UNCLASSIFIED (U) SOURCE DOCUMENT REFERENCE ID: (59133-28113) GROUP SEQUENCE NUMBER: (00001) SUBMITTED BY: COMNAVMARIANAS, LTJG HANSEN, 344-9289, 671 344-9289. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE (U) KEYWORDS: KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. (U) TITLE : SHORTAGE OF MEDICAL SUPPLIES (U) Observation: OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS A shortage of medical supplies (e. g. IV fluids, minor procedure kits, oxygen, etc.) for the Mass Casualty Team Supply Carts was noted in various patient care areas. 6. (U) Discussion: The problem was caused by the unavailability of funding for those items. Records show a list of supplies necessary for adequate stocking of Mass Casualty Supply Carts was placed on order. 7. (U) Lesson Learned: Supply runners were tasked with gathering and borrowing needed supplies from Materials Management Department and other care areas throughout the hospital. 8. (U) Recommendation: Stock and maintain required items in their appropriate carts upon receipt. Rotate required items out 9 months prior to expiration using an exchange system with the Supply Department. 9. (U) Comment: Additionally, as survivors were treated some items were necessarily shipped in from off island to augment Naval Hospital Guam's stocks. Specialty doctors and other medical personnel were needed to sustain medical treatment and mortuary requirements. UNCLASSIFIED 3 UNCLASSIFIED 1. (U) SOURCE DOCUMENT REFERENCE ID: (27553-58722) GROUP SEQUENCE NUMBER: (00002) SUBMITTED BY: COMNAVMARIANAS, LTJG HANSEN, 344-9289, 671 344-9289. 2. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97, 3. (U) KEYWORDS : KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. 4. (U) TITLE: MEDICAL STAFF RECALL SYSTEM 5. (U) Observation: Many staff members, including some of the CO/ XO Special Assistants, did not receive calls in a timely manner, and some not at all. 6. (U) Discussion: The existing standard operating procedures (SOP) did not provide the duty crew with sufficient guidance for conducting a rapid mass casualty recall. As personnel start coming in they were instructed to call all the people they knew ASAP. 7. (U) Lesson Learned: Disaster can strike 24 hours a day and recall bills need to be updated at least monthly. 8. (U) Recommendation: Review and update recall SOP as necessary. Provide specific guidance for use by all key members of the recall bill. Each director (including the CO/ XO) shall have 2 alternates designated in the recall bill who will perform the departmental duties for them in their absence. In turn, each department head shall have 2 alternates designated to do the same at the departmental level. Monthly departmental recall bill shall be routed through respective directors instead of going straight to the Chief of the Day's desk. The directors should ensure they have a complete recall roster with them at home. 9. (U) Comment: COMNAVMARIANAS is studying the possibility of buying an automatic dialing system (such as used in the Army OPS UNCLASSIFIED 4 UNCLASSIFIED Center/ Pentagon) to facilitate mass casualty recall bills. The time spent recalling all personnel is very time consuming and could/ may delay treatment of patients or response to disaster. UNCLASSIFIED 6? 5 UNCLASSIFIED 1. (U) SOURCE DOCUMENT REFERENCE ID: (90136-69244) GROUP SEQUENCE NUMBER: (00003) SUBMITTED BY: COMNAVMARIANAS, LTJG HANSEN, 344-9289, 671 344-9289. 2. (U) NICKNAME : K A L FLIGHT 801 CRASH , DATE 3. (U) KEYWORDS : KEYWORDS WILL BE ADDED BY OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS MANAGEMENT SITE. 4. (U) TITLE: INSUFFICIENT 5. (U) Observation: Upon initiation of the Mass COMMUNICATION EQUIPMENT Casualty Receivinq and Treatment Plan, team captains were instructed-to pick up hand held radios at the Chief of the Day's office. During this disaster there were not enough radios to go around. Some team captains needed radios more than others, but did not get them. Additionally, the hospital did not have the proper communication equipment to communicate with the incoming helicopters. 6. (U) Discussion: 7. (U) Lesson Learned: To alleviate the situation, everybody was instructed to use the telephone as the first and preferred method of remote communication. Messengers were also used to relay messages. 8. (U) Recommendation: Radios should be labeled for who they should belong to during a casualty (real or exercise) Purchase additional radios. Provide cellular phones to the Medical Response Team deployed to the site, and to any other remote operations with crucial need. Establish communications connections so medical personnel in helicopters can talk with emergency room personnel, on the ground coordinators at scene, or inflight medical enroute to hospital. 9. (U) Comment: UNCLASSIFIED 6 UNCLASSIFIED 1. (U) SOURCE DOCUMENT REFERENCE ID: (24345-61905) GROUP SEQUENCE NUMBER: (00004) SUBMITTED BY: COMNAVMARIANAS, CAPT WIGGINS, 339-2126, 671 339-2126. 2. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. 3. (U) KEYWORDS: KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. 4. (U) TITLE : CHAPLAINS' AREAS OF COVERAGE NOT CLEARLY DEFINED 5. (U) Observation: Force Chaplain was called from quarterdeck on the morning of the crash and was told to "go help the chaplain at the hospital" . Other chaplains went to the crash site immediately upon hearing about the crash. 6. (U) Discussion: At the time of the accident/ crash chaplains from 5 different commands and 3 different military components responded to the accident based on their commanders' assessment of the situation. 7. (U) Lesson Learned: The Guam region must have a consolidated religious support plan for mass casualty events to facilitate the notification of survivors and family members of the situation. 8. (U) Recommendation: COMNAVMARIANAS Force Chaplain work with Defense Disaster Coordination Officer' (DCO) in assigning Chaplains and Religious Program Specialists (RP) to various sites. Assign a Public Affairs Office representative to the Chaplains' Team in order that releasable information can be provided to the Chaplains for use to enhance their services. 9. (U) Comment: KAL officials did not have a family assistance program and NTSB officials did not arrive for 2 days. Notification procedures fell to hospital and military officials who treated the survivors, and received the human remains until the NTSB Family Assistance Team arrived from Washington, D. C.
(U) SOURCE DOCUMENT REFERENCE ID, (24345-45786) GROUP SEQUENCE NUMBER: (00005) SUBMITTED BY: COMNAVMARIANAS, LT BRADFIELD III, 366-6422, 671 366-6422. (U) NICKNAME : KAL FLIGHT 801 CRASH, DATE (U) KEYWORDS: KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS (u) TITLE: HELICOPTER COMMUNICATIONS WITH GROUND CREW NOT ESTABLISHED (U) Observation: On-scene Helicopter Combat Support Squadron Five (HC-5) aircraft was not able to establish communications with ground personnel at the crash site. 6. (U) Discussion: In an effort to save time and speed up rescue operation aircraft crew provided ground personnel on site with UHF radios. Upon delivery of one patient to the Naval Hospital (NAVHOSP), medical personnel retained the aicraft's rescue litter. This could have been prevented if proper communications were established beforehand. 7. (U) Lesson Learned: On crash site communication is necessary to fully facilitate the rescue efforts, however, no one other than a designated crash air support coordinator should have communication with the air rescue team to avoid confusion at the crash site. 8. (U) Recommendation: Establish a VHF frequency for ground communications with air support assets. Assign an air support coordinator to effect that communication. Limit the number of personnel who can talk to air support assets. COMNAVMAR purchase portable UHF/ VHF radios for use by military forces in support of rescue efforts. Additional cots need to be loaded at the TRIAGE site for further air support rescue efforts. Mass casualty drills should continue on a more frequent baais to ensure communications, fire fighting, and Command and Control issues are standardized, practiced and utilized. UNCLASSIFIED 8 UNCLASSIFIED 9. (U) Comment: Almost everyone wanted to talk to the helicopter, and most communication was handled by telephone to the HC-5 operations dispatcher which was very effective. At times the HC-5 operator became overwhelmed with requests to communicate with helo pilots and medical personnel aboard. Communication with helos must be constrained to prevent confusing directions to the pilot.
(U) SOURCE DOCUMENT REFERENCE ID: (24345-95902) GROUP SEQUENCE NUMBER: (00006) SUBMITTED BY: COMNAVMARIANAS, CDR LYNCH, 339-9251, 671 339-9251. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE (U) KEYWORDS: KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS (U) TITLE : FORCE JUDGE ADVOCATES NOT CONSULTED IN A TIMELY MANNER (U) Observation: The immediate issue of posse commitatus arises whenever the military is used in support of civil law enforcement or civil emergencies. In KAL flight 801 disaster, civilian fire and rescue as well as Navy and Air Force personnel were used to secure the site. 6. (U) Discussion: Staff and Judge Advocates should be consulted as soon as possible to begin evaluation of legal issues to include posse commitatus, assistance to foreign companies and governments, liability for services and service members; liaison with other Federal agencies (Dept. of State, Dept. of Justice) , and security among others. 7. (U) Lesson Learned: Judge Advocates maintained constant monitoring of the situations throughout the humanitarian relief operations. Close liaison was also maintained with the U. S. Attorney's Office and the Dept. of State to preclude potential international embarrassment for the U. S. Government relative to issues concerning the remains of the crash victims. 8. (U) Recommendation: Judge Advocates should be integral members of any disaster preparedness team. They should be included in all operational decisions. Ensure Judge Advocates keep their operational law chain of command fully advised to the highest level. Judge Advocates should, as soon as possible, determine identity of insured, insurance companies, local and foreign attorneys involved to ensure they are invited to negotiations sessions for contracted support of recovery efforts. Judge Advocates, once engaged, should be prepared to the sol federal attorney( s) engaged in the operation. 9. (U) Comment: From a Defense Disaster Coordinating Officer's (DCO) perspective, it is essential to withdraw military forces from human remains recovery efforts and crash debris removal phase as soon as possible. The Judge Advocates' role is essential to this withdrawal of forces. Civilian companies must be contracted, security forces assigned, using the carrier's (in this case KAL's) funding, at the same time those contractors must work for the DCO to facilitate the remains recovery efforts. UNCLASSIFIED (@�,,/ 12 UNCLASSIFIED
1. (U) SOURCE DOCUMENT REFERENCE ID: (11319-44490) GROUP SEQUENCE NUMBER: (00007) SUBMITTED BY: COMNAVMARIANAS, CDR SATTERLY, 339-7053, 671 339-7053. 2. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. 3. (U) KEYWORDS: KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. 4. (U) TITLE: LACK OF LOGISTICAL SUPPORT ,-' 5. (U) Observation: There was a lack of logistical support during first hours of the KAL flight 801 disaster. Facilities/ Environment (N4) and Supply (NE) representatives were not assigned to the site at the onset of disaster. 6. (U) Discussion: During the first days of disaster, N4 coordinated effort for providing camp lighting, fuel, water, refuse, porta-pots, pest control, and scheduling meals. N4 also coordinated Seabees efforts to provide site drainage and extended roadway, ordering all necessary gravel. 7. (U) Lesson Learned: Environmental, funding/ meals support, water and human necessities are essential to all disaster recovery efforts. In the extremely hot environment of Guam, water, meals and human support facilities will be needed within an hour or 2 of the rescue efforts. 8. (U) Recommendation: N4 and NE representatives should be trained to respond and provide onsite support to the on-scene commander. N4 is knowledgeable of the transportation and facility self-help assets within COMNAVMAR, and capabilities of Naval Construction Force. N8 knows contracting support, along with both the Public Works Center and Officer-In-Charge of Construction support. N4 officers are also qualified Seabee Combat Warfare Specialists, trained in contingency operations, emergency medical procedures and camp support. 9. (U) Comment: None UNCLASSIFIED 13 1. 2. 3. 4. 5. UNCLASSIFIED
(U) SOURCE DOCUMENT REFERENCE ID: (11319-81329) GROUP SEQUENCE NUMBER: (00008) SUBMITTED BY: COMNAVMARIANAS, CDR SATTERLY, 339-7053, 671 339-7053. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE (U) KEYWORDS : KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. (U) TITLE: INSUFFICIENT COMMUNICATION (U) Observation: OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS Insufficient communication between various command and control (security, operations, seabees, etc.) , leading to delays, miscommunication, and excess communication traffic on the nets available (cell phone and VHF radios). Also, there was a lack of telephone directories on site leading to delays and unnecessary communications in attempts to obtain phone numbers and points of contact. 6. (U) Discussion: In this time of limited funding, there was insufficient communications equipment for all the personnel assigned to the initial rescue effort. 7. (U) Lesson Learned: Supply (N8) should implement an emergency contract to obtain augmenting equipment for such emergencies. Everyone concerned was urged to bring their own telephone/ recall directory. 8. (U) Recommendation: Establish communication plan and gear, including a dedicated Facilities/ Environment (N4) net. This net should be dedicated to coordinating environmental, transportation, logistics, and self-help response. Ensure disaster preparedness lockers are stocked with phone books and command directories to be used by Crash Site Command and Control. 9. (U) Comment: None
1. (U) SOURCE DOCUMENT REFERENCE ID: (11319-88120) GROUP SEQUENCE NUMBER: (00009) SUBMITTED BY: COMNAVMARIANAS, LCDR C. MAUER, 339-6127, 671 339-6127. 2. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. 3. (U) KEYWORDS: KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. 4. (U) TITLE: ON-SCENE COMMANDER NOT IDENTIFIED IMMEDIATELY 5. (U) Observation: Seabees from the Naval Mobil Construction Battalion Forty (NMCB-40) often received conflicting guidance from the different agencies on site namely: Guam Civil Defense, National Transportation Safety Board (NTSB), COMNAVMAR Crash Site Duty Officer, Medical Officials, and Air Force Officials. 6. (U) Discussion: Guam Civil Defense was on-scene agency handling the initial rescue efforts, As requested, Navy and Air Force assets responded to the crash site. At that time, some confusion ensued. concerning which agency would assume command of the scene. Additionally, the Guam Civil Defense Director and his staff failed to open their command center in a timely fashion adding confusion to the rescue efforts. 7. (U) Lesson Learned: Guam's rescue response assets were limited in fire, rescue and emergency response capabilities. When military augment forces are assigned they must remain in an augment capacity to Guam Civil Defense. 8. (U) Recommendation: The DCO must liaison closely with the Guam Civil Defense Agency Command Center to Command Center. Hold update briefs at a predetermined time and location, at least hourly on the first day and daily until the effort is over. Present should be one representative from each command/ unit/ agency participating in the recovery effort. If the On-Scene Commander is a rotational position both incoming and offgoing watchstanders should be present for a well coordinated turnover. 9. (U) Comment: While Guam Civil Defense and the military components periodically practice disaster recovery scenarios---most are UNCLASSIFIED /---==-,' ((" j 15 UNCLASSIFIED oriented towards the expected tropical cyclones (typhoons) and major earthquake. Our most recent aircraft accident exercise was held at the Guam International Airport in April 1997, and a great success. While that exercise helped this effort, the remote area of the crash site required many assets not utilized in an airport crash, complicating this crash rescue effort.
(U) SOURCE DOCUMENT REFERENCE ID: (11319-12303) GROUP SEQUENCE NUMBER: (00010) SUBMITTED BY: COMNAVMARIANAS, LCDR C. MAUER, 339-6127, 671 339-6127. (U) NICKNAME: K AL FLIGHT 801 CRASH, DATE (U) KEYWORDS : KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS (U) TITLE: ACCESS OF ESSENTIAL PERSONNEL AND EQUIPMENT DELAYED BY SECURITY CHECKS (U) Observation: Several security check points, although necessary due to the nature of the incident, often had trouble determining who had permission to access the crash site. Several times, the entire Naval Mobil Construction Battalion Forty (NMCB-40) crew stood idle as they awaited the delivery of an important piece of equipment or part which was being delayed by security checks. 6. (U) Discussion: At one time, over 500 people were trying to gain access to the crash site which was in a remote highly inaccessible area. Many of these individuals were political entities, family members, and other non-essential observers. 7. (U) Lesson Learned: Screening individuals who should have access to the crash site was a time-consuming and tedious effort which could have been better done by an individual's agency, vice military security or eventually the commercial security company contracted. 8. (U) Recommendation: Have pre-made numbered security badges/ priority coded on the ready for this type of disaster. Issue controlled number of badges to authorized commands/ agencies that are participating in the rescue effort. Publish a list including those unit's block of badge numbers for the security posts to have on hand. Allow personnel with security badges to escort unbadged personnel as required to accomplish their assigned mission. 9. (U) Comment: Access to the site was severely limited by its remoteness and the narrow access road near the site. The on-scene commander must control entry to prevent overcrowding and blocking of the access points.
(U) SOURCE DOCUMENT REFERENCE ID: (11319-74915) GROUP SEQUENCE NUMBER: (00011) SUBMITTED BY: CONNAVMARIANAS, LCDR C. MAUER, 339-6127, 671 339-6127. (U) NICKNAME: K A L FLIGHT 801 CRASH, DATE (U) KEYWORDS : KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS (U) TITLE : SAFETY HAZARDS AROUND CONSTRUCTION EQUIPMENT IGNORED (U) Observation: Too many people were allowed to walk in close proximity of the construction equipment, posing a hazardous situation. . 6. (U) Discussion: Most construction equipment are large, not exact or fluid in movement and can pose significant danger to personnel who are generally unfamiliar with equipment operations. When construction equipment is operating, especially under load, the area of operation must be completely clear of unnecessary personnel. Considering the narrow site, constant rain, difficult terrain and slippery conditions, the constant disregard for requests to keep the area clear made for a potentially disastrous situation. Naval Mobil Construction Battalion Fortv (NMCB-40) personnel had 7. (U) Lesson Learned: On-scene commander must personnel to maintain a to constantly police the area themselves. assign equipment spotters and security clear zone around equipment operations. 8. (U) Recommendation: The On-Scene Commander must allow the experts to define the safe operating requirements for their portion of the mission. He must also provide support and authority to the unit's Officer-in Charge in the assurance that everyone heeds those requirements. 9. (U) Comment: The equipment operating areas and the remains recovery areas were both in a single access area which limited maneuvering room. Both equipment operations and recovery could not take place concurrently if rescue personnel were to remain safe. Conflicts in priorities were often seen. On-scene commander must control the efforts. UNCLASSIFIED 18 1. 2. 3. 4. 5. UNCLASSIFIED
(U) SOURCE DOCUMENT REFERENCE ID, (11319-46768) GROUP SEQUENCE NUMBER: (00012) SUBMITTED BY: COMNAVMARIANAS, LCDR J. LEHNER, 339 671 339-7026. (U) NICKNAME : KAL FLIGHT 801 CRASH, DATE OBSERVED: 7026, 09/ 23/ 97. (U) KEYWORDS : KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. (U) TITLE: RESPONDERS UNABLE TO COMMUNICATE WITH EACH OTHER USING RADIO EQUIPMENT (U) Observation: During the search and rescue efforts the various agencies involved were unable to coordinate responses with equipment and personnel. At various rescue sites communications between agencies was accomplished by yelling instructions and requests back and forth. 6. (U) Discussion: All of the rescue and recovery agencies, civilian and military components use different frequencies to communicate. During rescue or disaster recovery efforts a common frequency necessarily must be assigned to all agencies. 7. (U) Lesson Learned: A single frequency is necessary to effective communications. 8. (U) Recommendation: Continue and possibly speed up efforts to design and build a centralized emergency communications center to house 400 MHz systems for military police and fire and 800 MHz civilian police and fire capabilities. Additionally, provide radio equipment that can communicate directly with helicopters. The same capabilities also needs to be available in the command center at COMNAVMAR (CNM) .The CNM command center should be used as the command post for any emergencies of significant magnitude involving multi-agencies in the future. 9. (U) Comment: None UNCLASSIFIED 19 1. 2. 3. 4. 5. UNCLASSIFIED
(U) SOURCE DOCUMENT REFERENCE ID: (15389-90178) GROUP SEQUENCE NUMBER: (00013.) SUBMITTED BY: COMNAVMARIANAS, LCDR RODRIGUEZ, 339-4286, 671 339-4286. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE (U) KEYWORDS : KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS (U) TITLE: MANPOWER REQUIREMENTS DEFINITION (U) Observation: After initial rescue actions were completed by the end of the first day, emphasis shifted from rescue to the recovery of human remains and wreckage removal. 6. (U) Discussion: This gruesome work effort was conducted condition by several hundred volunteers. requirements from participating commands defined/ tasked, creating confusion. 7. (U) Lesson Learned: n extreme weather Initially, manpower were not clearly A n organizational structure was established which involved representatives from the logistics groups, staff civil groups, and security groups, along with a formal tasking delineating required support. This was essential in setting up a routine that allowed for smooth operations at the site. 8. (U) Recommendation: Use formal methods to follow up on initial taskings to any organization to minimize confusion. Provide representatives from those military organizations, to form an on-scene staff. 9. (U) Comment: None
(U) SOURCE DOCUMENT REFERENCE ID: (11319-74915) GROUP SEQUENCE NUMBER: (00011) SUBMITTED BY: COMNAVMARIANAS, LCDR C. MAUER, 339-6127, 671 339-6127. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. (U) KEYWORDS : KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. (U) TITLE: SAFETY HAZARDS AROUND CONSTRUCTION EQUIPMENT IGNORED (U) Observation: Too many people were allowed to walk in close proximity of the construction equipment, posing a hazardous situation. . 6. (U) Discussion: Most construction equipment are large, not exact or fluid in movement and can pose significant danger to personnel who are generally unfamiliar with equipment operations. When construction equipment is operating, especially under load, the area of operation must be completely clear of unnecessary personnel. Considering the narrow site, constant rain, difficult terrain and slippery conditions, the constant disregard for requests to keep the area clear made for a potentially disastrous situation. Naval Mobil Construction Battalion Forty (NMCB-40) personnel had to constantly police the area themselves. 7. (U) Lesson Learned: On-scene commander must assign equipment spotters and security personnel to maintain a clear zone around equipment operations. 8. (U) Recommendation: The On-Scene Commander must allow the experts to define the, safe operating requirements for their portion of the mission. He must also provide support and authority to the unit's Officer-in Charge in the assurance that everyone heeds those requirements. 9. (U) Comment: The equipment operating areas and the remains recovery areas were both in a single access area which limited maneuvering room. Both equipment operations and recovery could not take place concurrently if rescue personnel were to remain safe, Conflicts in priorities were often seen. On-scene commander must control the efforts.
1. (U) SOURCE DOCUMENT REFERENCE ID, (28380-18364) GROUP SEQUENCE NUMBER: (00014) SUBMITTED BY: COMNAVMARIANAS, LCDR RODRIGUEZ, 339-4286, 671 339-4286. 2. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. 3. (U) KEYWORDS : KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. 4. (U) TITLE: RELOCATION OF ORIGINAL BASE CAMP 5. (U) Observation: A decision to establish a base camp was made since rescue of survivors and recovery" of remains were expected to be a prolonged effort, only to be ordered later to relocate base camp. 6. (U) Discussion: An initial base camp was established at the Federal Aviations Administration (FAA) navigational beacon on the day of the crash. This effort involved the establishments of several tents, a temporary morgue, communications capability and a field kitchen to feed 200-300 volunteers doing work. Due to the need of the FAA to maintain the operation of the navigational beacon the decision was made to relocate the base camp to a nearby location. The personnel in charge at the scene did not have a full understanding of the importance of the navigational beacon to the overall operation of the airport, therefore they based their decision on setting up the base camp on accessibility considerations only. 7. (U) Lesson Learned: Need to talk to the FAA and airport operation control personnel to ensure safe and continuing flight operation. 8. (U) Recommendation: Personnel in charge at disaster scenes need to request/ be provided the information on what effects the crash had on surrounding equipment, structure and facilities, so as to prevent having to conduct massive relocation of supporting elements. As part of the initial response, personnel at the rear should conduct a concerted review with all applicable organizations (civil defense, etc.) to determine if any operational limitations exist due to the location of the emergency.
(U) SOURCE DOCUMENT REFERENCE ID: (46966-92501) GROUP SEQUENCE NUMBER: (00015) SUBMITTED BY: COMNAVMARIANAS, LTCOL FULTS, 366-5287, 671 366-5287. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. (U) KEYWORDS: KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. (U) TITLE: UNAVAILABILITY (U) Observation: OF FOOD FOR NIGHT SHIFT For the first 3 nights of thedisaster there were no formal arrangements made by either Navy, Air Force, or volunteer organizations to provide food or beverages for night shift workers (20) . 6. (U) Discussion: 7. (U) Lesson Learned: The first night, I called USAF 36th Services Squadron to bring box lunches. When they came, they wanted to charge folks $3.50 per box. This was not appropriate. As On-Scene Commander, I authorized the boxes to be given to night shift workers free of charge-it was the right thing to do. The next night, to avoid the same problem, I called the Navy galley (which was already closed) to provide the meals. Thev brought folks in to make sandwiches and did not charge for food. Navy also provided meals for the third night. 8. (U) Recommendation: Procedures be put in place so food and automatic for all shifts. Commanders Contingency Funds, or other source, be available for food and beverage provisions for responses to unexpected contingencies such as aircraft accident scenes. beverage operations are pre-arranged funding 9. (U) Comment: On the first day, there was much confusion as to who would retain the lead (Government of Guam or Military) for the recovery operations and security. It was late in the day when this matter was resolved. It took a bit of time to take over command and control of all site operations when the
(U) SOURCE DOCUMENT REFERENCE ID: (46966-07358) GROUP SEQUENCE NUMBER: (00016) SUBMITTED BY: COMNAVMARIANAS, LTCOL CLEMENTS, 366-5287, 671 366-5287. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE (U) KEYWORDS: KEYWORDS WILL BE ADDED BY MANAGEMENT SITE. (U) TITLE: QUICK RESPONSE OF CHAPLAINS (U) Observation: OBSERVED: 09/ 23/ 97. THE APPROPRIATE NLLS The early involvement of chaplains with both the Search and Recovery Team (SRT) as well as the Critical Incident Stress Management (CISM) process greatly facilitated the chaplains' being able to effectively work. 6. (U) Discussion: The Chaplains very early established their credibility with the troops by their extensive presence at the crash site 7. (U) Lesson Learned: The provision of CISM debriefing/ counseling each day with each group of rescue and then search and recovery personnel working at the crash site seemed to enable our personnel to avoid a massive outbreak of emotional trauma. The chaplains met with each Navy, Air Force, as well as Army and Army National Guard person working at the crash site to provide the opportunity for the individual to ventilate his feelings about what he had seen during the course of the day. The initiation of CISM debriefing/ counseling on the first day of the crash rescue and search/ recovery efforts was highly significant, in that, from the very beginning, our personnel had the opportunity to daily "decompress" emotionally from the day's experience. 8. (U) Recommendation: Make the Chaplain team an integral part of all recovery planning and efforts. 9. (U) Comment: None
1. (U) SOURCE DOCUMENT REFERENCE ID: (46966-29526) GROUP SEQUENCE NUMBER: (00017) SUBMITTED BY: COMNAVMARIANAS, MAJ BUELT, 366-5287, 671 366-5287. 2. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. 3. (U) KEYWORDS: KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. 4. (U) TITLE : PRESERVATION OF EVIDENCE 5. (U) Observation: Search and Recovery Teams (SRT) did a great job of balancing the need to recover remains with the need to preserve evidence for the investigation team. 6. (U) Discussion: While recovery of the remains is a high priority, the clues in the wreckage may be crucial in preventing another mishap. The National Transportation Safety Board (NSTB) investigators were pleased with the care we took to preserve and document evidence. Despite the huge effort of personnel during the rescue and recovery phases of the operation, the only injury that required treatment was one minor hand laceration. The potential for injury was there, but people did things smartly. The presence of mobile command post was a great help. Cellular phones are also great for outgoing calls and for people who are away from the command post. 7. (u) Lesson Learned: The survey team from 36th Civil Engineer Squadron (36 CES) did a great job of setting up a grid reference system for the SRTS and NTSB. Use of computer-aided design system was an excellent way to track locations of the remains and aircraft wreckage. 8. (U) Recommendation: A grid reference system is a must for mapping the aircraft wreckage for preservation of evidence and identification of remains. 9. (U) Comment: None
(U) SOURCE DOCUMENT REFERENCE ID: (79483-24235) GROUP SEQUENCE NUMBER: (00018) SUBMITTED BY: COMNAVMARIANAS, MAJ BUELT, 366-5287, 671 366-5287. (U) NICKNAME: KAL FLIGHT 801 CRASH, DATEOBSERVED, 09/ 23/ 97. (U) KEYWORDS: KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. (U) (U) "Water site. TITLE : LACK OR Observation: buffaloes" were ABSENCE OF EYE WASH STATIONS the only available source ofwater in the 6. (U) Discussion: Without the presence of ample supply of water and the absence of eyewash station there was a risk from biological and infectious diseases Initially, hand washing and other-means of reducing or controlling biological and infectious hazards were not stressed as much as they should have been. Although Korea is not a third world nation, the victims of the KAL flight 801 were potential sources of infectious diseases such as tuberculosis. The water buffaloes were used for hand washing but it took a while to put soap at the hand washing station to provide even the simplest control. The use of latex gloves did not take away the need for proper hand washing. Disposable coveralls were used, but personnel certainly risked contamination when they removed their own coveralls. 7. (U) Lesson Learned: Recovery of remains is a bio-medical hazard operation, and medical personnel must be at the scene to train and advise rescue personnel on handling remains. 8. (U) Recommendation: Ensure Public Health or trained medical personnel evaluate the adequacy of controls we used to reduce the health hazards. If procedures were inadequate, develop new procedures. Consider using decontamination procedures similar to those used for chemical and biological warfare decontamination and/ or on-site showers for personnel who have direct contact with human remains. Consider testing (for tuberculosis, for example) for individuals UNCLASSIFIED 28 UNCLASSIFIED exposed during the operation. Develop a briefing on methods of reducing biological and infectious disease hazards. Ensure all workers with exposure receive brief. 9. (U) Comment: All rescue workers were screened during a post-recovery individual medical debriefing. Many personnel were then inoculated for hepatitis-B and tetanus to preclude possible infection. Personnel who were exposed in any manner, have been advised to report for medical care upon notice of any unusual Symptoms or signs of infection resulting from the rescue/ recovery efforts.
(U) SOURCE DOCUMENT REFERENCE ID: (23884-75457) GROUP SEQUENCE NUMBER: (00019) SUBMITTED BY: COMNAVMARIANAS, CAPT SPRAGUE; 339-3207, 671 339-3207. (U) NICKNAME : KAL FLIGHT 801 CRASH, DATE OBSERVED: 09/ 23/ 97. (U) KEYWORDS: KEYWORDS WILL BE ADDED BY THE APPROPRIATE NLLS MANAGEMENT SITE. (U) TITLE : STATE INCIDENT (U) Observation: DEPARTMENT SUPPORT NECESSARY TO INTERNATIONAL Two days after the KAL 801 crash, the (Republic of Korea) ROK sent senior diplomat Tae Hyun Yoo, Director General, Overseas Residents and Consular affairs Bureau, Ministry of Foreign Affairs (equivalent in rank to DoD Assistant Secretary), to oversee the Koreans' crisis management team on site. However, according to ROK sources, when family members of Korean victims became increasingly dissatisfied with and hostile toward ROK operations in Guam, a political decision was made to send in a much more senior officer to deal with the families in order to demonstrate a high level of ROK involvement and concern. Ambasador Byong Hyon Kwon, formerly the ROK foreign minister, arrived in Guam shortly therafter, and began to make increasingly demanding and aggressive requests of the American side. 6. (U) Discussion: The National Transportation Safety Board (NTSB) and COMNAVMARIANAS therefore requested that the Department of State send an appropriate diplomatic representative to Guam to deal with Ambassador Kwon. In response, State dispatched Wayne G. Griffith, Minister Counselor for Consular Affairs and Consul General at U. S. Embassy Tokyo, to Guam on August 18. Mr Griffith's personal Senior Foreign Service rank of Minister Counselor equivalent to an O-8, made him an appropriate interlocutor for the senior members of the Korean delegation, and he thereafter acted as liaison and filter for the great majority of our dealings with Ambassador Kwon and Director General Yoo. The ROK representatives seemed pleased to have a senior American diplomat on site, and, although there continued to be friction and occasional differences of opinion between the two sides, both volume and emotional pitch dropped substantially, and the resulting operational relationship was professional and harmonious. 7. (U) Lesson Learned: State Department is a necessity in all mass casualty situations when a foreign government is a party to the situation. 8. (U) Recommendation: Assign a State Department representative (of some senior capacity) to liaison with diplomatic entities of foreign nations. 9. (U) Comment: None
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Obtained at www.ntsb.gov/events/KAL801/Exhibits/Ex_16F.pdf on 20 May 2000
