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Safety Recommendation Details

Safety Recommendation A-91-107
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: RETAIN THE NATIONAL OPERATIONAL POSITION STANDARDS AS A SEPARATE, INDEPENDENT ORDER AND: (A) DIRECT THE FAA'S HUMAN FACTORS AND AIR TRAFFIC SERVICE STAFFS ADEQUACY OF REDUNDANCIES AND INCORPORATE ANY RESULTANT RECOMMENDATIONS INTO THE NATIONAL ORDER; (B) EXPEDITE THE DEVELOPMENT OF CHAPTERS 5 THROUGH 10 OF THE NATIONAL ORDER.
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: 5/8/1995
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/8/1995
Response: THE BOARD NOTES THAT THE FAA CANCELED ORDER 7220.2A, "OPERATIONAL POSITIONS STANDARDS" ON 10/15/92, ABOUT 10 MONTHS AFTER THE BOARD'S RECOMMENDATION. AS A RESULT, A COMBINED REVIEW OF THE ORDER BY THE STAFF FROM THE FAA'S HUMAN FACTORS & AIR TRAFFIC SERVICE TO DETERMINE THE ADEQUACY OF REDUNDANCIES WAS NEVER ACCOMPLISHED. HOWEVER, THE BOARD NOTES THAT BASIC TENETS OF THE OPS, SUCH AS CHAPTER 4, "OPS ELEMENTS APPLICABLE TO ALL POSITIONS," SECTION 1, "AIR TRAFFIC PRINCIPLES," WERE NOT INCORPORATED INTO ANY OF THOSE ORDERS. IT WAS THESE BASIC PRINCIPLES, & OTHERS, CONTAINED IN THE OPS, THAT THE BOARD BELIEVE, AT A MINIMUM, SHOULD HAVE BEEN RETAINED TO PROVIDE STANDARDIZATION WITHIN THE CONTROLLER WORKFORCE. IN ADDITION, THE BOARD BELIEVES THAT THE OPS IS NOW BROAD-BASED, SUBJECT TO INTERPRETATION, & TO SOME DEGREE, LEFT TO THE DISCRETION OF THE FACILITY MANAGER TO DETERMINE WHAT INFO IS APPROPIRATE. THEREFORE, THE BOARD CLASSIFIES A-91-107 "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 11/3/1994
Response: AS STATED IN PREVIOUS RESPONSES TO THE BOARD, THE FAA CANCELED ORDER 7220.2A, OPERATIONAL POSITION STANDARDS, EFFECTIVE 10/15/92. THE FAA INCORPORATED ALL PERTINENT INFO & REQUIREMENTS FROM THE OPS INTO ORDERS 7110.10J, FLIGHT SERVICE & ADMINISTRATION. COPIES OF THE BRIEFING GUIDES DETAILING THE VARIOUS PARAGRAPH CHANGES WERE PROVIDED TO THE BOARD ON 4/6/93.

From: NTSB
To: FAA
Date: 4/8/1993
Response: ON THREE OCCASIONS, SENIOR FAA & NTSB STAFF HAVE MET TO DISCUSS THE FAA'S PROPOSAL TO INCORPORATE PORTIONS OF THE OPS INTO OTHER FAA DOCUMENTS SUCH AS THE FAA AIR TRAFFIC CONTROL HANDBOOK & THE FACILITY OPERATION & ADMINISTRATION HANDBOOK. THE BOARD APPRECIATES THAT THE FAA STAFF WILL KEEP THE BOARD APPRISED OF ONGOING WORK. THEREFORE, RECOMMENDATION A-91-107 IS CLASSIFIED "OPEN--ACCEPTABLE ALTERNATE RESPONSE."

From: FAA
To: NTSB
Date: 4/6/1993
Response: The Federal Aviation Administration (FAA) does not agree with this safety recommendation as stated in its letter to the Board on March 2, 1992. Effective October 15, 1992, Order 7220.2A, Operational Position Standards (OPS), was canceled. Pertinent information and requirements from the OPS were incorporated into Orders 7110.10J, Flight Service; 7110.65G, Air Traffic Control; and 7210.3J, Facility Operation and Administration. I have enclosed copies of the briefing guides detailing the various paragraph changes. I consider the FAA's action to be completed, and I plan no further action on this safety recommendation.

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA DOES NOT AGREE WITH THE INTENT OF THIS RECOMMENDATION ORDER 7220.2, OPERATIONAL POSITION STANDARDS, IS CUMBERSOME AND LOGISTICALLY DIFFICULT TO MANAGE. A MAIN CONCERN HAS BEEN THE INABILITY TO USE THE DOCUMENT FOR QUICK REFERENCE. ADDITIONALLY, THE OPS CONTAINS DUPLICATE INFORMATION INCLUDED IN OTHER DOCUMENTS, SUCH AS ORDER 7110.65, AIR TRAFFIC CONTROL, AND ORDER 7610.4, SPECIAL MILITARY OPERATIONS. IN SOME CASES, THE DATA CONTAINED IN OPS ARE INCOMPLETE AND OCCASIONALLY CONTRARY TO INFORMATION PROVIDED IN OTHER EXISTING DOCUMENTS. THESE LONGSTANDING PROBLEMS WERE RECENTLY ADDRESSED BY A WORK GROUP WHICH MET AT THE FAA CENTER FOR MANAGEMENT DEVELOPMENT. THIS WORK GROUP REVIEWED CHAPTERS 1 THROUGH 3 OF THE OPS AND RECOMMENDED THAT ORDER 7210.3 FACILITY OPERATION AND ADMINISTRATION, BE CHANGED TO REQUIRE THAT EXISTING POSITION BINDERS BE STANDARDIZED. A STANDARDIZED FORMAT FOR THE POSITION BINDERS, INCLUDING THE REQUIRED PERTINENT POSITION INFORMATION, WILL BE ADDED AS A SECTION OF ORDER 7210.3. THE REVISED POSITION BINDERS WILL SERVE AS VEHICLES FOR STRENGTHENING STANDARDIZATION AND WILL REQUIRE MINIMUM MAINTENANCE. THE NEW FORMAT WILL ALSO ALLOW QUICK REFERENCE TO CRITICAL POSITION SPECIFIC INFORMATION. CHAPTER 4 THROUGH 30 OF THE OPS WERE REVIEWED FOR INFORMATION WHICH IS REDUNDANT AND CONTAINED IN OTHER EXISTING AIR TRAFFIC ORDERS. PERTINENT INFORMATION AND REQUIREMENTS WHICH ARE NOT CONTAINED IN OTHER AIR TRAFFIC ORDERS OR DOCUMENTS WERE IDENTIFIED AND 27 DOCUMENT CHANGE PROPOSALS WERE DEVELOPED TO PLACE THIS INFORMATION IN THE APPROPRIATE AIR TRAFFIC ORDER OR DOCUMENT.