AIRCRAFT ACCIDENT REPORT
C CO ONT TR RO OL LLED FLIIIGHT IIINTO TERRAIIIN
AIR CHINA INTERNATIONAL FLIGHT 129
MOUNTAIN DOTDAE, GIMHAE
APRIL 15, 2002
Findings Related to Probable Causes
1. The flight crew of flight 129 performed the circling approach, not being aware of the
weather minima of wide-body aircraft (B767-200) for landing, and in the approach
briefing, did not include the missed approach, etc., among the items specified in Air
China’s operations and training manuals.
2. The flight crew exercised poor crew resource management and lost situational
awareness during the circling approach to runway 18R, which led them to fly outside
of the circling approach area, delaying the base turn, contrary to the captain’s
intention to make a timely base turn.
3. The flight crew did not execute a missed approach when they lost sight of the runway
during the circling approach to runway 18R, which led them to strike high terrain
(mountain) near the airport.
4. When the first officer advised the captain to execute a missed approach about 5
seconds before impact, the captain did not react, nor did the first officer initiate the
missed approach himself.
3.2 Findings Related to Risk
1. The flight crew’s training for the circling approach was conducted with the simulator
only for Beijing airport, and they had never been trained for the circling approach to
Gimhae airport’s runway 18R.
2. The crew resource management (CRM) training of Air China was insufficient for the
three flight crew complement.
3. Air China did not perform the improving action for Service Bulletin (SB)
767-34-0067(May 31, 1989), which was issued by the Boeing Company for the
reinforcement of the GPWS functions.
4. Air China provided one set of Jeppesen manuals to the flight crew, which the captain
was using during the instrument approach, making it difficult for the other flight
crewmembers to crosscheck the information in the manuals.
5. Instrument approach chart used by the flight crew of flight 129 did not depict the
high terrain north of the airport.
Conclusions Aircraft 140 Accident Report
6. During the circling approach, the flight crew of flight 129 did not use standard
callouts defined by Air China.
7. Flight 129 was flown between 150 and 160 kt on the downwind leg, which exceeded
the maximum speed of 140 kt of Gimhae airport’s circling approach category “C,”
and the width of the downwind leg was narrower than normal, for which corrective
actions were inappropriate.
8. The second officer, tasked with handling radio communications, did not reply
correctly to controllers’instructions a number of times, however, the captain and
first officer did not correct the second officer’s inappropriate replies.
9. When the tower controllers lost visual contact with the flight 129 aircraft on the
downwind and base legs, they tried to find the flight 129 aircraft visually, however,
they did not use the tower BRITE, which is an aid to complement visual
10. The flight crew did not reply appropriately to the local controller’s question when
the controller asked them the possibility of landing, because the local controller did
not have the flight 129 aircraft in sight after issuing the landing clearance.
11. The approach controller felt that the flight 129 aircraft was flying on a longer pattern
than normal, so he asked the local controllers via intercom, “Does it seem go
around?”however, the local controllers stated that they did not hear this question.
12. The local controller asked a question to the flight crew to confirm the position of the
aircraft, however, the local controller did not issue any direct warning or advice
based on his own subjective awareness of the situation.
13. “The Korean Standard Air Traffic Control Procedures”and “Gimhae Base Local
Procedures”did not specify radar monitoring of the aircraft on a circling approach
by means of the BRITE and MSAW systems.
14. The MSAW system installed in Gimhae tower at the time of the accident was
designed only with the function of visual warning, which was not consistent with
the ICAO recommendation to include an aural warning also. Thus, the low altitude
(LA) warning would not have been noticed in a timely manner, unless the
controller monitored the BRITE closely.
Conclusions Aircraft 141 Accident Report
15. The MSAW activation area was programmed in the vicinity north of the circling
approach area of Gimhae airport, which was set to be higher than the altitude of the
circling approach pattern, and the MSAW would be activated in the case of a
normal base turn in close proximity to the MSAW activation area within the
circling approach area due to its predictive warning function.
16. When the aircraft disappeared from radar, and radio communication was lost
between the tower and the aircraft, the tower controllers did not notify the search
and rescue department in a timely manner.
17. The measuring equipment of runway visual range (RVR) of Gimhae airport runway
(18R/36L) had been out of order for a considerable time period, thus it had not been
operated appropriately for the purpose of category II runway-use.
3.3 Other Findings
1. The flight crew and flight attendants received training in accordance with the CAAC
and Air China regulations and procedures, and they were certified and qualified for
2. The flight crew took an adequate rest before the flight.
3. There was no evidence of any medical problems that would have affected the flight
4. Toxicological test results of the captain were negative for alcohol and drugs.
5. Autopsies performed on the victims of the accident revealed severe burn injuries,
however, it could not be determined with a certainty whether the causes of death
were from the impact trauma, fire, or a combination of both.
6. Airworthiness certificate of the flight 129 aircraft was valid, and its weight and
balance were within the specified limits.
Conclusions Aircraft 142 Accident Report
7. In the preflight aircraft maintenance inspection prior to departure from Beijing
airport, no defects were found in the fuselage of the aircraft, or its systems and
engines. During flight, the crew did not report any malfunction, and the examination
of the aircraft wreckage did not show any possible malfunction.
8. The GPWS installed on the flight 129 aircraft operated as designed, and it did not
generate any warning before the ground impact, because the aircraft was configured
for landing, and the terrain closure rate was insufficient to trigger the Mode 2
9. The controllers handling flight 129 were properly qualified to perform their duties.
10. The weather forecast and ATIS broadcasts available to the flight crew were accurate
and up to date.
11. The south wind was strong and there were low clouds and precipitation near Gimhae
airport at the time of the accident, and the mountainous area in the north was covered
with cloud and fog.
12. There were no international requirements that the aircraft’s approach category (ies)
and/or weather minima for a circling approach should be informed officially to the
air traffic control authority.
13. The pilot should determine the official or existing weather adequate for approach or
landing based on the approach category and landing minima, and the controller
should take actions such as issuing appropriate instructions to the aircraft to hold or
proceed to another airport when reported by the pilot that the weather conditions are
below the landing minima of the aircraft.
14. In accordance with Airforce regulations, it was a normal procedure for the approach
controller to ask and confirm with flight 129 about its approach category in order to
determine whether to issue the approach clearance, considering the weather
conditions at that time.
15. When the approach controller issued flight 129 a control transfer instruction to the
tower for the first time, the flight did not change to the tower frequency accordingly,
of which the reason could not be confirmed. And 1 minute and 8 seconds after
issuing the first control transfer instruction, the delayed initial contact with the tower
was established upon receiving the second control transfer instruction, however, the
landing clearance to flight 129 was issued by the tower controller at the usual
Conclusions Aircraft 143 Accident Report
16. The local controller had flight 129 in sight briefly at the point passing nearly mid
point on the downwind leg, and at the time of issuing the landing clearance, the flight
disappeared from his sight. Thus, the local controller issued the landing clearance to
the flight including the term, “Not in sight.”
17. The local controller could not be precisely aware that the aircraft was dangerously
approaching mountainous terrain, as he lost visual contact with flight 129 from the
time of landing clearance issuance until crash on the base turn, due to poor visibility.
18. All of the Korean, ICAO, and FAA procedures for the use of BRITE or Surveillance
Radar describe that the local controller may use the BRITE optionally, as an aid
augmenting “visual observation”function.
19. Circling approach is visual maneuvering, which the pilot has to confirm ground
obstacles visually in the circling approach pattern, and is an extension of an
instrument approach procedure which provides for visual circling of the aerodrome
prior to landing.
20. The circling approach area and terrain in the vicinitywere not depicted on the Gimhae
radar video map. So the tower controller was in a poor environment to accurately
identify the situation that an aircraft was flying outside the circling approach area
and approaching dangerous obstacles, so he could issue a warning or advice by
monitoring the BRITE.
21. The use of the certified BRITE was described in the Korean Standard Air Traffic
Control Procedures. The certification standard of the BRITE installed in the tower at
the time of the accident was not specifically described, however, the tower BRITE
could be used as the technically certified BRITE, since it was certified for the
completion of installation in accordance with the specifications and design drawing
of the ordering authority (Seoul Regional Aviation Bureau), and was regularly
maintained and inspected by qualified technicians.
22. The differences between the ICAO and Korean criteria for the flight procedure
establishment of Gimhae airport were not described in the ROK AIP effective at the
time of the accident.
23. The flight information material used by the flight crew of flight 129 was Jeppesen
manual, and it was described in the manual that the circling approach procedure of
Gimhae airport was established in accordance with the FAA criteria.
24. The procedure for the circling approach to runway 18R at Gimhae airport was a
general circling approach procedure, without the prescribed circling approach track
established using the ground visual references, which could cause difficulties in
conducting a circling approach flight in poor visibility.
Conclusions Aircraft 144 Accident Report
25. Gimhae airport has the instrument approach procedure only to runway 36, thus in the
case of runway 18 in use, it requires more time to separate aircraft approaching
runway 36 before making a circling approach to runway 18 from the aircraft
departing from runway 18.
26. The visual weather observation site at Gimhae airport did not deviate from the
establishment requirements of a weather observation site, but as its northern airspace
was partially obscured, the weather observer had to move to the observation site
located in the ramp to observe the weather, which could be considerably
27. At Gimhae tower operated by the Airforce, a Korea MOCT civil air traffic control
coordinator was assigned to be on duty in accordance with a related mutual consent,
however, the civil controller was not positioned in the tower at the time of the
accident. And due to the system of non-authorization of relevant ratings for the
substantial air traffic control services, the civil controller was not able to
appropriately carry out the supervision of the regulatory compliance of civil aircraft
pilots, and coordination with the civil aviation related organizations, which were
described in the mutual consent.
28. The clock installed in the recording equipment of the automatic on-off lighting
system of Gimhae airport had been running fast by 19 minutes, which no one was
aware until the accident investigation.
29. Air China had not designated Gimhae airport as a “special airport,”which would have
required the additional preflight training and procedures for the flight crew.
30. The Korea MOCT designated Gimhae airport as a special airport in Flight Safety
Regulations, however, it did not include the detailed information in consideration of
the characteristics and requirements of the airport, and the required pilot
qualification for this information.
31. All the in-flight public announcements of flight 129 were conducted only in English
and Chinese, not in Korean for many Korean-speaking passengers, who could not
understand the meaning of those announcements clearly.
32. A local resident called 119 immediately after the accident, so the rescue guard could
be dispatched expeditiously.
33. Because of no regulation specified for assisting accident victims and their families of
aircraft operating to Korea, there were difficulties with assisting the victims and their
3.4 Consultation of Draft Final Report
In accordance with Annex 13, Paragraph 6.3, the KAIB forwarded copies of the
Draft Final Report to China (State of Registry and Operator) and the United States (State
of Design and Manufacture) inviting their significant and substantiated comments on
June 8, 2004. The KAIB accepted all of the comments204 returned by the United States
(NTSB) on August 8, and made appropriate revisions to the Draft Final Report.
The KAIB received comments from China (CAAC Aviation Safety Committee) on
August 5, 2004, but the KAIB could not accept all of the comments returned by China.
Therefore, the KAIB and CAAC held a technical meeting to discuss the differences from
August 26 to 30, 2004. Following the meeting, the KAIB made several changes to the
report. A second Draft Final Report was then forwarded to China (CAAC Aviation Safety
Committee) for additional consultation in a technical meeting held from November 1 to 4,
China (CAAC Aviation Safety Committee) could not fully accept the KAIB’s
second Draft Final Report, therefore, a second response was forwarded to the KAIB on
December 19, 2004. The KAIB held a third technical meeting from February 17 to18,
2005, and a fourth technical meeting from March 31 to April 1, 2005, on the second
comments returned by China (CAAC Aviation Safety Committee). However, the KAIB
and CAAC still could not reach agreement on certain parts of the factual information,
analysis, and conclusions.
In spite of several technical meetings held by the KAIB of the State responsible for
the conduct of the flight 129 accident investigation, the KAIB was not able to accept all
of the comments returned by China (CAAC Aviation Safety Committee). Therefore, in
accordance with Annex 13, Paragraph 6.3, the comments from China (CAAC Aviation
Safety Committee) are included in Appendix 6 to this report.
Comments on KAIB Aircraft Accident Report (Draft)
Aviation Safety Committee of CAAC
3.1 Findings of the Investigation
1. The flight crewmembers and flight attendants had received training. They were certified and qualified for this flight.
2. The aircraft was certified airworthy; weight and balance were within the specified limits.
3. In the final preflight maintenance inspection prior departure at Beijing Capital International Airport, any defects were not found in the fuselage of the aircraft as well as its systems and engines. During flight, the crew didn\'t report any malfunctions, and the examination of the aircraft wreckage did not show any possible malfunctions.
4. The south wind was strong at Gimhae airport when the accident occurred. There was low clouds and precipitation. The mountainous area in the north was shaded by cloud and fog. The circling approach was difficult under such weather condition.
5. The air traffic of Gimhae Airport was controlled by Air Force. It was appropriate in accordance with the related regulations and procedures of Korea for the Air Force controller to provide services to civil aircraft.
6. When the tower controllers lost the visual contact of CA129, they failed to use radar to determine the location of aircraft, and when low altitude warning displayed, they did not issue a safety alert.
7. When the approach controller found that the downwind leg of CA129 was longer than the normal and MSAW warning, he reminded the tower controllers, but no response received. The approach controller failed to take further measures to alert the flight crew.
8. The functions of Minimum Safe Altitude warning system (MSAW) at Gimhae airport did not conform to the relevant prescription of ICAO, for it was not equipped with aural alert.
9. Transfer instruction issued by the approach controller was hard to recognize, resulting in the short interruption in ATC process.
10. On the control radar display, the boundaries of the protected area of circling approach for all categories of aircraft were not depicted, and the marks of obstacles in the mountainous north of the airport were not complete.
11. In the Jeppesen approach chart used by CA129 flight crew, the position relationship between the runway and the key obstacles relating the site of the accident was wrongly marked.
12. The flight crew’s training in circling approach was conducted in the simulator, but they had never conducted the training of circling approach to Gimhae Airport\\\'s runway 18R.
13. Air China provided an insufficient Crew Resource Management (CRM) training for the three-pilot crew.
14. The flight crew participated in classes of various legal regulations according to Air China\\\'s operational requirements, but during this flight they performed its circling approaching in violation of the circling minimum of wide-body aircraft.
15. When the crew performed circling approach to enter the downwind leg, the width was narrower than normal, and no corrections were made.
16. It cannot be confirmed that the circling guidance lights was turned on when the aircraft was approaching.
17. The contents of Automatic Terminal Information Service manually recorded at Gimhae airport was hard to comprehend, and the controller did not use VHF to inform the crew of the important information that the weather conditions were below the minima of circling approach for Category “D”.
18. The ground proximity warning system (GPWS) installed at the aircraft, due to the fact that the terrain warning was inhibited when aircraft had been in landing configuration, , did not generate any warning just before the ground impact.
19. As of April 15th, 2002, there was no recording of any difference from ICAO Standard on aircraft category in ROK AIP.
20. The visual field of meteorological observation site of Gimhae Airport did not meet the appropriate requirements of 《Guide to practices for meteorological offices serving aviation》of World Meteorological Organization.
21. When the aircraft disappeared from radar and radio contact of the aircraft with tower was lost, the tower didn\\\'t notify search and rescue department in time, while local residents called 119 about the case.
22. The Korean Civil Aviation Authority did not inform the CAAC and Air China of listing the Gimhae airport as a “special airport”.
1. 沒有approach briefing 所以大家不清楚approach procedure
2. lost visual contact 沒有馬上 go around (不管從CAAC還是ICAO的角度來看都是違規)
3. 沒有按照approach procedure (這點就強調了 briefing 的重要性) 而且飛到自己在哪裡都不知道 ?
有一點很重要的是 circling approach都已經歸類在Visual flight maneuver 裡面了
(另外有點不確定的事情是 是不是個個航空公司circling approach的程序都一樣 如果不一樣的話請問ATC要怎麼記牢全世界各航空公司approach的procedure ..... 而且根據ACI影片的內容看起來是每個航空公司有自己的approach procedure 但是這點有待專家確認)
而且如果真的是天氣的問題 那不是更應該misapproach ?
加上當天也有不少飛機執行一樣的approach 然後 misapproach