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NTSB Report
February 2, 1991 · Boeing 737-300 · N388US
Los Angeles, CA
Overview
Report Status
Probable Cause
Event Type
Accident
Date
February 2, 1991
Injury Outcomes
64 injuries (34 fatalities, 13 serious injuries, 17 minor injuries), 37 uninjured
Location
Los Angeles, CA
Aircraft
Boeing 737-300
Tail Number
N388US
Operator
Usair
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
DCA91MA018
SKW5569, N683AV, HAD BEEN CLEARED TO RWY 24L, AT INTERSECTION 45, TO POSITION AND HOLD. THE LOCAL CONTROLLER, BECAUSE OF HER PREOCCUPATION WITH ANOTHER AIRPLANE, FORGOT SHE HAD PLACED SKW5569 ON THE RUNWAY AND SUBSEQUENTLY CLEARED USA1493, N388US, FOR LANDING. AFTER THE COLLISION, THE TWO AIRPLANES SLID OFF THE RUNWAY INTO AN UNOCCUPIED FIRE STATION. THE TOWER OPERATING PROCEDURES DID NOT REQUIRE FLIGHT PROGRESS STRIPS TO BE PROCESSED THROUGH THE LOCAL GROUND CONTROL POSITION. BECAUSE THIS STRIP WAS NOT PRESENT, THE LOCAL CONTROLLER MISIDENTIFIED AN AIRPLANE AND ISSUED A LANDING CLEARANCE. THE TECHNICAL APPRAISAL PROGRAM FOR AIR TRAFFIC CONTROLLERS IS NOT BEING FULLY UTILIZED BECAUSE OF A LACK OF UNDERSTANDING BY SUPERVISORS AND THE UNAVAILABILITY OF APPRAISAL HISTORIES.
NTSB Probable Cause
THE FAILURE OF THE LOS ANGELES AIR TRAFFIC FACILITY MANAGEMENT TO IMPLEMENT PROCEDURES THAT PROVIDED REDUNDANCY COMPARABLE TO THE REQUIREMENTS CONTAINED IN THE NATIONAL OPERATIONAL POSITION STANDARDS AND THE FAILURE OF THE FAA AIR TRAFFIC SERVICE TO PROVIDE ADEQUATE POLICY DIRECTION AND OVERSIGHT TO ITS AIR TRAFFIC CONTROL FACILITY MANAGERS. THESE FAILURES CREATED AN ENVIRONMENT IN THE LOS ANGELES AIR TRAFFIC CONTROL TOWER THAT ULTIMATELY LED TO THE FAILURE OF THE LOCAL CONTROLLER 2 (LC2) TO MAINTAIN AN AWARENESS OF THE TRAFFIC SITUATION, CULMINATING IN THE INAPPROPRIATE CLEARANCES AND THE SUBSEQUENT COLLISION OF THE USAIR AND SKYWEST AIRCRAFT. CONTRIBUTING TO THE CAUSE OF THE ACCIDENT WAS THE FAILURE OF THE FAA TO PROVIDE EFFECTIVE QUALITY ASSURANCE OF THE ATC SYSTEM. (NTSB REPORT AAR-91/08)
Full Narrative
SKW5569, N683AV, HAD BEEN CLEARED TO RWY 24L, AT INTERSECTION 45, TO POSITION AND HOLD. THE LOCAL CONTROLLER, BECAUSE OF HER PREOCCUPATION WITH ANOTHER AIRPLANE, FORGOT SHE HAD PLACED SKW5569 ON THE RUNWAY AND SUBSEQUENTLY CLEARED USA1493, N388US, FOR LANDING. AFTER THE COLLISION, THE TWO AIRPLANES SLID OFF THE RUNWAY INTO AN UNOCCUPIED FIRE STATION. THE TOWER OPERATING PROCEDURES DID NOT REQUIRE FLIGHT PROGRESS STRIPS TO BE PROCESSED THROUGH THE LOCAL GROUND CONTROL POSITION. BECAUSE THIS STRIP WAS NOT PRESENT, THE LOCAL CONTROLLER MISIDENTIFIED AN AIRPLANE AND ISSUED A LANDING CLEARANCE. THE TECHNICAL APPRAISAL PROGRAM FOR AIR TRAFFIC CONTROLLERS IS NOT BEING FULLY UTILIZED BECAUSE OF A LACK OF UNDERSTANDING BY SUPERVISORS AND THE UNAVAILABILITY OF APPRAISAL HISTORIES.
Flight
Event TypeAccident
Event Time18:07 PST
Nearest AirportLos Angeles International (0nm)
Runway24L
Runway Length10285 ft
Runway Width150 ft
Flight Plan FiledIFR
Aircraft FireGrd
Aircraft ExplosionNo
Aircraft
AircraftBoeing 737-300
Tail NumberN388US
Aircraft CategoryAir
DamageDestroyed
OperatorUsair
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsGe · CFM56-3-B1 · Turbofan · 20000 | Garrett · TPE-331 · Turboprop · 680
Seats128
People & Injuries
Injury Summary64 injuries (34 fatalities, 13 serious injuries, 17 minor injuries), 37 uninjured
Fatal34
Serious13
Minor17
Uninjured37
Total101
Crew 1Age 48 · First Class
Crew 2Age 32 · First Class
Conditions
ConditionsVMC
LightDusk
Wind260° @ 6 kt
Visibility15 sm
CeilingNone
Temperature / Dew Point57 / 43 C
Altimeter30.00 inHg
Observation Time01:51
Weather SourceWFAC