# Korean Air Flight 801 investigation/March 25

Source is http://web.archive.org/*/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
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
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
(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
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
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
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
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
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.)
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