Korean Air Flight 801 - Aircraft Accident Report (NTSB)/Flight Safety Foundation Study Recommendations

by National Transportation Safety Board

Appendix C

Flight Safety Foundation Study Recommendations

The Flight Safety Foundation Approach and Landing Accident (ALA) Reduction Task Force made several recommendations to support each of its study's nine conclusions (see section 1.18.3.1 for more information). The conclusions and recommendations are as follows:

Conclusion 1: Establishing and adhering to adequate standard operating procedures (SOP) and crew resource management (CRM) processes will improve approach and landing safety.

Recommendations:

• States should mandate, and operators should develop and implement, SOPs for approach and landing operations.
• Operators should develop SOPs that permit their practical application in a normal operating environment. The involvement of flight crews is essential in the development and evaluation of SOPs. Crews will adhere to SOPs that they help develop and understand.
• Operators should implement routine and critical evaluation of SOPs to determine the need for change.
• Operators should provide education and training that enhance flight crew decision-making and risk (error) management.
• Operators should develop SOPs regarding the use of automation in approach and landing operations and train flight crews accordingly.

• There should be a clear policy in all operators' manuals regarding the role of the pilot-in-command (PIC) in complex and demanding flight situations. Training should address the practice of transferring pilot-flying duties during operationally complex situations.

Conclusion 2: Improving communication and mutual understanding between air traffic control (ATC) services and flight crews of each other's operational environment will improve approach and landing safety.

ATC recommendations:

• Introduce joint training programs that involve both ATC personnel and flight crews to promote mutual understanding of such issues as procedures, instructions, operational requirements, and limitations; improve controllers' knowledge of the capabilities and limitations of advanced-technology flight decks; and foster improved communications and task management by pilots and controllers during emergency situations.
• Ensure that controllers are aware of the importance of unambiguous information exchange, particularly during in-flight emergencies. The use of standard ICAO phraseology should be emphasized.
• Implement procedures that require immediate clarification or verification of transmissions from flight crews that indicate a possible emergency situation.
• Implement procedures for ATC handling of aircraft in emergency situations to minimize flight crew distraction.
• Implement, in cooperation with airport authorities and rescue services, unambiguous emergency procedures and common phraseology to eliminate confusion. *Develop, jointly with airport authorities and local rescue services, emergency training programs that are conducted on a regular basis.

Flight crew recommendations:

• Verify understanding of each ATC communication and request clarification when necessary.
• Report accurately, using standard ICAO phraseology, the status of abnormal situations and the need for emergency assistance.

Conclusion 3: Unstabilized and rushed approaches contribute to ALAs.

Recommendations:

• Operators should define the parameters of a stabilized approach in their flight operations manuals, including at least the following: intended flightpath, speed, power setting, attitude, sink rate, configuration, and crew readiness.
• Company policy should state that a go-around is required if the aircraft becomes destabilized during the approach.
• The implementation of certified constant angle, stabilized approach procedures for nonprecision approaches should be expedited globally.
• Flight crews should be trained on the proper use of constant angle, stabilized approach procedures. Flight crews should also be educated on approach design criteria and obstacle clearance requirements.

• Flight crews should "take time to make time" when the cockpit situation becomes confusing or ambiguous, which means climbing, holding, requesting vectors for delaying purposes, or performing a missed approach early.

Conclusion 4: Failure to recognize the need for and to execute a missed approach, when appropriate, is a major cause of ALAs.

Recommendations:

• Company policy should specify well-defined go-around gates for approach and landing operations. Parameters should include visibility minima required before proceeding past the final approach fix or the outer marker, assessment at the final approach fix or the outer marker of crew and aircraft readiness for the approach, and minimum altitude at which the aircraft must be stabilized.

• Companies should declare and support no-fault go-around and missed approach policies. Conclusion 5: The risk of ALAs is higher in operations conducted during low light and poor visibility, on wet or otherwise contaminated runways, and with the presence of optical physiological illusions.

Recommendations:

• Flight crews should be trained in operations involving these conditions before being assigned line duties.
• Flight crews should make operational use of a risk assessment tool or checklist to identify approach and landing hazards. Appropriate procedures should be implemented to mitigate the risks.
• Operators should develop and implement constant angle, stabilized approach procedures to assist crews during approach operations.
• Operators should develop and implement a policy for the use of appropriate levels of automation of navigation and approach aids for the approach being flown.

Conclusion 6: Using the radio altimeter as an effective tool will help prevent ALAs.

Recommendations:

• Education is needed to improve crew awareness of radio altimeter operation and benefits.
• Operators should install radio altimeters and activate "smart callouts" at 2,500, 1,000, and 500 feet; the altitude set in the decision height window; and 50, 40, 30, 20, and 10 feet for better crew terrain awareness.
• Operators should state that the radio altimeter is to be used during approach operations and specify procedures for its use.

Conclusion 7: When the PIC is the pilot flying and the operational environment is complex, the task profile and workload reduce the flying pilot's flight management efficiency and decision-making capability in approach and landing operations.

Recommendations:

• Operators should develop a clear policy in their manuals defining the role of the PIC in complex and demanding flight situations.
• Training should address the practice of transferring pilot flying duties during operationally complex situations.

Conclusion 8: Collection and analysis of in-flight parameters (for example, flight operations quality assurance programs) can identify performance trends that can be used to improve the quality of approach and landing operations.

Recommendations:

• Flight operations quality assurance should be implemented worldwide along with information-sharing partnerships, such as the Global Analysis and Information Network, British Airways Safety Information System, and FAA Aviation Safety Action Programs. Examples of flight operations quality assurance benefits (safety improvements and cost reductions) should be widely publicized.
• A process should be developed to bring flight operations quality assurance and information-sharing partnerships to regional airlines and business aviation.

Conclusion 9: Global sharing of aviation information decreases the risk of ALAs.

Recommendations:

• Deidentification of aviation information data sources should be a "cardinal rule" in flight operations quality assurance and information-sharing processes. Public awareness of the importance of information sharing must be increased through a coordinated, professional, and responsible process.

The Flight Safety Foundation ALA task force said that its conclusions and recommendations "must be translated into industry action" according to the following principles:

• cohesiveness across all aviation sectors and regions to participate jointly in the implementation process and
• commitment to a significant awareness campaign that will ensure availability of this information to participants in approach and landing operations worldwide so that they can play a part in improving safety within their "spheres of influence."