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Safety Recommendation Details

Safety Recommendation A-91-106
Details
Synopsis: ON FEBRUARY 1, 1991, AT 1807 PACIFIC STANDARD TIME, USAIR FLIGHT 1493 (USA1493), N388US, A BOEING 737-300 (B-737), COLLIDED WITH SKYWEST FLIGHT 5569(SKW5569), N683A, V, A FAIRCHILD METROLINER (SA-227-AC), WHILE USA1493 WAS LANDING ON RUNWAY 24 LEFT AT LOS ANGELES INTERNATIONAL AIRPORT (LAX), LOS ANGLES, CALIFORNIA. SKW5569 WAS POSITIONED ON THE SAME RUNWAY, AT INTERSECTION 45, AWAITING CLEARANCE FOR TAKEOFF. AS A RESULT OF THE COLLISION, BOTH AIRPLANES WERE DESTROYED. ALL 10 PASSENGERS AND 2 CREWMEMBERS ABOARD THE METROLINER AND 20 PASSENGERS AND 2 CREWMEMBERS ABOARD THE B-737 WERE FATALLY INJURED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: INCLUDE IN THE OFFICE OF SAFETY QUALITY ASSURANCE THE AUTHORITY AND RESOURCES TO: (1) INDEPENDENTLY EVALUATE AIR TRAFFIC CONTROL FACILITY COMPLIANCE WITH FAA DIRECTIVES AND; (2) AUDIT FACILITY EVALUATIONS PERFORMED BY THE OFFICE OF AIR TRAFFIC SYSTEM EFFECTIVENESS TO DETERMINE THAT NOTED DEFICIENCIES ARE CORRECTED.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: LOS ANGELES, CA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA91MA018AB
Accident Reports: Runway Collision of USAIR Flight 1493, Boeing 737 and Skywest Flight 5569 Fairchild Metroliner
Report #: AAR-91-08
Accident Date: 2/1/1991
Issue Date: 12/3/1991
Date Closed: 4/8/1993
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/8/1993
Response: THE BOARD IS DISAPPOINTED WITH THE FAA'S RESPONSE TO A-91-106 & REMAINS CONCERNED ABOUT THE FAA'S DEPTH OF COMMITMENT TO PROVIDE EFFECTIVE QUALITY ASSURANCE & SAFETY OVERSIGHT OF THE ATC SYSTEM. WHILE THE BOARD BELIEVES THAT DAY-TO-DAY EVENTS SHOULD BE ADMINISTERED WITHIN THE OFFICE OF AIR TRAFFIC, IT DOES NOT BELIEVE THAT THE TOTAL QUALITY ASSURANCE OF THE ATC SYSTEM IS APPROPRIATELY VESTED IN THE AIR TRAFFIC ORGANIZATION & SPECIFICALLY WITHIN THE OFFICE OF AIR TRAFFIC SYSTEM EFFECTIVENESS. IT WAS THE BOARD'S BELIEF THAT AFTER THE RECENT FAA REORGANIZATION OF THE OFFICE OF THE ASSOCIATE ADMINISTRATOR FOR AVIATION SAFETY, A DIVISION WOULD BE TASKED TO EVALUATE QUALITY ASSURANCE PROGRAMS IN KEY SAFETY AREAS. THE BOARD UNDERSTANDS THAT THE DIVISION CHOSEN FOR THIS FUNCTION IS STAFFED WITH FOUR SPECIALISTS & THAT ONLY ONE SENIOR STAFF MEMBER HAS ATC EXPERTISE. IT IS NOT LIKELY THAT ONE PERSON COULD PROVIDE EFFECTIVE OVERSIGHT & EVALUATION OF THE ATC SERVICE. BECAUSE OF THE HISTORY OF THIS ISSUE, THE BOARD DOES NOT BELIEVE A PROLONGED EXCHANGE OF RESPONSES TO THIS RECOMMENDATION WOULD CHANGE EITHER AGENCY'S POSITION. THEREFORE, RECOMMENDATION A-91-106 IS CLASSIFIED "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA HAS REVIEWED THE POSITION OF THE BOARD CONCERNING THE STAFFING AND AUTHORITY OF THE OFFICE OF SAFETY QUALITY ASSURANCE UNDER THE ASSOCIATE ADMINISTRATOR FOR AVIATION SAFETY. THE FAA CONTINUES TO BELIEVE THAT TOTAL QUALITY ASSURANCE OF THE AIR TRAFFIC CONTROL SYSTEM IS APPROPRIATELY VESTED IN THE AIR TRAFFIC ORGANIZATION AND SPECIFICALLY WITHIN THE OFFICE OF AIR TRAFFIC SYSTEM EFFECTIVENESS. IN JANUARY 1989 THIS MATTER WAS ADDRESSED AND IT WAS DETERMINED THAT RATHER THAN HAVING THE AVIATION SAFETY ORGANIZATION ROUTINELY INVOLVED IN DAY-TO-DAY EVENTS OCCURRING IN THE SYSTEM, THAT OFFICE WOULD MONITOR AND ASSESS PROGRAMS ON A BROAD NATIONAL SCALE. ALSO, THE EVALUATION FUNCTION IN AIR TRAFFIC WAS ELEVATED TO A NATIONAL PROGRAM BY VIRTUE OF REPORTING DIRECTLY TO THE ASSOCIATE ADMINISTRATOR. THIS ENSURED THE INDEPENDENCE OF FIELD EVALUATION OFFICIALS WHO WOULD NO LONGER REPORT THROUGH FIELD FACILITIES AND OTHER FIELD OFFICIALS. THIS DECISION WAS BASED ON TWO IMPORTANT FACTORS: (1) THE POSSIBILITY THAT EVALUATION FUNCTIONS COULD LOSE A CRITICAL LEVEL OF TRUST IN THE FIELD AND DAMAGE THEIR ABILITY TO DO THE JOB EFFECTIVELY; AND (2) THE AVIATION SAFETY MISSION MAY BECOME CONFUSED BY COMBINING AN AGENCY WIDE ANALYTICAL FUNCTION WITH A LARGE OPERATIONAL FUNCTION. THESE FACTORS REMAIN RELEVANT, AND I BELIEVE THAT THE AVIATION SAFETY ORGANIZATION SHOULD CONTINUE IN ITS BROAD ROLE OF SYSTEM OVERSIGHT AND EVALUATION RATHER THAN BECOMING INVOLVED IN THE EVALUATION OF INDIVIDUAL FACILITY COMPLIANCE AND DAY-TO-DAY OPERATIONAL ISSUES.