and continued until at least 23 seconds afterward. These actions would have resulted in an earlier notification of the accident to emergency rescue personnel and possibly an earlier emergency response. (See section 2.7 for a discussion of the emergency response.)
Further, if the CERAP controller had been monitoring the flight on the terminal radar display, which was located to his immediate right and would have been clearly visible to him,[1] he might have seen the airplane descend prematurely toward high terrain and have been able to alert the flight crew and prevent the accident. This radar display would have shown the flight descending through 2,000 feet msl while almost 7 miles from the airport and outside of the outer marker. The radar display would have also shown the airplane crossing the outer marker almost 800 feet lower than the established crossing altitude of 2,000 feet.[2]
Although the CERAP controller told Safety Board investigators that he did not continue to monitor the flight because he was engaged in other duties about the time of the accident, the ATC transcripts indicated no activity during that time. The transcripts indicated that the controller instructed the flight crew, about 0140:42, to contact the Agana tower. The controller then made a radio transmission to another aircraft about 0140:54. From about 0141:14 to 0141:30, the controller had a conversation with another controller at a different center, and about 0142:05, he acknowledged a transmission from another aircraft. However, the transcripts indicated no further activity until 0143:49, when the CERAP controller called the Agana tower with a flight plan. Thus, the ATC transcripts indicated no activity during the time period beginning 21 seconds before and continuing until 1 minute 23 seconds after the flight 801 crash (which occurred about 0142:26). Therefore, the CERAP controller should have been able to monitor the flight during this time. If the controller had done so, he would have had an opportunity to warn the flight crew of the flight's premature descent and possibly prevent the accident.
The Safety Board concludes that the CERAP controller's performance was substandard in that he failed to provide the flight crew with a position advisory when he cleared the flight for the approach, inform the flight crew or the Agana tower controller that he had observed a rain shower on the final approach path, and monitor the flight after the frequency change to the tower controller. It could not be determined whether the
- ↑ The Safety Board recognizes that the en route radar display was set to a range of 265 nm and therefore could not be used for effectively monitoring the final approach. The terminal radar display was set to a range of 60 nm and displayed the final approach course for runway 6L.
- ↑ Although the CERAP controller told Safety Board investigators that his last observation of the target of flight 801 on the terminal radar display was when the airplane was 7 miles from the airport at an altitude of 2,600 feet, FDR and radar data do not support his statement. The data indicated that, when the CERAP controller instructed the flight to contact the Agana tower, the airplane was at an altitude of about 2,200 feet and maintained a continual descent. Therefore, the airplane was probably farther than 7 miles from the airport when the CERAP controller last observed the flight.
