN MISENCIK: Would a procedure turn on this as an entry to this procedure would have done away with the necessity for the note DME required?

THE WITNESS: No, sir. There's high terrain out in -- out in this area that a procedure turn would require us to maintain the thousand foot of clearance in here. We would have to develop DME fixes because if we came to here, we would have too steep a descent angle to make an approach from.

CAPTAIN MISENCIK: Well, I think the VOR Alpha approach has a procedure turn entry, if I'm not mistaken. Does it have a different procedure turn altitude?

THE WITNESS: No, sir. But that makes it a non-straight-in approach, and it's a circling approach only because of the height at the VOR. It's too steep to get down.

CAPTAIN MISENCIK: But it's still flying over the same terrain essentially, isn't it?

THE WITNESS: Yes, sir. But it's -- it is much higher than with the DME that we could put the final approach fix out farther.

CAPTAIN MISENCIK: The -- the note DME from UNZ VOR, what provides the specific guidance for that note?

THE WITNESS: There's a paragraph in our manual that before using a -- a DME, other than the paragraph, that we need to do that.

CAPTAIN MISENCIK: Is that -- the -- is that the paragraph that says that the note required is DME from -- and the way it's written in the book, DME from XYZ vortec, simultaneous reception of the ILS and the VOR, DME is required?

THE WITNESS: I think that paragraph you're quoting is an ILS slant DMEs or localizer slant or VOR slant DMEs.

CAPTAIN MISENCIK: So, that doesn't have any bearing on this one?

THE WITNESS: That's correct.

CAPTAIN MISENCIK: The 8260.19(c), Paragraph 814, states, "Avoid caution notes about obstacles. Notes such as high terrain all quadrants, steeply-rising terrain, etc., are not appropriate."

What is the rationale for that paragraph not to mention terrain?

THE WITNESS: It is my belief that that would put the procedure developer in a position to try to identify the terrain that they should chart, that if you ignored some piece of the other terrain would be accused of showing or requesting a terrain, and someone else would consider that another piece of terrain is the more significant one if they hit it, and if we fly the procedures as developed, the terrain is not a factor.

CAPTAIN MISENCIK: Well, what -- what's your opinion on including notes regarding significant terrain or terrain profile, at least on the profile view of the approach plate?

THE WITNESS: I believe still in the -- in an obstacle which area -- in other words, having several obstacles, which one do you define, and the problem becomes of what you don't define. So, I again don't think it's a good idea personally. The required obstacle clearance should keep us away from everything.

CAPTAIN MISENCIK: But the particular air space on the -- say on the approach segments has -- have finite widths, and if the highest obstacles within those approach segments would be defined, wouldn't that make sense?

THE WITNESS: Well, you could have the controlling, which would be the highest obstacle, but you could have several of those in there, and the chart clutter, if you put everything that was in that area protected air space, you'd make it almost impossible to see the rest of the approach.

CAPTAIN MISENCIK: Did any of the Guam approaches require a waiver of standards?

THE WITNESS: No, sir.

CAPTAIN MISENCIK: Are you familiar with PANS OPS or the ICAO standards?

THE WITNESS: No, sir. We are -- the U.S. standard is TERPS.

CAPTAIN MISENCIK: With your experience, both as an aviator and working in this field for some time, what is your appraisal of the TERPS manual and the guidance you receive for developing these approaches and certifying them?

THE WITNESS: The TERPS manual is -- has a lot of information. It takes a TERPS individual to be a journeyman specialist quite some time to master it and know where to look, but it's there, and with our 8260.19(c) and other orders for different types of equipment, I think there's several guidance. Some of it could be probably cleared as you talked about. The 288(c) that has two identifications, and our manual has many more areas of when you would need dual approaches and examples.

CAPTAIN MISENCIK: Well, are these manuals subject to interpretation? For example, in the case of Guam, the localizer approach, there is no dual minimums published, but is that uniformally applied or under the same circumstances?

THE WITNESS: I believe it is. Any place that it's a mandatory required piece of equipment, it would not be appropriate to put a second set of minimums because it would lead the pilot to believe that if that piece of equipment was failed in his airplane or absent in his airplane, that he could fly that approach, and that he or she would be in serious trouble if lost communications and tried to make a missed approach.

CAPTAIN MISENCIK: Do you -- do you feel any changes to these manuals to clarify -- to clarify the points? Basically what I'm asking is, do you think these manuals maybe should keep up with -- with the times or are they -- what's your evaluation of them?

THE WITNESS: Well, I think they should keep up with the times, but when we design a procedure, we must consider what equipment can fly that procedure, and there are many airplanes of much less performance than some of the newer aircraft and equipment, and they must be able to fly the procedure as well as high-performance aircraft with the very best avionics.

CAPTAIN MISENCIK: Do you believe that the user input you're receiving now is adequate or should it be expanded on to take advantage of the technology advances in aviation, people who are familiar with the glass cockpits, the GPS?

THE WITNESS: We welcome all users' comments, and we will continue to do so, and the more user comments that we get would certainly not hurt anything and probably enhance everything we do, may even make it an easier for our designers when we're doing a procedure.

CAPTAIN MISENCIK: Have you recommended any -- do you recommend charting procedures or have you recommended any charting procedures which would make the charts more user-friendly to some technique, such as constant descent, that Captain Woodburn talked about earlier?

THE WITNESS: Well, I'm not quite sure what we -- if -- we -- we have parameters of glide descent. I think the procedure that we did at Guam, and the altitudes that would be computed, they're very close to a constant descent, if they were flown that way from point to point, but that's not the primary design, is the required obstruction clearances.

CAPTAIN MISENCIK: How do you feel about the inclusion of minimum sector altitude areas on the planned view as was depicted in the charts that Captain Woodburn showed to give the pilot a view of terrain he was flying over?

THE WITNESS: Those were very interesting charts that he had. As it appears to me that it would have some great advantage for pilots. However, that's the charting folks in Washington to do, and if chart clutter has always been a problem from all aviators and all airports we have, that that seems to be a problem, also.

CAPTAIN MISENCIK: Okay. As one of my final questions, when you develop a procedure and have it certified, and then the procedure goes to the chart manufacturers, like Jeppesen or Air Rad, or any of the NOS, how much leeway do they have in implementing the -- what they think should be on the -- on the chart?

THE WITNESS: They must put the information that we have on the 8260 forms that are sent, must be there. Our standard for the U.S. Government is NOS, and those charts are -- are charted. Those are the charts that my specialists check as soon as they are published, after -- before the public sees them or before they're in use for the public.

They may have a shipment before, but we make sure that everything is on that plate is what we have put on the forms, the 8260 forms. What other cartographers and other agencies of charting, I can't comment on that. It's not my area.

CAPTAIN MISENCIK: Based on the information we've received to date regarding the accident at Guam, have you any -- any thoughts on what you would like to see done or any recommendations you may make in developing approaches or in the future?

THE WITNESS: Are you talking about at Guam?

CAPTAIN MISENCIK: Anywhere.

THE WITNESS: The continued coordination, and I would use Guam as we're talking. We are working on two additional procedures for Guam that are R-NAV/V-NAV approaches, and they're in the coordination phase, and the original -- the first look.

At the same time, we will review all of the procedures that we have now, and on this particular area, radar was -- the air traffic told me that they at the time could not support full-time radar exceptions of doing the approach or required radar on the approach. They've got quite an area, I understand, and we will -- I will ask -- ask that to be revisited and see what they would think about having radar required or DME, and if the flight check fixes could be confirmed, they must be done before the radar fixes, and if that would fit into their scheme and the flow of traffic for them.

CAPTAIN MISENCIK: Thank you, Mr. Henderson. I don't have any further questions. I believe Mr. Feith may.

MR. FEITH: Good afternoon.

THE WITNESS: Good afternoon.

MR. FEITH: Pardon my ignorance because I stepped out of the room. So, I'm not really sure I caught all of the answers to all the questions that have been asked. So, if I am redundant, Mr. Chairman, I apologize.

CHAIRMAN FRANCIS: You are taking your turn now rather than after the parties?

MR. FEITH: Yes, because we are -- I may have a follow-up after the parties, too. But we'll get to that if I need to.

Let me just make sure I understand. There was some testimony on Monday regarding markers as they relate to an approach, and --

THE WITNESS: Could I get a little more volume on that? I'm having a little difficulty hearing you.

MR. FEITH: As -- as it relates to an approach, the outer marker and middle marker are not required parts of the approach? Do I understand that correctly?

THE WITNESS: Are not required?

MR. FEITH: Yes.

THE WITNESS: That's correct.

MR. FEITH: Okay. Teddy, could you put that chart back up? The approach plate.

On this, the question was asked regarding why isn't this an ILS DME given the fact that the note up there says DME required.

THE WITNESS: The -- the manual instructs us what it takes to fly the final approach, is what the chart's name. This chart takes glide scope intercept at -- on the glide scope and a DH. That's what you need to fly the approach, the final approach, and that's all it talks about, the final. That's the naming.

MR. FEITH: How do you identify the missed approach point?

THE WITNESS: DH on ILS.

MR. FEITH: Okay. If you look at this chart and just correct me if I'm wrong, the middle marker here is the missed approach point, if I'm -- if we're looking at the appropriate chart. Go up to the planned view, Teddy. I mean the profile.

THE WITNESS: We need some more -- the bottom of the -- it's the bottom of the approach. Over here is the decision height. That is the missed approach point.

MR. FEITH: Okay.

THE WITNESS: It is very co-located close to this, but that is the missed approach point on glide scope at that height.

MR. FEITH: Are you using DME to get to that point?

THE WITNESS: No, sir.

MR. FEITH: Okay.

THE WITNESS: DH.

MR. FEITH: Okay. Now go back to the -- the planned view, Teddy. With regard to trying to identify on a missed approach where the intersection is for flake, it says that it's seven DME out, you see the Note Number 1?

THE WITNESS: Yes.

MR. FEITH: If you didn't have DME or DME isn't required, how would you identify that?

THE WITNESS: You could not.

MR. FEITH: So, wouldn't you need to have DME?

THE WITNESS: That's why the note DME required.

MR. FEITH: Okay. But given all of that, should -- should there not be some sort of change -- I see the note up there, but is that an appropriate place to get someone's attention or to make sure that a pilot knows that DME must be used either as part of the initial part of the approach or a missed approach segment?

THE WITNESS: The question is do I think that having the DME required versus having it named DME --

MR. FEITH: Yes.

THE WITNESS: -- would be less or more for an experienced pilot?

MR. FEITH: Any kind of pilot because these charts apply to everybody, not just --

THE WITNESS: Yeah.

MR. FEITH: -- the commercial airline pilot.

THE WITNESS: I think it's the same.

MR. FEITH: Okay.

THE WITNESS: DME required. If it was an ILS DME, it would be required. The note on this one says it's DME required, and it is required for the -- the missed approach area in holding to get the pilot out of the low place.

MR. FEITH: Did you -- was -- I don't know if the question was asked. Since the accident, have they co-located the DME in the localizer?

THE WITNESS: No, sir.

MR. FEITH: So, it's still separated?

THE WITNESS: Yes.

MR. FEITH: Okay. Is there any plans to do that?

THE WITNESS: I -- I don't know of any. First of all, this -- the VOR here is the DME, and it's a major, major, very powerful VOR here in the Pacific area. It reaches far out. Historically, when we've -- the agency installs a procedure like that, it's up on a hill, and, so, it's not blocking out because if we have a VOR, mountains or other buildings or something can stop the radiation, and it's not near as usable.

MR. FEITH: And just one other question. You had talked about that you solicited comments from users on the approach or users of the approach during the course of -- of trying to determine what problems may exist on specific approaches?

THE WITNESS: If they have users -- air traffic is our probably first line of defense on users comments from someone who has been flying an approach because they will get the complaint, and they are very good at funneling those to us to tell us there's something wrong with approach, and a user has a complaint on them, and we will consider them all.

MR. FEITH: Okay. I don't have any further questions right now, but I may have some on the way back.

CHAIRMAN FRANCIS: Can I ask a question just on sort of a follow-up here? Is -- is it possible -- I understand your explanation of the -- you've sort of got a long-range VOR DME there for -- for a lot of en route navigation over the Pacific.

Is it -- is it technically possible to have

-- to leave that facility as it is and put a co-located DME on the ILS?

THE WITNESS: Yes, sir. Having two DMEs, you're talking?

CHAIRMAN FRANCIS: Yes.

THE WITNESS: Yes.

CHAIRMAN FRANCIS: And -- and I mean I guess you always have a problem of potential confusion, but if you -- if you -- if you dial in the ILS, you automatically get the ILS DME?

THE WITNESS: Some -- I understand, and from my experience, that there are some equipment that that's not true. We have -- the agency has had problems when we have two DMEs forward on the -- from an aircraft commencing its approach. They've had problems in the past, and we try to limit that and put very clear notes that -- and that is a potential problem.

CHAIRMAN FRANCIS: That was the question. So, -- so, the agency tends to try to avoid that because of possible confusion?

THE WITNESS: I don't know if -- that's not again in my area of expertise, but I know that is a problem, and what they tend to avoid, I'm not sure. That's a flight standards, and our AO folks are doing it.

CHAIRMAN FRANCIS: Thank you. I'm through. Finished.

FAA?

MR. DONNER: Yes, thank you, sir. Just one. In addition to using the DME for the missed approach, isn't it true that it's -- the DME's also necessary to locate the three initial approach fixes?

THE WITNESS: The initial approach fixes? Yes, sir.

MR. DONNER: Is there any alternative way to locate those fixes?

THE WITNESS: Not on this procedure because of an isolated island with one major VOR.

MR. DONNER: Thank you.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. We have no questions.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman. Just one question. On the airport, when you look at the approach plates, on Runway 6 left localizer approach procedure, has the final decision altitude immediately after the accident from 560 feet to 580 feet -- it has changed to 580 feet, and then it was changed back to 560 feet again. They changed it to 580 feet, and then again it was -- it went back to 560 feet.

Was there any particular reason for that?

THE WITNESS: Yes, sir, there was. We were asked to evaluate the missed approach area in a 40:1 because of the approach plate chart had an obstacle that appeared it might be in the 40:1, and we evaluated it, and it was. So, we had a 20-foot increase on the DMA.

However, that was -- that obstacle was not there when we originally developed the procedure. We have since researched that thoroughly and had it verified that that obstacle was in error, and it was a hundred feet too high, and we have since lowered the MDA back to its original because the obstacle was a hundred feet lower than we first believed when we looked at it.

MR. LEE: The question -- let me just ask you one more question. Based on the FAA tough standards, when there is DME available, you don't necessarily have to have the outer marker.

In the future, are you planning to continuously operate the outer marker? The reason I am asking this question is when we visit Guam, we visited -- when we visited Guam, we experienced malfunction on numerous occasions. It doesn't even have a monitoring function.

When you need a DME, I think it's probably more advisable to remove the outer marker and maybe better for the flight operation. Do you have any personal view on that?

THE WITNESS: I have no knowledge of the problem of the outer marker or any knowledge of planned removal. So, I can't comment on that.

The DME is also co-located when possible at the outer marker. The DME fix, I'm talking about. But I have no knowledge of removal or I have no knowledge of the problem that has been as you say for your flight crews.

MR. LEE: Thank you very much. That's all.

CHAIRMAN FRANCIS: Barton?

MR. EDWARD MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCEY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions, Chairman.

CHAIRMAN FRANCIS: Mr. Feith, you want another shot?

MR. FEITH: No.

CHAIRMAN FRANCIS: Mr. Cariseo?

MR. CARISEO: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Mr. Berman?

MR. BERMAN: Thank you, Mr. Chairman.

Mr. Henderson, could you tell me when the flight procedures offices were changed to work under the Air Traffic Service?

THE WITNESS: The flight procedures -- they were called branches, was in April of 1995. The reorganization took place, and they become part of AVN at that time.

MR. BERMAN: Okay. Thank you. Since that time, has there been an increase in the number of procedures specialists who are not pilot qualified?

THE WITNESS: There are increases at Oklahoma City of non-pilot qualified, but if I could add, the hiring has been predominantly ex-military procedure specialists who retired, and most of them had from 10 to 20 years experience developing it for the military.

MR. BERMAN: These are the non-pilot specialists? That's what you're saying?

THE WITNESS: Sir?

MR. BERMAN: The ones who are non-pilots --

THE WITNESS: That's right.

MR. BERMAN: -- are in that category? Okay. Has there been any change in your office in terms of non-pilot specialists?

THE WITNESS: Any changes in my --

MR. BERMAN: Yes, in your -- in your office in Los Angeles, have you hired on specialists --

THE WITNESS: No. Los Angeles are all -- have all -- have four pilots, and they're all -- that's my authorized strength there.

MR. BERMAN: Okay. Thank you. How does the FAA evaluate the flyability or the difficulty of an instrument approach procedure?

THE WITNESS: Well, that's a little out of my expertise now, but I was at one time a flight inspector, and it was -- we actually flew the procedure, and we evaluated it again for the lowest, in our estimation, quality -- not quality, experienced pilot, could he fly that procedure on the original commissioning flight check.

MR. BERMAN: Hm-hmm. And has that type of a procedure changed since the reorganization?

THE WITNESS: No, sir.

MR. BERMAN: Hm-hmm. Do you know how the ILS approach to Runway 6 left glide scope inoperative procedure was evaluated for flyability?

THE WITNESS: How it was evaluated for -- the -- we were doing the Navy flight check follow-on. So, the FAA was evaluating it from the original day of 1972 when it was commissioned.

MR. BERMAN: Okay. Thank you. No further questions.

CHAIRMAN FRANCIS: Mr. Schleede?

MR. SCHLEEDE: Just one clarification. Regarding -- again, I know you were asked, and I'm not sure I got the answer correctly. The approach at Guam that you were discussing, if it -- the name of it was changed to ILS/DME approach, would that change anything about the approach, where the nav aids would be or anything?

THE WITNESS: We would remove the DME- required note.

MR. SCHLEEDE: It could still be -- the DME could be remotely located. It does not have to be co-located at the localizer to be called an ILS DME approach?

THE WITNESS: It should be co-located and is required again to fly final on that approach.

MR. SCHLEEDE: You say it should be, but can be a non-co-located DME and still be called an ILS DME approach?

THE WITNESS: Yes, sir, if that was required to fly the final approach according to our book, or there'd be a waiver to that requirement.

MR. SCHLEEDE: Okay. Thank you.

CHAIRMAN FRANCIS: Mr. Montgomery?

MR. MONTY MONTGOMERY: No questions. Thank you.

CHAIRMAN FRANCIS: Thank you, sir. Appreciate your contribution.

THE WITNESS: Thank you, sir.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: Our next witness is Mr. James Terpstra, Senior Corporate Vice President, Flight Information Technology and External Affairs for Jeppesen Sanderson.

Whereupon,

JAMES TERPSTRA

having been first duly sworn, was called as a witness herein and was examined and testified as follows:

TESTIMONY OF JAMES TERPSTRA SENIOR CORPORATE VICE PRESIDENT FLIGHT INFORMATION TECHNOLOGY AND EXTERNAL AFFAIRS JEPPESEN SANDERSON, INC. ENGLEWOOD, COLORADO

MR. SCHLEEDE: While you're booting up, let me ask you for your full name and business address for the record.

THE WITNESS: My name is James Terpstra, also known as Jim. My business address is Jeppesen, 55 Inverness Drive East, Englewood, Colorado.

MR. SCHLEEDE: And what is your position at Jeppesen?

THE WITNESS: I'm the Senior Corporate Vice President of Flight Information Technology and External Affairs.

MR. SCHLEEDE: And would you give us a summary of your experience and education that brings you to your current position?

THE WITNESS: I have a Bachelor of Science degree. Follow that, I was an instrument flight instructor and airline transport pilot before I joined Jeppesen in 1968. I first went to work for Jeppesen and wrote the -- a number of the textbooks for pilots to pass their FAA written examinations for the private, commercial, instrument, ATP, and then went to work in the charting department in 1973, where I was responsible for flight information design, eventually became responsible for all the production of all the charts and the databases.

MR. SCHLEEDE: Thank you. Captain Misencik will proceed. Oh, I'm sorry. Mr. Feith.

MR. FEITH: Good afternoon, Mr. Terpstra.

THE WITNESS: Good afternoon.

MR. FEITH: Mr. Chairman, I -- I had asked Mr. Terpstra to prepare a presentation regarding charting. Since Mr. Henderson was able to enlighten us on the information that is required by the FAA to determine an approach procedure, it is not up to the FAA to actually produce the charts, and, so, I'd like to have Mr. Terpstra just give us a brief overview of how they take the information that the FAA has on their specific forms and provide it to a producer like Jep to produce the approach plate procedures that are in use right now, both commercially and -- and GA-wide around the world.

CHAIRMAN FRANCIS: I saw that raft going down the river, and I thought maybe we were getting a marine-charting presentation.

THE WITNESS: That's a lot more fun than this, I can assure you.

CHAIRMAN FRANCIS: Go ahead, Jim.

THE WITNESS: Mr. Chairman, ladies and gentlemen, thank you for giving me the opportunity. I will do my presentation in a little different style than what we've been doing previously.

I prepared a presentation at the request of Mr. Feith, and my presentation is on instrument approach charts, and the three items which you can see up on the screen are our sources of information, how Jeppesen designs a chart, and the validation of the sources that we have from the various different government organizations.

MR. FEITH: Excuse me, Jim. Can we just drop the lights a little bit so that we can get better contrast? Will you be able to still see your presentation?

THE WITNESS: I'm doing fine. Thanks.

MR. FEITH: Okay.

THE WITNESS: Some of the material which I have prepared is a little bit of a duplication of Mr. Henderson's. So, I will go rapidly past the things which he has talked about, but you'll see some of the things that Mr. Henderson talked about now in a graphic form. So, hopefully maybe that will give you a better picture of some of the things that are in the input into what goes on in the world of aeronautical charting.

This is a picture of the approach into Runway 6 left at Guam. This is to show that the requirement for an instrument approach procedure is first established by airport and by user. So, this is the start of the entire process.

The process, the very first thing that's very important about this is what Bill talked about, and that is that the instrument approach procedures are designed according to a document which we call the United States Standard for Terminal Instrument Approach Procedures, an acronym of TERPS, which has been used for that.

It's also important to know that this is a common document for both the U.S. military and the civilians who use the same standard, and this document was originally issued November 18th, 1967, but actually follows another document that was there for some time before. So, the business of specifications of standards for approach procedure design is not new.

In February, just last month, the Change 7 to the TERPS was signed. I said here it's issued. It really was signed, and it will be issued after it comes out of the government publications, but it's important that there is a continual updating of the criteria that goes into the TERPS, and we are now about to have Change 17.

We heard mentioned a couple times earlier today a document called PANS OPS. That's actually the international design, according to ICAO or the International Civil Aviation Organization. PANS OPS Document 8168, which is an equivalent document for an international standard.

MR. FEITH: Can I just interrupt you and -- and just for the benefit of the audience, can you just tell us what PANS OPS is?

THE WITNESS: PANS OPS is the document. It's not at an annex level. It's a level below, and PANS OPS is -- well, I'm not sure what that stands for. It's operations, but PANS something. Wally? Pardon? Yeah. Navigation Operations.

But this is the document that's, as I said, not as a standard, but it's a recommendation within ICAO which is used by most of the governments throughout the world as their standard for the design of the instrument approach procedures, and it's equivalent to the U.S. TERPS criteria. However, there are some slight differences between the two.

MR. FEITH: Thank you.

THE WITNESS: The illustration you're looking at here is the cover of the actual document that's out in the field right now. The next part of this I hope you can see, but what's important that you look at here is that at the bottom of the cover is a series of people who comply with this document, which includes the Army, Navy, Air Force, Coast Guard, and the FAA.

The reason that this is important is because this procedure originated as Mr. Henderson told you a number of years ago as a military instrument approach procedure and was eventually converted to a civilian approach procedure, but the difficulty in doing that is not that large because they both comply with the same criteria.

Some of the elements of the TERPS for the construction of this are from the en route environment all the way down through and including landing, and in the event landing is not accomplished, then also the missed approach procedure, and there are terms which are used, like initial approach segment, final approach segment, missed approach point and so forth, and each of these have a required obstruction clearance which is the amount of altitude between the flight altitude and the obstructions below that within a specified width. That also is what determines the landing minimums for each one of the approaches.

As Bill said, the tools that are available for the TERPS experts are very plentiful. They are all trained by the FAA in Oklahoma City. They do use the local topographical charts which are a lot of times the largest scale, usually about 1:24,000. They also use obstacles from the NOS Obstacle File. That is the National Ocean Survey branch of the Department of Commerce within the United States, who has the responsibility of collecting and distributing all of the obstacles throughout the United States.

In addition to what NOS has, if there are any obstacles that are known locally by the instrument approach procedure specialists, those are also included.

The next-to-last item on here, which is important, is the FAA has an instrument approach procedure automation software, and what this means is that there is now a much more standardized approach to the creation of instrument approach procedure because the variations in that are limited because the automation makes sure that the standard applications are done.

Also, it's very important that no instrument approach procedure can be accomplished until it has been coordinated with air traffic control.

The illustration you're looking at here is an excerpt out of the topographical chart that's on the approach in to Runway 6 left, and I think you can see the detail there, even down to some of the buildings that are surrounding the airport, and this is the information that's used to accumulate the terrain and the obstacles on the approach procedure into the airport.

Once those are done, they're flight checked by the FAA. They are then entered into the FAA Form 8260-3, which is for instrument -- for the precision instrument approach procedures or what's known as a -5 for the non-precision instrument approach procedure. There's also a -7, which is used for the tailored approaches as published by the FAA.

Now the part in here that you see is part of where we start to get involved. These are submitted to Oklahoma City for review, and then they are coordinated back with the designer of the procedure for any corrections that need to be made, and then they are sent to the aviation industry for review, and I think Bill gave you the list very well of people that do look at this.

At that point, we talked about a transmittal letter, but it's also submitted to the Federal Register, which is an important part, because it becomes a legal document, and then it is sent to the FAA National Flight Data Center or NFDC within the FAA in Washington, D.C., 800 Independence Avenue, where then it is released for the official distribution as a public instrument approach procedure chart, and that piece of information is then picked up by charting agencies, such as ourselves, and NOS gets it at the same time as well as Air Ad and other charting agencies.

What you're looking at here is the actual FAA Form 8260-3 for the ILS Runway 6 left approach at Agana. The part that you see highlighted in red here is very, very important. This FAA Form 8260-3 is actually an FAR Part 97.29. This is now a legal document. It's within the Federal Register. It's a Federal Aviation Regulation, and any changes that are made to it have to go through a legal process to do that.

Look at some of the pieces of it. If you look at the top, as you remember from the approach chart that you looked at earlier, the DME arch is an example. Go up into the top portion of the 8260 that show the altitudes, the beginning and the ending of the DME arch segment.

The next block at the bottom has all of the information that's applicable for the final approach segment, where it starts, what its altitudes are, glide scope angle and so forth, and then the minimums actually specify how low the airplane is authorized to go while it is still in instrument meteorological conditions.

There's also additional flight data in the lower right-hand corner that gives us information, such as DME required or simultaneous reception or whatever type of note that's applicable. In addition to that, there are obstacles that are included when the instrument approach procedure specialist deems that it's appropriate that an obstacle be placed on to the instrument approach chart, it's noted in this area.

One of the things that I think is very, very important to recognize, and what I'm calling a distinction, what you have seen now is the development of an instrument approach procedure.

As of this moment, there still is no instrument approach chart. The chart does not happen until the government officially releases the instrument approach procedure. So, my third line that you can see down there says "an approach procedure is not the same as an approach chart".

The procedure is the -- what the pilot flies from a procedural standpoint. The chart is what's used in order to depict what the pilot actually does. The distinction here is the FAA or other governments create the instrument approach procedures, whereas Jeppesen, NOS, Air Ad, Swiss Aire, and so forth actually then produce instrument approach charts.

One of the things that you saw at the beginning that Mr. Feith had requested that I give to you are some of the sources of the information that's there and where those pieces come from, and as you look at this illustration here, Agana ILS is shown at the bottom, just atop that chart, but you can see through the -- I don't know how well this is -- it doesn't read quite as clearly as what I would like to.

So, I will read some of these to you. Every approach procedure, you can see that the FAA Form 8260-3 is one segment of that entire approach chart. That's one piece of it. In addition to that, the intersections and their formations come from the NFDC fix list. The components out minimums come from the TERPS criteria. The Jeppesen speed and descent rate calculations, which are the time, speed and distance box, are additional pieces. The special use air space come from air space dockets. The holding patterns come from different documents. The communications come through the National Flight Data Center in the NIFDIs. The obstacles come from the NOS sources as well as do the terrain, and, additionally, some of the terrain, the digital terrain elevation data and the approach lights come from a completely different source for us to know that there are approach lights available at an airport.

What I would like to do now is to show you some of those official sources that are used as the input into the approach chart, and what you're looking at here is the National Flight Data Digest published by the FAA through their National Flight Data Center, and this is for a date that's effective 7 -- it's a NIFDI that was released on July 25th, 1996, and it says in here distances are magnetic, distances are nautical and so forth, Azimuths are magnetic, and then effective on October 10th, and that's the information, and the details of that down here show that for Guam, I have two illustrations up here, for Guam, the flake intersection, which you saw as a note for one of the initial approach fixes for that instrument approach chart, actually is designed here.

It's been modified from a previous depiction or specification of how it's constructed, that in this case, you can see that it's from the UNZ or Nimitz Vortac 241.04 degree radio at 7.00 nautical miles, and its latitude and its longitude, and in this particular case, the FAA says that this flake intersection is to be charted on the instrument approach procedure chart, which means that you will not find that same intersection on any of the SIDS or STARS, if they were there, or the en route or area charts.

The communications which are on the chart that are at the top of the approach chart with one series of communications and the top of the airport chart for another series, these are a series of entries that we have created from source, and you can see that the NIFDI, which is the National Flight Data Digest 145, that was issued July 28th, 1995, in the com section of the Pacific area shows that Agana, Guam, International Airport, the ground frequency of 119.0 is changed to 121.9.

So, you can see in here that the chart that was current at the time of the accident shows a ground control is 121.9, and also over here, it's 121.9, and that's because of what the FAA issued through the National Flight Data Digest.

In addition, in July of '95, the ATIS or Automatic Terminal Information Service, was also added on a frequency of 119.0. So, you can see the frequencies of ATIS 119.0 on both of them. So, this is how the communications that are created at an airport get into the system to ensure that that's available to all the producers of charts.

The minimums that are on the chart themselves actually come from the FAA Form 8260, which includes the visibility, and since there's no runway visual range or RVR, they're expressed in miles rather than in feet, but there also are a couple components out minimums in here.

This is the runway alignment indicator lights or approach lighting system. I one of those are out, the visibility goes up to three-quarters. So, in this case, the minimums for the components out are stated in Sections 3 and 4 of the TERPS, and there's also -- whether there's glide scope availability changes the minimums, of course, becomes -- now becomes a localizer approach and approach light availability, and the content of 8260-3 is where the approach content actually is derived.

The obstacles that you heard Mr. Henderson talk about earlier are the bases on which the instrument approach procedure altitudes are created and also the optimum paths that are there, and you heard him tell why the procedure turn was not there on this approach, and it has to do with the obstacles.

In order to create the instrument approach with the obstacles that are there, that comes from a number of sources, and what we do to pick up those sources is that we create a digitizing capability off of a number of sources.

Primarily what we see here are operational navigation charts, topographical pilot charts, sectional aeronautical charts, world aeronautical charts, AIPs or aeronautical information publications, and also 8260.

So, this represents all of the obstacles that are significant on the island of Guam, and this -- these are from the Hawaiian sectional chart that's dated '97. In the lower right-hand corner over here, you can see there's a final approach segment controlling obstacle as well as a 724-foot antenna which is at this latitude-longitude, and that's why when you look on the chart itself, you will see an altitude of 724 feet depicted on the chart just next to the VOR location.

The terrain depiction, and you heard this morning from Captain Woodburn that there are a couple different ways of doing depiction on, whether it's color or black and white or green or brown, and a lot of variations, and what we have decided to do, because of the flight tests that we conducted, is to do those in brown.

We did a whole series of flight tests with about six different airlines in simulators in all different kinds of light conditions, and we -- when we first decided to put terrain on the chart, we had a number of samples that were in both green, and we did samples that were also in brown, and my personal preference was going to be green because I like the color green. I don't think it was so strong with the other things that are on the chart.

It's kind of interesting how wrong you can be proved when you give it to a number of pilots in a controlled environment where we had human factor specialists that were running the tests, and the pilots came back overwhelmingly in favor of the brown color, and when we asked why, the overwhelming answer is that brown scares me, green is pastoral.

So, that's the reason why we went to the brown color, and as you know from Captain Woodburn this morning, that that is also the criteria within the ICAO Annex 4 for terrain contours when it's actual ground, but it was very interesting to have that validated through human factors tests with actual pilots flying it, that they decided that the brown was the better of the two colors.

The criteria for when terrain goes on because one of the questions probably has come up in your mind, is why the Agana ILS 6 left approach did not have terrain, and that's because through the agreements that we've had with our airlines, seminars in the airline community, as well as a lot of the general aviation input, is that there should be a criteria because you don't want terrain to be on all charts, you want it there when it's significant.

So, the definition of significant is difficult to come by, but where we drew our line is we said that in order for terrain to be on a chart, there needs to be at least one elevation that's 4,000 feet or greater above the airport in at least one planned view of the airport or if there's one elevation that's 2,000 feet above the airport within six miles, then once we do that, then every one of the contour lines, they start at the nearest 1,000 feet to the airport elevation, and then they are at 1,000-foot intervals all the way up to the top altitude that's depicted.

It also -- you'll find some of the charts that we have, if there's been a special customer request that says we would like terrain on here because it's a special airport for us, and then we will do that as well.

It's important to know that there are many sources for the terrain information. Some of that's digital terrain elevation data that comes from the military, but as you heard said before, that from Don Bateman, that the availability of the volume and detail of that is still considered to be secret by a lot of militaries, and that information really needs to come out in the -- in the public, we believe.

In addition to the digital terrain, we also use sectional charts and topographical charts as the basis for where the terrain comes from. Special areas prohibited alert and so forth, those come from special documents.

Just south of the Guam Airport is a military warning area called W-5.17, and you can see in the upper part of the illustration here, that these are the boundaries of that 5.17, and then there are the Class D air space or other air spaces around. Every one of those come from a different set of dockets that are released officially by the -- by the FAA.

The airport lighting. What's interesting about this airport and a bit unusual is that it was converted from a military to a civilian airport, and the military is also a bit stingy on how they release their information. So, we picked up all of our first information for the lighting of the airport from the airport facility directory or the FLIP, and then from that point, any revisions, once it goes into the official FAA system, then the National Flight Data Center is responsible for issuing additional NIFDI items.

So, the approach lights for Runway 6 left off the end of the runway that you can see in the planned view illustration as well as the airport diagram that have all the different kinds of lights here come from in this case the airport facility directory and will be updated by the National Flight Data Center.

Conversion table, which is at the bottom, the three-degree angle is specified, and you saw Bill Henderson talk earlier about that value on the 8260. From that information and that he specifies that the distance from the final approach fix to the missed approach point is 4.4 nautical miles.

With those two values, then we can compute for the pilot use at various air speeds that he may fly the approach, what his descent rate would be in feet per minute as well as the timing from the non-precision final approach fix to the missed approach point.

One of the things that's important is that once you get something out in the field, it never stays current because there's always changes that are going on, and the revisions to the procedures come to us from many different sources, and you can see here the National Flight Data Center is usually the releasing authority for the changes which will be by 8260, changes or could be communications or notes, and here's an actual change that we just processed the chart last month, and you can see our date stamp on here for February 3rd, 1998, because there is now a note that went on to the Guam chart, and it says here to add the note "localizer minimums require simultaneous reception of IGUM", which is the localizer, "and the Nimitz Vortac."

So, the simultaneous reception discussion which you heard Bill talk about a few minutes ago, there's now revision to the chart that is now out in the field as the current chart that has a February 28th revision date on it because of this change that went out February 3rd. So, that's a -- if you look at the chart that's in the field today, the simultaneous reception note is now on that chart.

Just as a reminder, one of the important things we're talking about now so far just the FAA, there are over a 190 countries throughout the world, and, so, this is only one of the many. We also get source information from Korea for all the airports that are in the Korean air space, and all the other countries throughout the world that require charting for instrument approach procedures.

Question is how we design a chart, and I'll not spend much time on here, but it's important, first of all, Captain Jeppesen, who was an airline pilot for United Airlines, started this in 1934, and there is a department which we call the Flight Information Design Department, that includes pilots and flight instructors as well as former controllers and chart experts and cartographers who are responsible for the design, but very important is the next bullet up from the bottom here, what we call our Jeppesen Listens Comment Cards.

They're a blue color, so our people inside call them the Blue Cards, but what these are is comments that come back from the customer to say why don't you do this or would you do that or I would suggest this or I saw this, and if you would have done it this way, which is a very valuable input, it's a feedback loop from the actual end user, followed by chart seminars that we have been conducting for years, in addition to the airline seminars, which every three years, we get all of our airline customers together in a room for about four days and go over the proposals, and it's based on the proposals that we have created for the designs of which the airlines then make a decision on which direction that we should be doing with our charting specifications. That bottom bullet is a very, very important part because it's the user who really drives what needs to be done from a charting standpoint.

A couple things to look at, and as you look at the design of a chart, I'd like to start it from two different approaches. One is from the smallest detail, and then also from the highest overview, and the smallest detail, what's interesting is if you look at this number right here, it looks like it's a 215, and if you use a normal PC with a font, you'll see that that's 215.

The reality is that's the identifier for the Rand Tool Illinois Airport, and the identifier is 2I5. It is not 215. So, from the smallest detail, we have created our own font. We do not use a standard font for the charts. We create a font that has the seraphs on the I's so that the pilot can tell that's a 2I5 rather than a 215, and also this is very interesting because this is from Captain Jeppesen about six years ago.

He said to me, "Jim, I got an idea now, why don't you do it?" And what he was suggesting because the 3, if you put a line on the front side of that, it can be very easily confused with the Number 8. He said, "If you put a bar across the top of it, you'll never get it confused with a Number 8." So, we have all of our 3s that have this shape of number, you can see the 3 here, the 3 here, and the 3 here, but where it's really important is when it's a latitude-longitude on a chart that gets close to another element that's on the chart.

That's the detail level, but from the highest overview, it's very important to recognize the design of the Jeppesen charts are based on the intended use, which is by experienced instrument-rated pilots. So, we assume that the pilot has his instrument rating or ATP and is a certified pilot.

Without human factors, a lot of the things that we do would not really come up the way that they should because the human factors experts find a lot of things that we, that are so close to it, don't find.

The Volpe National Transportation System Center has done a lot of human factors work on our charts with us, and the FAA sponsored a program which is a human factors program conducted by Dr. Bill Connor and Jill Cox, which did a complete human factors. There are numerous flight and simulator tests. Boeing has sponsored a study of what the pilot's eyes do when they look at the approach charts.

The ATA Charting and Data Display Task Force has been doing a lot of work from a human factors that do flight tests of the actual changes that are recommended, and at the bottom is an important effort that was initiated because of an NTSB recommendation a couple years ago of a new task force called the ATA Charts Database and Avionics Harmonization Task Force, which really looks at the human factors of what all information a pilot has to look at and where they should be the same and where they cannot be, how do you go about training the pilot to understand where those differences are. It's a very important education thing for everybody that's involved in the system.

We just introduced a new briefing strip, and what's important about the approach to this concept is that it was in prototype use actually out in the field in the pilots' hands that were their charts to be used for a period of about two years.

We received literally more than 4,000 pilot surveys, had to hire a couple people just to do the analysis of the surveys, but based on the surveys, we released a new format that was in September of last year, and everything that you see here, which is known as a briefing strip, is a result of a very large effort that was mostly human factors driven by actual flight tests of pilots in simulators followed by the pilots in the airplane that did the test, and the responses back that we got were very, very good and caused us to change some things.

A very subtle little change in here is that we put our logo right in the middle of the chart at the top because that used to have communications in there, and the pilots were complaining because the clipboard on the control yoke of the airplane was covering up important stuff. So, now we put the Jeppesen logo up there, and they get to cover our logo.

In addition to that, one of the latest changes is what we are using as missed approach icons, and again a series of flight tests that said when you do the missed approach, the first thing that you do is climb straight ahead to 5,800 feet, and it also has the type of approach lights that the pilot should expect when he lands out from underneath on the approach as he's approaching the airport. These are the lights that he should be looking for. So, it's another aid from a human factors standpoint, so that if he breaks out underneath and doesn't see this, he's got another check for what he should be looking for.

The question about how often pilots go into airports and what they do for the first time resulted in a new design that we came up with called airport qualification charts, and this is a whole series of charts for all the airports throughout the world that are the very difficult, challenging airports of which Agana is one of those, and this is one chart out of the series that goes through the details from a pilot briefing standpoint, so that they know specifically the kind of things to look at in a challenging airport, and this is one of the designs that came out of some of our human factors efforts that we did.

Now going to the third bullet of the outline, the overall bigger unit, and that's the validation of source, and two things that I think are very, very important for us all to understand is that, Number 1, is that every FAA approach procedure is FAR Part 97 and is technically illegal for us to make a change. It is not Jeppesen's job to go in and make a change to an FAR.

What we do is if we find problems, then we go back to the FAA, and then they re-issue it because they're the only authority that can release and change FARs. That same thing is true for every international approach procedure that's included in each one of the state sovereign domains. So, the right of the content belongs to the government and not to us or to the chart-maker and that makes a difference in how we do the changes.

What's important is if there are obvious errors, we seek clarification from the authorities on any element that appears questionable as a result of routinely processing the procedure for publication in graphic form. So, those things which we spot that say uh-oh, if they're obvious, we'll send them back or if we find them for any reason, we send them back for clarification.

One of the things that's also important is we make no attempt to determine that the procedures prescribed by the governing authorities are in compliance with their own criteria. I think one of the questions which you heard asked by Mr. Misencik a little while ago to Mr. Henderson is were there any waivers that were issued against this instrument approach procedure. That's one of the questions that we would not know the answer to, and it could be that there is a waiver that's applied to it, and we would not know it.

We do not go in and check if the government's in compliance with their own criteria, either through criteria that they have made or changed or waivers. So, that's really the authority of the government on their own criteria.

However, one of the things that we do do is we enter all of the instrument approach procedures into the navigation database, into a very large computer database, as a way to validate a lot of the pieces of information that are on the approach chart itself. Those kinds of things, I won't go through the detail of this very complicated chart, but just to let you know there's a very large structure on how all these pieces connect together. When I say pieces, I'm talking about VORs, NDBs, airways, instrument approach procedures, final approach courses, the locations, the latitude-longitude. All of those are entered into a database, and the information as I want to show you one example that we use for an edit, we do a bearing and distance edit, so that for the location on this approach procedure is an example of the location of the outer marker, the Nimitz VOR, the end of the runway, the fixes, the initial approach fixes, an example.

We take the values that Mr. Henderson would have put on his 8260-3. We take every one of those pieces of information that he has put in there, and we take that and put it into a database and do a calculation. So, if he says the bearing is 06 -- six degrees is an example, we'd go in, and we'd compute it to be 063 degrees. We say oops, and we have a validation to -- to check that.

So, this is how we check against the source, and the kinds of things that we find, these -- from one bearing and distance calculation between two fixes, these are all the things that we are able to check in that one calculation.

In addition to that, all of the charts are created out of a database, so that when the instrument approach procedure chart is actually generated into a graphic picture, that that picture, if there's anything that was in the database that's incorrect, a lot of the things that you will never find by editing lots of text, you will find immediately obvious as you have those show up on a screen in the wrong location.

So, our computer graphic visual edits, as we create the chart, are kinds of things that are beyond which we talked about earlier that go into the database for those validation, and since we use the database for chart production, if we find an airway that actually has a misalignment in it, we find by drawing a straight line how much misalignment there's there, and the graphic placement from the database actually sticks it there, and this is done for every place throughout the world, and there are a number of geographical locations. If something's not co-located or something's on top of each other, and one of the things that you've noticed in the approach is that flake intersection and the initial approach fix on the localizer are very close together. Those pop up and show up very graphically when you're looking at the charts and the creation of that.

The -- we have also an agreement with a number of programmers with our -- we have formed a venture with the Russian AIS Government for their aeronautical information, and we're using those programmers that have created an editing tool where every piece of information that goes into the database, we have a chance to visually edit that, which checks paths, but it's important to know what things are checked, but it's probably as important or maybe even more important to know what's not checked.

We do not check any obstacles because the obstacles are not in there on the database. We do not check the procedure validity. So, if the -- if Bill decided not to put a procedure turn in there, we don't check to see that Bill should have or should not have put in a procedure turn because we assume that he knew what he was doing.

We also do not check the MDAs or the segment altitudes against the obstacles or terrain because I think you heard Mr. Henderson say as an example, there was an obstacle that changed the MDA from a 560 to a 580 back to a 560, and there's no way that a chart producer would have any knowledge of that kind of information that's going on out in the field, and we do not check compliance with the TERPS or the PANS OPS.

This -- I have a demonstration, but I think because the time is getting a little bit long, I won't go through the demo, but this is an actual graphic that I lifted from the editing tool, and you can see on here, if I would have pressed this button, you would have seen the DME arch on here as well, but what this does is it shows the lay-out of the instrument approach procedure that comes from the initial approach fix that's very close but slightly adjacent to the missed approach track.

So, flake and the initial approach fix are very close together, but they are not at the same place, and the holding pattern out of flake is drawn this very large because it's shown to the scale of an airplane that's flying about, I think it is, 200 knots, and then the actual missed approach that goes up and makes a right turn till it does a capture to the fixed coming in-bound to the -- or out-bound from the radial, from the VOR, that physically forms the -- the flake intersection.

Okay. Mr. Feith, that's the end of my formal part of my presentation.

MR. FEITH: Thank you, Mr. Terpstra. That was very informative. It clears up a lot of questions from the standpoint of who's responsible for -- for the actual procedure versus charting.

Can we bring the lights up, please? The -- I'll give you an opportunity. I know that you just touched on it briefly with the terrain, but Captain Woodburn talked about how they on the one chart that he showed this morning shows a minimum safe altitude over terrain versus Jep, who shows the actual terrain elevations.

Do you have any opinion on which -- which charting is better, worse, any --

THE WITNESS: Well, I think it's important, first, to recognize, as Captain Woodburn said, is that, first of all, the most important part is that terrain is actually there. The terrain depiction, we started in 1975. So, we've been doing it not quite as long as British Airways but for about 23 years, and we started out by using the minimum altitude, minimum safe altitude, which we call the area minimum altitude, and also did it in green.

So, we started that way as a recommendation from the airlines on the direction that we go and applied that on the area charts first but not on the approach charts.

As we started to create some changes to what we wanted to put on the approach charts, we tried to make some decisions on which direction we were going to go. We have approximately 30,000 different instrument approach procedures that we publish at Jeppesen, and one of the things that we're very careful to do is to make sure that we do enough samples so that we have a method that will work every place.

One of our favorite sayings is one robin does not a spring make. You can't use one example and apply it to everything.

What we did is we found that the application of the area minimum altitude in many cases actually was higher than segment altitude, and we -- we were concerned that if a pilot flew the actual instrument approach procedure as published by the government, in some cases, the minimum safe altitudes were actually higher than those altitudes, and now you've put the pilot in a dilemma of which altitude you actually should be using, the one that's part of the instrument approach procedure published by the government or whether you ought to use the minimum safe altitudes.

As a result, we made the decision to go to contours and create the actual contours on the ground. When we did that, it also presented us with a new dilemma. We now have the area minimum altitudes in green on the area charts, and contours in brown on the approach charts, and the human factors there are really not good, and we decided as a result of the differences between the two, it's best to be one way, and we felt that the contours were the better of the two, and as a result of that effort that we had done and the human factors that we had done with the pilots actually flying them, we ended up converting everything to brown.

The other part that's of a concern to me is that the minimum altitudes are not legal altitudes for pilots to be flying, and those altitudes that are on there are nice to tell you what the buffer is, but the reality is, is that there are FARs that say a pilot is not authorized to create his own minimum altitudes, and he should not be using those altitudes. He should actually be flying the altitudes as prescribed by the instrument approach procedure and whatever the vectors are given to him by air traffic control.

So, those are the reasons why we went to actual contours with the brown color on not only the approach charts but also on the area charts. Different philosophy. Neither one of them are perfect, but the best thing is that the information is there, so that the pilot has an awareness, and as you can see on both the British Airways presentation and our presentation, the higher altitude, the darker the color. It starts out with a lighter color and goes to a darker color. So, the pilot has an immediate cognitive recognition of the change, so that he can see what it is without really having to look at numbers.

MR. FEITH: Thank you. Teddy, will you do me a favor and please put up the approach plate real quickly?

With regard to terrain and terrain depiction on an approach plate, and slide it up to the profile, Teddy, please, given the fact that the VOR sits up on top of the hill looking at this, it's basically flat plate.

Has there been any attempt or should there be any attempt to depict terrain, especially when it comes to mountainous terrain or -- or high obstacles along the approach corridor on this part of the approach plate, so that a pilot knows that they are in an area of high terrain in the area of the step-downs for this approach?

THE WITNESS: We have done quite a few studies in order to determine whether the feasibility of terrain in the profile view would actually be able. There -- we have actually presented these even at airline seminars to determine what should be done.

We came to the conclusion that they should not be done for a number of reasons. Number 1 is that the profile view is not drawn to scale, and the reason it's not drawn to scale is because some profile views may encompass a total area of maybe five miles. Some profile views may be 30 and 40 miles long. If you do the entire profile view to scale, if it's a very long one, all the real critical information, which is in the five -- last five miles, gets so tight together that you really lose the ability to present the information in the form that's helpful to the pilot. That's one of the factors.

The other -- another factor with it is the decision on which profile to use, whether you should use the terrain profile right down the very center of that line or whether you should use the profile that encompasses a wider area. It's not determined which of the two are better and which one should be done. So, that's a complexity there as well.

The other thing is it's really not been determined that the addition of that information really is that beneficial. We found that in the planned view, that has been very much of an assistance, but I think there are better ways to solve the problem of descent profile in the profile view rather than applying the terrain.

We should look at it again, but those are the reasons why they have not been done.

MR. FEITH: You had spoken during your presentation that, of course, Jep is not the only chart vendor. Of the numerous chart vendors out there around the world, do you all interact, talk to each other, to try and come up with some of the common problems amongst the charting vendors and eliminate some of those problems or some of the interpretation confusion that may exist?

THE WITNESS: Yes, we do, in a couple different ways. Number 1, there's an ICAO meeting that's being held this week, which I will leave tonight to get there by next day or two, that's for two weeks, an ICAO, to deal with these exact same issues.

Also, within the United States, there is an FAA/industry aeronautical charting forum which is attended by FAA personnel as well as military charting and Jeppesen and NOS, to determine any differences that are there and what we can do about them.

Also, there's an SAE G-10 charting committee that's chaired by Captain Young, who's with us today, where we also deal with these issues with cross cultures.

In some of the international forums, we are dealing with Transport Canada and also to some extent with Swiss Aire, but we have not had much participation with -- by Air Ad and SAS and some of those.

MR. FEITH: With regard to the charting, this is, of course, a precision approach that where we lost the -- the glide scope, it now becomes basically a non-precision approach.

Are there any efforts right now by the industry or specific airlines to try and rectify, given the fact that we have two different sets of minimums, any better guidance to a pilot when we do lose the precision part of the approach?

THE WITNESS: There are a lot of things that are going on at the moment that are going to provide a lot of assistance to this. One of the things that's significant about Change 17 to the TERPS criteria is that the FAA has decided that they are going to publish the vertical angles on the 8260 for the non-precision paths down on the final approach segment.

There are some holes that they need to fix in that, but that's one of the major efforts that's going on, and one of the things that's as a result of FAA participating in the RTCA efforts and some of the other efforts, the industry coordination efforts that are going on. So, within the FAA community, the TERPS Criteria Change 17 does add a vertical component as well as an evaluation of the obstructions below the MDA.

In addition to that, Jim Gregory of Transport Canada is the chairman of the ICAO Obstacle Clearance Panel, and they are meeting this week in Brazil to come up with the same criteria for applying a non-precision path for non-precision approaches in the ICAO standards.

MR. FEITH: And let me just make one point real quick. This is, of course, a paper-produced approach plate, but we do have this kind of criteria also programmed into some of the newer-generation airplanes in the FMS system.

Are there any efforts right now to program in minimum criteria for non-precision approaches where -- what's the best way I can ask this? Where the precision approach information is in the FMS, but if there's -- if you lose the precision like in this one, where we've lost the glide scope, the non-precision minimums are also in the FMS?

THE WITNESS: There are two things that are going on right now with a couple lead carriers doing the largest share of the work, and it's U.S. Airways and Northwest Airlines, and both of them are -- they have the VNAV or the vertical navigation path into their FMSs, and both of those systems, all the FMS databases in the world now currently have the VNAV path for the final approach segment coded into the database.

What U.S. Airways is in the process of doing is creating an approach concept within their industry that says an approach is an approach is an approach, and it doesn't matter whether it's a precision approach or non-precision approach, if we've flown exactly the same way using a descent path, that is a final descent that goes right down to the runway threshold.

Northwest Airlines will be starting probably in the next month or two to start putting all the localizer non-precision approaches into their database, so they will always have the vertical path for their localizer-only approaches in their databases.

MR. FEITH: So, that basically goes along with some of the comments that Captain Woodburn had talked about, about standardizing all approaches and using the autopilot on as many approaches as possible to reduce workload. This would do --

THE WITNESS: Yes, this is correct. I think as a result of the non-precision approach accidents that have been happening over the last three or four years and the technology that's now here, the airlines are recognizing that they need to be doing this and are now starting to create an environment where all the approach procedures will be flown essentially the same regardless whether they're precision or non-precision.

MR. FEITH: One last question for you, and this is my softball question to you. Is there anything that, based on what you've learned through us and this accident, is there anything that you believe that we, the NTSB, the FAA or the industry, should be doing to improve safety from the standpoint of charting instrument procedures, giving pilots better tools?

THE WITNESS: Well, there are some new tools out there that have VNAV capability and electronic ability. Right now, there is really no back-up if you look at the classic airplanes. There is no back-up when the glide scope is gone. It's strictly fly over fixes at pre-specified altitudes and do a series of steps that are coming down.

If you have a -- with the new generation systems, where the vertical portions are certified for approach capability, the vertical portion is in there as a back-up. So, if the glide scope is gone, there is a secondary VNAC electronic path to glide the pilot down to -- to final, and I think that capability, the more that that's initiated within the industry, the better off we are.

There are some problems with some of the previous FMSs that may not have quite the level of integrity of getting that accomplished. So, that's an issue that also needs to be dealt with.

MR. FEITH: Thank you, Mr. Terpstra. I appreciate your time. Do you have any questions, Paul?

We have no further questions, Mr. Chairman.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: Thank you. No questions.

CHAIRMAN FRANCIS: Barton?

MR. EDWARD MONTGOMERY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCEY: No questions, Mr. Chairman.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Chairman. One question.

Regarding this Jeppesen manual, how do you locate the non-precision procedure? Altitude, descent, procedure is indicated as one of the step-down methods.

Given that, the manual published by the FAA indicates that it is supposed to be the constant descent. Is there any particular reason as to this discrepancy or the difference between the Jeppesen material and the FAA data?

THE WITNESS: You ask a very good question. The reason for the depiction that we have and, by the way, the NOS depiction or the U.S. Government charting depiction shows a constant rate, but by definition, that is not a constant rate of descent the way it's designed.

The way the approach procedure is designed at Guam, there are numerous altitudes at different fixes that are not on a constant descent rate. By showing the profile view and the manner in which it is, it shows that the altitudes that are each one of the fixes are the ones that are to be maintained until the fix is actually passed.

Because the approach procedure as is designed on a non-precision, you cannot fly a constant straight line all the way down and make all the altitudes and fixes work.

MR. LEE: Thank you very much. That's it.

CHAIRMAN FRANCIS: Do you have a further question?

MR. FEITH: Well, I just want to follow up on -- you just made a comment, Jim, about that you can't make a constant rate of descent work on this step-down. Am I understanding you correctly?

THE WITNESS: Yeah. The way that most instrument approach procedures are designed, that you cannot start at an altitude and follow a constant rate of descent all the way down to the runway and make all of the altitudes work at the exact fixes. It just doesn't work.

MR. FEITH: Why -- why is that?

THE WITNESS: Because the criteria that's used by both the TERPS criteria as well as the PANS OPS have a policy in most cases that the altitude that's prescribed at each one of the fixes in the approach procedure will be the absolute minimum altitude that will have the required obstruction clearance as specified in the previous segment.

As a result of those -- as a result of that criteria, each of those altitudes is the minimum altitude, and when you build your criteria that way, you don't build your criteria for constant descent rate, and that's one of the issues that really needs to be addressed by the FAA, and if you look at the approach procedures around the world that also should be addressed by the PANS OPS, that there needs to be a criteria that says that the fixes that are on a non-precision final approach segment should always be at locations with altitudes that are consistent with a straight line.

There are probably six or seven governments throughout the world that do that, and in those cases where there's a constant non-precision descent rate specified by the government source, and Germany does a number of these, then we produce a non-precision constant rate descent, but until the governments actually specify the altitudes that are appropriate for a constant descent rate, that's not the way those approaches can be flown and match all your altitudes with your fixes on the way down.

MR. FEITH: Well, given the fact that the last couple of days, we've been talking about constant rate descents with Paul talking about it a little earlier to standardize those types of approaches, and the fact when we were talking to Korean Air, the management pilots, talking about how some of their crews do in fact fly these constant rate descents for passenger comfort, you're telling us basically you can't do it.

THE WITNESS: That's correct. And my belief is that there needs to be a new criteria established for non-precision approaches, and the ICAO has done that in some cases as a recommendation, and Germany -- I wish I had some of those here, but I would show you that what a number of the governments have done is they have specified non-precision constant rates of descent, and what they do is they have a straight line that goes all the way down on a stabilized descent, and every one of the fixes that are on there that are limitation fixes because of the altitudes that are there, the distances and the altitudes are adjusted so that as you hit each one of the steps, the apex of each one of these steps is on a straight line down.

FAA does not design the non-precision approaches that way. That needs to be changed.

CHAIRMAN FRANCIS: Can they be legally flown, Jim, without those changes? I mean if -- if you -- if you pick the highest of -- of the fixes and then accept the fact that some of them, you're going to be higher than the minimal, can't you fly your own constant?

THE WITNESS: Yes, and, Bob, what you bring up is a very good flight technique in order to accomplish that, but my feeling is that that -- the criteria by which that's done, even though you can do that now, that criteria ought to be created as the basis from which the non-precision approaches are flown.

The -- what we have done in our database is exactly what you've talked about. In the database, there is a non-precision vertical path that goes down to 50 feet above the runway threshold that has a line that projects all the way up that goes at or above each one of these fixes on the way out to where the approach starts. So, there is a way to get that accomplished, but I consider that to be a work-around to the real solution on the long-term basis.

CHAIRMAN FRANCIS: Which is to -- which is to -- to standardize it efficiently?

THE WITNESS: Yes.

CHAIRMAN FRANCIS: Okay. Greg?

MR. FEITH: Plus, that would also mean that you'd have to establish some point in space where you start that -- that procedure on a non-precision approach --

THE WITNESS: Yes.

MR. FEITH: -- so that you hit all of those steps at those minimum points?

THE WITNESS: And that can be as it is today, either at the final approach fix or further out on the approach, depending on the traffic that's in the area, but that's why I had mentioned there's a basic philosophy within the FAA and other governments today that each of the altitudes are absolute minimum altitudes, and they're not really operational altitudes. They should be changed to operational altitudes.

Some of the approach paths today are as shallow as one and a half degrees, and they -- you can't fly a 747 at one and a half degrees. They should be up to a nominal three-degree descent.

MR. FEITH: Well, that was my next question. Will -- will a standard like that apply to all types of aircraft?

THE WITNESS: It -- it should because currently, today, the ILS default or the standard descent rate on an ILS glide scope today is three degrees or roughly 300 feet per nautical mile, and that works very well for almost any size of airplane, and once you've defined that as the standard for precision, that can also be applied to the standard for non-precision as adjusted for obstacles in the final.

MR. FEITH: One last question. We know that there are some airports, though, that do on their precision approaches have a steeper than three degree glide scope.

THE WITNESS: Yes.

MR. FEITH: And there are some that have less than three-degree glide scope, depending on -- I mean they're pretty close, but --

THE WITNESS: The military still has a number of ILS glide scopes that are 2.5 degrees. Almost all of the U.S. ILS glide scopes by the FAA are at three degrees, and they will not go above 3.77 degrees, except by waiver, which is occasionally.

MR. FEITH: So, at those airports that have a greater than three degree glide scope, you'd have to make some sort of exception for your constant rate of descent non-precision type approach.

THE WITNESS: Well, but the exception is very easy because the information will be shown on the charts, so that you'd know what the descent rate is and the angle. So, that's -- as it currently is by looking at any ILS approach chart today, that information is there and could be on a non-precision approach.

MR. FEITH: Very good. Thank you, Mr. Terpstra.

CHAIRMAN FRANCIS: Pat?

MR. CARISEO: No questions.

CHAIRMAN FRANCIS: Mr. Berman has one question.

MR. BERMAN: Hello. Mr. Terpstra, if you'd just take another look at the approach chart for Runway 6 left at Agana. Teddy, can you put that up? Yeah.

I'd like to refer to the initial approach fix definition for flake, 063 degrees IGUM, and then in the next slide, it says ILS/D 7.0. Do you consider that that second line there might have an implication to a pilot that the ILS is the source of the DME information?

THE WITNESS: Not when you consider it's designed to be used by an experienced instrument pilot. The slash in there separates two lines. So, when you read that 063 degrees of IGUM ILS and then followed by that, the DME is from the UNZ VOR.

I mean there's always potential for mis-reading of any piece of information on a chart. That's always possible, but in this case, the slash between the two of them is the same as you see in the profile there to illustrate that same kind of differentiation.

MR. BERMAN: Hm-hmm. Is -- is or has Jeppesen given any consideration to the human factors of the line breaks on the charts?

THE WITNESS: We have done a lot of work with the human factors. With the line breaks like this, we've done some, but this has not been our largest area of concentration.

MR. BERMAN: Okay. Thanks.

CHAIRMAN FRANCIS: I think that's it, Jim. We appreciate your time and having come and missed some of Montreal. It's a sacrifice to have to stay in Honolulu instead of being in Montreal this time of year.

THE WITNESS: Thank you.

CHAIRMAN FRANCIS: Thanks.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: Our final witness is Captain Wallace Roberts from ALPA, if he could come up.

Whereupon,

CAPTAIN WALLACE ROBERTS

having been first duly sworn, was called as a witness herein and was examined and testified as follows:

TESTIMONY OF CAPTAIN WALLACE ROBERTS FORMER CHAIRMAN, ALPA CHIPS COMMITTEE AIR LINE PILOTS ASSOCIATION (ALPA) HERNDON, VIRGINIA

MR. SCHLEEDE: Captain Roberts, could you give us your full name and business address for our record?

THE WITNESS: My name is Wallace Roberts. I go by Wally. And my business address is Air Line Pilots Association, 535 Herndon Parkway, Herndon, Virginia.

MR. SCHLEEDE: And you work for the Air Line Pilots Association?

THE WITNESS: I am a retired TWA pilot, and when I was active, I was the first chairman of ALPA's Terminal Instrument Procedures Committee or, as you've heard the acronym, TERPS, and the name of the committee was changed later on to Charting and Instrument Procedures. For the last five years, since I retired, I've been assisting them in the TERPS areas.

MR. SCHLEEDE: Assisting ALPA with that?

THE WITNESS: Yes.

MR. SCHLEEDE: Okay. Captain Misencik will start the questioning.

CAPTAIN MISENCIK: Hello, Captain Wallace -- Captain Roberts. The -- could you give us an overview of the -- what the CHIPS Committee does?

THE WITNESS: The CHIPS Committee is active on several fronts, all relate to charting issues and TERPS issues. The two are quite different. TERPS, as you learned here from Mr. Henderson and Jim Terpstra, involves obstacle clearance and aircraft performance, nav system performance. Charting involves the issues of how the pilot reads their chart, and we're into new areas of flight management systems, lateral nav systems, space-based systems, and the door's open for new and wonderful things, but it requires that we do it on an evolutionary basis, and mind the store with the older airplanes that are going to be around a long time.

In that vein, we meet with the FAA on a regular basis. Jim mentioned the aeronautical charting form. The next one's coming up next month. We meet with the FAA, Air Force people and some industry users and discuss TERPS on a rather informal basis, and then on occasion, we request meetings or vice-versa and go down to Oklahoma City and meet not so much with Mr. Henderson's shop but more with the people that develop the criteria.

CAPTAIN MISENCIK: How long have you worked with the CHIPS and the TERPS committees?

THE WITNESS: I started doing -- I went to work with TWA as a pilot in 1964 and checked out as captain in 1967 and then started working with ALPA's national all-weather flying committee in 1970, and the chairman of the committee at the time decided we needed a TERPS committee, and I took that over in 1971 and worked as the chairman till 1976 and then assisted the committee after that time until the early '80s when I took a hiatus and worked in different ALPA work until I retired.

CAPTAIN MISENCIK: Were you involved in any other activities regarding aviation safety?

THE WITNESS: At the present time, I'm writing a monthly technical article for a newsletter that's designed for instrument-rated pilots called IFR Refresher distributed throughout the United States, and I guess throughout the world, and I write technical articles that are too technical for general aviation -- for general-type aviation publications, and they seem to be well received, and I maintain them on a Web site for people that want to see them after the fact.

I know they're read generally. I get a lot of feedback from Air Force instructor pilots that refer to them. I'm trying to get the word out in the more technical esoteric areas that are important that the FAA just is trying to get out there, but, you know, they have the manpower problems with getting out publications and how you do these things.

CAPTAIN MISENCIK: Captain Roberts, could you give us a brief description of what the purpose of instrument approach and procedure charts are?

THE WITNESS: I think that my friend Jim Terpstra did a pretty good job there. My just slightly different bent on it is that it started in 1930s with, I think, Jimmy Doolittle really did the first successful approach. It was called an instrument let-down, and that's literally what it is. To get out of the en route environment to a point where you can see the runway and land in poor weather conditions and safely avoid obstacles and being able to safely maneuver the airplane for landing without seeing out the window until you're quite near the runway generally, and we even have new systems now where they can land automatically without ever seeing the runway.

Those are limited applications but nonetheless very important.

The air space required to fly an airplane on instrument so far has been far greater than is required when you're flying an airplane on a nice sunshiny day because you don't have the same cues. The pilot certainly cannot react as quickly.

CAPTAIN MISENCIK: In your opinion, are all of the -- we discussed all the considerations in designing and -- or developing and certifying approach construction, and in your opinion, are all the considerations motivated by safety?

THE WITNESS: I'm sorry. Would you --

CAPTAIN MISENCIK: I said in -- we're discussing chart approach procedure development. In your opinion, are all the considerations motivated by safety?

THE WITNESS: Not entirely, although I think that by far, -- I'm not familiar -- too familiar with how it's done in other countries, other than to know that not every country is as diligent as our country is.

I think the FAA does a commendable job overall. I think certain times, there are political considerations that force our friends in Bill Henderson's shop to design procedures that we might not rather see, like greatly offset localizers at places like Washington National or the approach at Kennedy is one that sticks out. Everybody that is really not a very good instrument approach.

By the same token, they're difficult to fly, but they're really quasi-visual approaches because the weather ones are higher, but they are approaches that pilots would rather not have in their manuals at all.

But those are the minority.

I think that most of the places, especially major air carrier airports, where the terrain isn't a problem, in particular the FAA's done a pretty good job overall providing us with instrument landing systems.

CAPTAIN MISENCIK: We've been discussing the Guam ILS 6 left approach plate. Would you consider that -- how many different procedures are depicted on that chart?

THE WITNESS: Well, I -- I think I -- I have as good a handle on TERPS probably as any airline pilot out there, and -- and the chart has meant different things to me on different days.

With the glide scope working, the procedure is a very standard international ILS, except that it does require DMA in an indirect sense to fulfill the entry into the procedure of no radar vector and to complete the missed approach.

With the glide scope gone, and I heard Mr. Henderson testify, and he -- he opened -- he -- he lit up another light for me today. This is really not only a localizer procedure but it's a localizer DME procedure, and not only is it that, it's a localizer DME VOR procedure, and in many ICAO countries, I suspect that's exactly what the title would say. It would say ILS DME VOR, and -- and maybe that would serve pilots better in an oddball location like this to be a real heads-up. You've got something here that's a little different than you're used to at most locations.

CAPTAIN MISENCIK: Well, before we get your comments on the -- the design of this particular approach, could you tell us, in your experience, how many non-precision approaches an airline pilot would expect to perform in the course of a year?

THE WITNESS: That would depend upon the airline. If you take a major national airline of the United States, where this country has done a pretty good job overall providing ILSs at all our high-traffic airports, I heard a remark made by a management pilot at American Airlines shortly after one of their recent tragedies, that they surveyed their airline and found that the average American Airlines line pilot flew one non-precision approach a year.

My personal experience at TWA on the route structure that we had then, I flew domestic and out here to Honolulu, which is really domestic, also, that I might fly two or three non-precision approaches a year, not very many.

Now we get to the commuter airlines or to the Alaskan airlines folks, and they may shoot a lot -- quite a few non-precision approaches a year.

CAPTAIN MISENCIK: As an airline pilot and as a recognized expert on TERPS and charting, could you give us your impressions of the localizer approach into Guam and comment on the design of that particular approach?

THE WITNESS: It appears to be that the approach is probably the residual of a U.S. Navy design which I've assessed this procedure very carefully from a TERPS obstacle clearance standpoint, laid out the topographical maps and all. The procedure from an obstacle clearance standpoint is certainly full compliance with TERPS. There's a lot of options and procedures a specialist has in those areas to create a smooth-flowing approach for the pilot.

If you'll note, the VOR DME Runway 6 left has a rather different profile than the localizer procedure. That may not be necessary. If you can make them both the same, the TERPS is complied with in either case, but there's an extension of this flyability, and -- and I think when you get into these type of procedures, there's a missing link, and not only in the FAA but probably throughout most of the PANS OPS ICAO member nations that -- that the people flying the really heavy iron-like air carrier pilots and our Air Force friends flying C-145s and C-5s and these, their needs are not necessarily thought through when the flight inspection's being done in something like a Beechcraft King Aire.

CAPTAIN MISENCIK: In your opinion -- would you care to comment specifically on the localizer approach to Guam?

THE WITNESS: Well, if I were magically suddenly in charge of facilities at Guam based on what they had in position on the day of the accident, I'm not sure that I may have redone the -- attempted to redone the -- do the localizer procedure to make it a little more like the VOR procedure, VOR DME procedure, but that would require a DME fix similar to the 1.3 DME.

But what I would really be crying out to me is I got a facilities problem at this airport, and I'm going to correct it, and there's two things I would have pushed for real hard to change, and the most important one, which is important to airline pilots everywhere, is a frequency paired co-located ILS DME facility, so we don't have to rely upon the DME on the VOR, and we can get the VOR pretty much out of the picture, except we still need it to transition on to the procedure and for the missed approach.

But I can solve that problem by adding something that's contrary to the FAA policy today, but I'd put in an MDB at the outer marker, a compass locator, particularly since this is a remote island station, and I would create all kinds of flexibility now with all those facilities, and, further, I would seriously consider -- and this is something we're going to take up, is that a procedure this complicated should very possibly be on its own chart, and -- and that brings up the issue of even if localizer approaches are going to continue to be on ILS charts, in most cases, they probably should have their own title, and the controller should clear you for that localizer approach when he knows the glide scope -- or she knows the glide scope's out, and, further, there should be a note by that localizer procedure saying disregard glide scope indications, just as we have today on back course approaches.

CAPTAIN MISENCIK: What -- what inhibits those changes? Is that contrary to regulations now, having a localizer-only approach?

THE WITNESS: Well, no. Right now, if -- if the procedures specialist and his managers deemed it necessary, they'd be well within their prerogative today to pull it off and put it on a separate chart. But that's contrary to conservation of paper.

I mean if you did that everywhere, you would have -- people would be carrying hundreds of more charts around, and in most cases, it wouldn't be necessary. At this location, it's a judgment call. I would have judged to pull it off and put it on a separate piece of paper, but that doesn't mean the FAA did anything wrong by not doing that.

CAPTAIN MISENCIK: Regarding Guam, is it common procedure to have a step-down on the final approach segment?

THE WITNESS: Very common to have a step-down fix in a localizer procedure in the final approach segment, but this is the first time I've ever seen it be a VOR station, and -- and I think that that paragraph we talked about earlier, 288(c)(4)(c), would more properly have a minimum there.

I understand Bill's argument, though, that VOR is really required here, but the thing we have to remember is that our people sometimes elect not to split the cockpit because the captain only really has one VOR set, and the co-pilot has one, and they like to do the same thing whenever possible, and this is something that's not true in light airplanes or even military airplanes.

We cannot split our DMEs, and the policy is that both sides should be reading the same thing whenever possible. Therefore, to have the option of the higher minimums which result in a lot higher visibility minimums would -- with a crew additional flexibility to the procedure and also help the guy that shows up with just one VOR set. He's going to use it for the localizer in-bound, but then he doesn't miss, he can retune his VOR for the missed approach, and that guy's not taken care of by not having 1440 as a minimum.

CAPTAIN MISENCIK: How about the segment altitudes and the minimums? Do you consider them appropriate in this -- in this approach?

THE WITNESS: I'm sorry. Would you say that one more time?

CAPTAIN MISENCIK: I said the segment altitudes and the minimums --

THE WITNESS: Oh.

CAPTAIN MISENCIK: -- on the Guam approach, do you consider them appropriate?

THE WITNESS: Oh, I've evaluated the procedure. Everything's correct. Like I said, the -- whether you have 14 -- 1440 at the VOR is a lot higher than -- than is needed by criteria, but that's where the facility was, and the procedures specialist only has so much flexibility.

If he or she is electing to use that VOR station as a step-down, they're kind of married now to the altitude and the terrain out earlier in the approach. So, yes, the altitudes are appropriate, but -- but not as flexible as if I were using a localizer DME. I could do more things.

CAPTAIN MISENCIK: And would you care to comment on the notes on the approach plate? In your opinion, what was the intent of the DME-required note?

THE WITNESS: I -- I don't like the note. I've never seen a note like that before. Generally when DME is not in the title, it's because it's used as conditional, like radar or DME required. ADF or DME required for something other than the final approach segment.

It also brings out to me that we need the DNR work going the naming convention for the final approach segment has been in a state of controversy within the people that work in the U.S. TERPS community, and this cries out for the fact there's something wrong with the naming convention because we shouldn't end up with a note like this in my view.

If we do, it should become intuitively apparent to a pilot why that note's there, and that certainly is not the case.

CAPTAIN MISENCIK: Well, do you feel that note is unnecessary or incomplete or what exactly do you --

THE WITNESS: By putting it up in the title, that note is necessary. You can't -- the note is necessary. I guess I would have to agree that maybe it is incomplete. I think that the air traffic facility at this location due to sparseness of nav aids should have committed to the fact they'll provide radar vectors with the terminal radar on demand, like most U.S. domestic facilities do. Then the note would have read radar or DME required at least for the approach plates, but we still have the missed approach problem.

But then we could have taken the missed approach back to the VOR like we did in the VOR alpha approach, and then we could have gotten away from the note DME required, and it would have been radar or DME required.

CAPTAIN MISENCIK: There's also a note DME from UNZ. Is that note appropriate and adequate in your opinion?

THE WITNESS: That note is the note that is required whenever the DME on an ILS does not come from a frequency pair co-located DME station, and, of course, that begs the comment I made earlier that we need ILS DME on all these facilities, but nobody did anything wrong on the day of the accident by not having it that way, but moving forward, yes, I think it's -- it's a note we should get rid of by putting in ILS DMEs.

CAPTAIN MISENCIK: Some of the criticisms that you've voiced or comments voiced about the -- the approach, do you feel that the TERPS procedures are applied uniformly in -- in approach development and charting?

THE WITNESS: It's moving in the right direction but probably not as well as it should. The answer is a qualified no, not as to fundamental safety or obstacle clearance. I think the FAA's people are very careful. They're not perfect in that regard, but I think they're diligent.

The -- when it was out in the fields, we feel in ALPA that they were less -- there were less standardization on areas of criteria that weren't used a lot, and, so, you would see some local variances, but the local flight inspection people and the procedures being designed in the field gave the procedure designer a better feeling for the procedures. So, that was the plus side.

Now we've moved it all to Oklahoma City, which is a down side on having people out in the field familiar in developing the procedures, but the plus side is we have the potential for real standardization, but it's not there yet.

The differences are usually areas of confusion and question marks rather than something that's egregious that's going to cause a pilot to have -- you know, not have obstacle clearance or run into a mountain. I don't mean those kinds of problems.

CAPTAIN MISENCIK: Are there any modifications or changes you'd like to see made in the way approaches are designed and approved and flown?

THE WITNESS: We would like to see the serious users of the system have a more formal input into the criteria and into the daily design of the procedures. We believe the -- not only do certain segments of the procedures staff need to be pilots, they need to be pilots that have heavy aircraft experience, C-141 types from the Air Force that are airline pilots, and my ideal would be to have a selected number of active airline pilots trained in TERPS and assigned for a tour of duty along with their flying duties to do some oversight with -- with some teeth in it over at the FAA by the -- in this area.

By the same token, the FAA people should have some of their people trained as second command on some of our major airlines that can go fly the jumpseat with that training and knowledge when the weather's really bad and see what we're up against out there flying when the going's real rough.

So, yeah, there's some areas in there where we could all be communicating on a technical level a lot better.

CAPTAIN MISENCIK: Do you feel that user input is solicited enough or there's enough user input taken into consideration in chart development?

THE WITNESS: Not on an effective level. The FAA, like Mr. Henderson said, they definitely coordinate with a designated representative from each user group, but what you get -- and I receive these forms for the Western U.S., which is Mr. Henderson's area. So, he and I have dealt with each other quite a bit the last three years or so, and the FAA's been very accommodating to me in providing additional forms to help me assess these procedures, but I've been looking at these forms for 25 years, and even then, I still don't see the same thing as I would if I had that approach chart in front of me to evaluate what was in the formulation stage.

So, I think that with the average user group, let's say of somebody's that done TERPS for 25 years like I have, they just really are not looking at these things. The FAA sends them out. There's no doubt about it, but I just -- with some rare exceptions where people have local knowledge, they just can't look at the thing in that form and get much out of it.

CAPTAIN MISENCIK: So, essentially, what are you advocating, that user input continues after -- even after the chart is certified then?

THE WITNESS: Well, the FAA will always listen to users after the fact. The door never closes completely, but it becomes a lot more difficult for everybody at that time, and it's not even fair to the FAA that somebody comes in, you know, three months after the thing's out and say, hey, look at this.

Whenever I brought up anything serious, like Mr. Henderson's always been very responsive. We don't always agree on how serious it is, but I think we agree most of the time.

But it would save a lot if the user saw it in a nice chart form and could get in there during the comment period so the FAA can keep the ball rolling where most of the time they should be able to keep it rolling.

CAPTAIN MISENCIK: As an airline pilot, what are your recommendations regarding the constant descent? We've heard input from various people here, also Captain Woodburn. How do you feel about the constant descent and also the monitored approach techniques?

THE WITNESS: Well, let me take the monitored approach first because that came into being on my airline while I was there as it did most airlines after a series of accidents, I think, in the late '70s or the early '80s. TWA's flight operations management decided it was a good idea to let the -- basically when the weather is really crummy, to have the co-pilot fly the approach preferably with the autopilot, so the captain was freed up to be a monitor and take over at minimums, and I can guarantee I tried it that way. It took awhile to get used to it, but it was a lot better.

But it requires that your co-pilot be a very strong aviator, too, and during a period of rapid expansion when some of the co-pilots were new, then sometimes there's a little kink in that system, but, conceptually, it's very sound.

As to constant rate descents, as a TERPS -- as a pilot, I'm all for them. As a TERPS guy, I just have to issue some caveats because often where we have our most difficult non-precision approaches, and this is not true of Guam, there's places a lot worse than Guam, the terrain along the intermediate and final approach segments, we have so much terrain, we can't even put an ILS in. It won't even work because I have to -- I misunderstood -- either misunderstood Mr. Henderson or -- that an ILS has much more obstacle clearance than a non-precision approach until you get to about a mile and a half off the end of the runway.

The typical outer mark of the ILS has 6 or 7-800 feet of obstacle clearance, particularly with the new MLS criteria that's taking over. Well, with a non-precision, you only need 250 feet with additives for precipitous terrain, if necessary. So, -- plus, you can make them steeper because they can go up to 3.77 degrees.

So, we end up, we've got non-precision approaches that are pretty steep in some locations, and if we start flying a constant descent like Mr. Terpstra mentioned, clear all those step-down fixes, we end up with four-degree glide scopes in some locations, and we have one more problem, is that we have non-precision approaches that are lined up straight in for a runway, but they have no straight-in minimums because the descent gradient exceeds TERPS for non-precision.

So, if a pilot lands straight in on one of those, he may be doing a six-degree slope in, and I'm not sure we're advising pilots enough about those kinds of traps.

CAPTAIN MISENCIK: Captain Roberts, for my final question, do you have any other thoughts concerning TERPS or the procedures that you would care to share with us or any thoughts that we may look at concerning this Guam accident?

THE WITNESS: Well, I think that -- that I would continue -- I can't emphasize enough how important co-located frequency paired DME is because now the air carriers all have the equipment. They show up in the localizers on both sides. The DME's there, and now we can use this DME for a lot of things, even when the ILS is working, and we haven't used that tool to its fullest.

These marker beacons are 1930s technology. The FAA wants to get rid of them. They're expensive to maintain. The little markers are already being decommissioned. The outer markers will probably disappear, but with DME, we have a running fix that can be -- that can mark the glide scope intercept point, so we can have a reasonableness test of the accuracy of the glide scope, and we can have a fix mark the decision height point. We have all this flexibility, but this will only work if it's frequency paired because the splitting of the sets just drives airline crews up the wall.

I think if nothing else comes out of this, I would urge the Board to recommend that the frequency paired DMEs be put on every FAA ILS that doesn't have them.

CAPTAIN MISENCIK: Thank you, Captain Roberts. No questions.

CHAIRMAN FRANCIS: KCAB?

MR. LEE: Thank you, Mr. Chairman. We have no questions. Thank you.

CHAIRMAN FRANCIS: FAA?

MR. DONNER: Yes, thank you, Mr. Chairman. Captain Roberts, thank you for that testimony. I enjoyed that.

I have two questions for you, sir, and the first is do you think that the FAA should require pilots to fly a minimum number of non-precision approaches annually?

THE WITNESS: I'm sorry. Would you repeat that?

MR. DONNER: Do you think, sir, that the FAA should require pilots to fly a minimum number of non-precision approaches?

THE WITNESS: There could probably be more done in the simulators. If they don't have an actual score out on the line, it might not be a bad idea, and with some real-world diversions and thrown them in and just, you know, give them some time to brief on it, and then do it in a training and not a punitive checking environment, it would be very beneficial.

MR. DONNER: Very good. One last question. In your statement in Exhibit 2 Victor, and you don't have to refer to it, it says, "The FAA should employ persons familiar with real-world airline operations, such as former airline pilots."

I just wondered if you were available should we have a vacancy.

THE WITNESS: Not -- not unless it's within 30 miles of San Clemente, California, no.

MR. DONNER: I don't think Oklahoma City's quite that close.

THE WITNESS: No, not quite, no. If it were near where I lived, I certainly would consider it on a consulting basis, but the FAA has its ways, and it takes a long time to get to certain things, and I would presume there's other people that may be in airline fields, and they're out on the street at age 45 or something that sure would like to see some of those people working in those jobs.

MR. DONNER: Thank you very much, sir. No further questions.

CHAIRMAN FRANCIS: Government of Guam?

MR. DERVISH: Thank you. No questions.

CHAIRMAN FRANCIS: NATCA?

MR. MOTE: Thank you, Mr. Chairman. No questions.

CHAIRMAN FRANCIS: Korean Air?

CAPTAIN KIM: No questions. Thank you.

CHAIRMAN FRANCIS: Boeing Company?

MR. DARCEY: No questions.

CHAIRMAN FRANCIS: Barton?

MR. EDWARD MONTGOMERY: No questions.

CHAIRMAN FRANCIS: Mr. Feith?

MR. FEITH: Just a couple. I just want to make sure that for the record, we're clear. In your statement that you had provided, Captain Roberts, in 2 Victor, let me just read you what you had written. I just want to make sure that we have covered all the points and all your concerns.

You made the statement in the second paragraph, "Our assessment shows that the FAA's published procedures for Guam International Airport and the resulting approach plate are seriously flawed. The procedures do not comply with the agency's own standards."

And I had heard you earlier saying that it met all the criteria, all the TERPS criteria. Is there something else that this doesn't meet that you haven't already talked about?

THE WITNESS: The -- the area that -- Number 1, I didn't write that statement, although I certainly read it and agreed with it. I think the general impression I have to say in all candor, if I showed up that night and not familiar with Guam and with those notes and that VOR step-down without local knowledge, I would have requested a VOR to DME Runway 6 left approach.

I just did not feel comfortable with this procedure, and I mentioned the fact, and only today did it finally sink into me that technically, technically 1440 did not have to be a minimum on this chart. When we wrote that, I felt it did, and I have looked at it a lot, and if I have that kind of problem, we have a problem. The system has a problem.

MR. FEITH: And one last question. We heard testimony today from Captain Woodburn about mandatory go-around of 500 feet. What's your opinion on that?

THE WITNESS: Well, that was the call-out on TWA. So, obviously I did it for most of my crew. I don't think they had it maybe the first few years I was there. Absolutely agree with it completely. In fact, I agree with his idea. I think there should be a thousand-foot call, a 500-foot call, and a hundred-foot call.

I think that that really helps crews on their awareness as to this critical, critical phase of flight, particularly in low-visibility conditions and non-precision approaches.

MR. FEITH: Very good. Thank you very much for your testimony.

THE WITNESS: Yes, sir.

CHAIRMAN FRANCIS: Mr. Berman for a point of clarification.

MR. BERMAN: Sir, when you refer to the 500-foot procedure, are you referring to a call-out or a mandatory go-around that's above the minimums?

THE WITNESS: I'm referring to call-out. In some better non-precision approaches, our MDA may have a height above touchdown well below 500 feet. This would just be a call for stabilization.

MR. BERMAN: Okay. Thank you. I understand.

CHAIRMAN FRANCIS: I think I have the last question, and this is a -- this is a question that I asked to Mr. Henderson, and I think you were here, on the co-located DME issue.

THE WITNESS: Yes, sir.

CHAIRMAN FRANCIS: And the feasibility of having a co-located DME in Guam, realizing that you have a powerful VOR DME, which is essential for en route navigation and the -- and the difficulties or non-difficulties of having the two DMEs.

THE WITNESS: There's no difficulty at all, except for dollars. That VOR DME is there to service a huge oceanic area, and it's really not even appropriate to the ILS as far as I'm concerned and should be as far removed from it as possible, and the ILS -- use the VOR DME to get on to the approach, fine, but we have many approaches where the arc initial approach segment south of VOR DME, but the ILS has its own DME, and when we switch over to the ILS, we're using the ILS DME. That's very common in this country.

CHAIRMAN FRANCIS: Thank you very much, sir, and I appreciate your -- your comments particularly about more all-around communication between those that are -- have different perspectives on trying to accomplish the same thing which is safer approaches.

Thank you.

THE WITNESS: Thank you.

(Whereupon, the witness was excused.)

CHAIRMAN FRANCIS: That concludes our hearing here. I'm not going to read this statement. It's going into the record, but let me say that we remain open to new and pertinent information whenever it may come in.

We reserve the right to reopen this hearing should we feel that that's warranted. We would encourage people to send, particularly the parties, the accredited representative, any further information to us, to the Board, in Washington, to Mr. Feith, and there will be at some point a deadline on that, but he or Mr. Schleede will -- will let you know when that is.

The -- everything that's been developed here will be coupled with that which is gathered at the other elements of this investigative process and will be considered in the preparation of the final report and ultimately the Board meeting to determine cause and to make recommendations.

I'd like to thank a whole lot of people here. I guess I'll start with the parties and the accredited representative. These are never easy times that we're going through after a major accident like this, and whether it's the on-site investigation or the continuing investigation or the hearing or that which comes on subsequently, it's very, very difficult, and I think that -- that we all appreciate, we at the NTSB, all appreciate the cooperative and forthcoming attitude on the part of -- of the parties here.

As you know, the way we run our investigations, we are -- we are enormously dependent on the parties in terms of generation of the evidence in the factual part of these -- of these investigations. So, our thanks to all of you and for being here and for helping us.

I'd also like to thank some folks from the NTSB without whom, in addition to those here present ad up here who do some of the work for part of the time, but Carolyn Dargan and Candy and Teddy and Van and Elaine and Ann are the folks who have worked long and hard to set this all up and to make sure that we have been able to keep rolling through these three days. So, I'm not sure that all of us ever truly appreciate what these folks do, but -- but certainly our -- our warmest thanks to these people.

The interpreters, thank you. The fact that we, for the -- for the Korean interpretation yesterday on the very technical sessions, ended up relying on somebody who spoke three languages rather than just two, it really was a problem of some -- finding someone who spoke not just Korean and English but also aviation, and certainly no reflection on you, and we appreciate all you did.

To our court reporter, thank you. We created a couple problems for you at the beginning, but we all seem to have gotten through.

Convention center staff, this is a brand-new facility. We're, I think, the first occupants, and they certainly couldn't have been more helpful for us. The Honolulu Police Department has been enormously helpful, and I'd like in that context to -- to -- to thank our temporary employee, John O'Brien, who has come here to help us with security liaison. He's been a pleasure to work with and enormously helpful for us. Hopefully I haven't forgotten anyone.

Let me make a comment about the families. We started with the families, and I think it's appropriate to end with the families.

I can imagine or try to imagine the difficulty that you encountered in trying to follow what is enormously technical and complex. I would -- I would hope that if any of us can continue to be helpful to you in understanding what we're doing and what's going on, that you will -- that you will let us know.

As I mentioned on the first day, we are going to make a concerted effort to -- to ensure that we are in good and constant touch with you and can be responsive to -- to your needs.

We appreciate very much your being here, your interest. This is very much being done, as you know, to -- to ensure that this kind of a thing does not happen again, and -- and your support and your interest is -- is very, very important and very much appreciated by us. So, thank you very much.

Lastly, Mr. Schleede and Mr. Feith will be hosting a meeting immediately after this in Room 301 for the parties and the accredited representative, and I think if anyone else can think of something that I've forgotten? No?

We are then concluded here, and thank you all for being here and enjoy the rest of your time in Hawaii.

(Whereupon, the meeting was concluded.)

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