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Safety Recommendation Details

Safety Recommendation A-91-108
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: PROVIDE AIR TRAFFIC CONTROL SUPERVISORS WITH FORMAL TRAINING TO IMPROVE THEIR UNDERSTANDING OF THE INTENT, OBJECTIVES AND ADMINISTRATION OF THE TECHNICAL APPRAISAL PROGRAM.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 5/14/1998
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Airport Operations, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/14/1998
Response: A-91-108 ASKED THE FAA TO PROVIDE AIR TRAFFIC CONTROL (ATC) SUPERVISORS WITH FORMAL TRAINING TO IMPROVE THEIR UNDERSTANDING OF THE INTENT, OBJECTIVES & ADMINISTRATION OF THE TECHNICAL APPRAISAL PROGRAM. BASED ON THE FAA'S ACTION, THE BOARD CLASSIFIES A-91-108 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 1/6/1998
Response: (Letter Mail Controlled 1/12/98 3:45:58 PM MC# 980030) THE NEW AIR TRAFFIC QUALITY ASSURANCE ORDER 7210.56 HAS BEEN SIGNED & BECAME EFFECTIVE 2/1/98. CHAPTER 3, TECHNICAL TRAINING DISCUSSIONS, CONTAINS PROVISIONS FOR REGULAR, DOCUMENTED TECHNICAL PERFORMANCE TRAINING DISCUSSIONS BETWEEN AIR TRAFFIC CONTROLLER & THEIR FIRST-LEVEL SUPERVISORS. PRIOR TO IMPLEMENTING THIS NEW ORDER, AIR TRAFFIC MANAGERS, SUPERVISORS, & QUALITY ASSURANCE SPECIALISTS WILL BE TRAINED ON THE INTENT, PHILOSOPHY, & ADMINISTRATION OF THE NEW PROGRAM. THE NEW PROGRAM IS DESIGNED AROUND THE EXISTING TECHNICAL TRAINING ORDER & ITS PROVISIONS, SO IT WILL BE EASILY ADOPTED & UNDERSTOOD BY AIR TRAFFIC CONTROL SUPERVISORS.

From: NTSB
To: FAA
Date: 3/10/1997
Response: THE BOARD UNDERSTANDS THAT THE FAA CANCELED THE TECHNICAL APPRAISAL PROGRAM ON 11/1/93, & DRAFTED A NEW ORDER ENTITLED, "NATIONAL AIR TRAFFIC QUALITY ASSURANCE PROGRAM." THE BOARD NOTES THAT THE NEW PROGRAM WILL ADDRESS PERFORMANCE APPRAISALS & IDENTIFY TRAINING NEEDS FOR AIR TRAFFIC CONTROL SPECIALISTS. IN ADDITION, IT WILL REQUIRE THAT CONTROLLER EVALUATIONS BE RETAINED FOR 2 YEARS. ALTHOUGH THE PROGRAM WAS TO BE IMPLEMENTED IN SEPTEMBER 1996, THE EFFORT HAS BEEN DELAYED SO THAT THE FAA CAN ADDRESS INPUT FROM THE NATIONAL AIR TRAFFIC CONTROLLERS ASSOCIATION (NATCA) & OTHER FAA UNITS. IT IS NOW ANTICIPATED THAT THE NEW NATIONAL PROGRAM WILL BE IMPLEMENTED BY OCTOBER 1997. THE BOARD IS CONCERNED ABOUT THE SIGNIFICANT DELAY IN IMPLEMENTING THE INTENT OF THESE RECOMMENDATIONS. CONSEQUENTLY, THE BOARD STRONGLY URGES THE FAA TO CONTINUE ITS EFFORTS TOWARD THE DEVELOPMENT OF THIS PROGRAM &, IF POSSIBLE, TO EXPEDITE ITS IMPLEMENTATION. PENDING THE BOARD'S EVALUATION OF THE FAA'S PROGRAM ONCE IMPLEMENTED, THE BOARD CLASSIFIES A-91-108 & -109 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 1/13/1997
Response: THE FAA STATES THAT THE TECHNICAL APPRAISAL PROGRAM WAS SUSPENDED ON 11/1/93. HOWEVER, THE FAA EXPECTS TO IMPLEMENT A NEW APPRAISAL PROGRAM AS PART OF ITS NEW NATIONAL AIR TRAFFIC QUALITY ASSURANCE PROGRAM. THE PROGRAM WAS EXPECTED TO BE IMPLEMENTED IN SEPTEMBER 1996, BUT HAS BEEN DELAYED AS A RESULT OF HAVING TO ADDRESS INPUT FROM THE CONTROLLER'S UNION & OTHER FAA UNITS. IT IS NOW ANTICIPATED THAT IMPLEMENTATION WILL OCCUR BY OCTOBER 1997. THE FAA ALSO NOTES THAT THE NEW PROGRAM WILL REQUIRE THAT THE APPRAISALS WILL BE RETAINED FOR A 2 YEAR PERIOD.

From: NTSB
To: FAA
Date: 9/4/1996
Response: THE BOARD NOTES THAT THE FAA HAS CANCELED THE TECHNICAL APPRAISAL PROGRAM & DRAFTED A NEW ORDER ENTITLED, "NATIONAL AIR TRAFFIC QUALITY ASSURANCE PROGRAM," WHICH SHOULD BE EFFECTIVE BY SEPTEMBER 1996. WHILE THIS ORDER WILL ADDRESS THE APPRAISAL & TRACKING OF CONTROLLER PERFORMANCE, THE FAA'S RESPONSE DOES NOT ADDRESS ENDEAVORS TO PROVIDE SUPERVISORS WITH FORMAL TRAINING TO IMPROVE THEIR UNDERSTANDING OF THE INTENT, OBJECTIVES, & ADMINISTRATION OF THE NEW PROGRAM, AS URGED IN A-91-108. AS A RESULT OF THE FAA'S LETTER OF 8/2/95, WHICH OUTLINED THAT BRIEFINGS & FORMAL TRAINING FOR SUPERVISORS & CONTROLLERS REGARDING THE IMPLEMENTATION OF THE "OPERATIONAL ASSESSMENT PROGRAM" WOULD BE CONDUCTED, THE BOARD CLASSIFIED A-91-108 "OPEN--ACCEPTABLE ALTERNATE RESPONSE," PENDING COMPLETION OF THE PROGRAM. TO MAINTAIN THIS CLASSIFICATION, THE BOARD REQUESTS CONFIRMATION THAT THE "OPERATIONAL ASSESSMENT PROGRAM" & THE NATIONAL AIR TRAFFIC QUALITY ASSURANCE PROGRAM ARE ONE & THE NATIONAL AIR TRAFFIC QUALITY ASSURANCE PROGRAM ARE ONE & THE NATIONAL AIR TRAFFICE QUALITY ASSURANCE PROGRAM ARE ONE & THE SAME. IN ADDITION, WE REQUEST CONFIRMATION THAT SUPERVISORS WILL BE PROVIDED FORMAL TRAINING TO IMPROVE THEIR UNDERSTANDING OF THE INTENT, OBJECTIVES, & ADMINISTRATION OF THE NEW PROGRAM, REGARDLESS OF ITS TITLE.

From: FAA
To: NTSB
Date: 6/7/1996
Response: DURING NOVEMBER 1993, THE FAA CEASED USING THE TECHNICAL APPRAISAL PROGRAM & IN OCTOBER 1994 BEGAN DEVELOPMENT OF AN "OPERATIONAL ASSESSMENT PROGRAM." IN THEIR LETTER OF AUGUST 2, 1995, THEY ADVISED THAT BRIEFING & FORMAL TRAINING FOR SUPERVISORS & CONTROLLERS WOULD BE CONDUCTED AS A PART OF THE PROGRAM'S INCEPTION. IN THEIR CURRENT RESPONSE THEY ADVISE THAT THEY HAVE DRAFTED A NEW ORDER ENTITLED NATIONAL AIR TRAFFIC QUALITY ASSURANCE PROGRAM. THEY ANTICIPATE THAT THE NEW ORDER WILL BE EFFECTIVE SEPTEMBER 1996.

From: NTSB
To: FAA
Date: 11/14/1995
Response: THE BOARD NOTES THAT IN NOVEMBER 1993 THE FAA CEASED USING THE TECHNICAL APPRAISAL PROGRAM & IN OCTOBER 1994 BEGAN DEVELOPMENT OF AN "OPERATIONAL ASSESSMENT PROGRAM." THIS NEW PROGRAM WILL ALLOW SUPERVISORS TO IDENTIFY INDIVIDUAL CONTROLLER DEFICIENCIES &/OR SKILL AREAS THAT REQUIRE IMPROVEMENT. BEFORE THE PROGRAM'S INCEPTION, THE FAA PLANS TO CONDUCT BRIEFINGS & FORMAL TRAINING FOR SUPERVISORS & CONTROLLERS. PENDING RECEIPT OF ADDITIONAL INFO REGARDING IMPLEMENTATION OF THE OPERATIONAL ASSESSMENT PROGRAM, THE BOARD CLASSIFIES A-91-108 "OPEN--ACCEPTABLE ALTERNATE RESPONSE."

From: FAA
To: NTSB
Date: 8/2/1995
Response: THE TECHNICAL APPRAISAL PROGRAM, SPECIFICALLY THE OVER-THE-SHOULDER REVIEW, WAS A SEMIANNUAL REVIEW OF THE AIR TRAFFIC CONTROLLER'S TECHNICAL ABILITIES. THE OVER-THE-SHOULDER REVIEW DID NOT CREATE AN OVERALL PICTURE OF THE CONTOLLER'S TRUE ABILITIES AS THEY REPRESENTED A MINIMUM OF ONLY 80 MINUTES OF MONITORING TIME PER YEAR. THE FAA'S DESIRE WAS TO CREATE A NEW TYPE OF TECHNICAL APPRAISAL SYSTEM THAT REPRESENTED A TRUER INDICATION OF THE CONTROLLER'S PERFORMANCE BY REQUIRING A CONTINUAL MONITORING BY THE FIRST-LINE SUPERVISOR. THE FAA BELIEVES THAT THIS CONSTANT MONITORING & COACHING SHOULD ALSO BE DOCUMENTED PERIODICALLY THROUGHOUT THE YEAR & EMPHASIS SHOULD BE PLACED ON ASSISTING THE CONTROLLER TO STRIVE TOWARDS THE HIGHEST QUALITY OF SERVICE.

From: NTSB
To: FAA
Date: 7/12/1993
Response: THE BOARD NOTES THAT THE FAA WILL IMPLEMENT ORDER 3430.X, TECHNICAL APPRAISAL PROGRAM IN SEPTEMBER 1993. FURTHERMORE, THE BOARD NOTES THAT THE OPERATIONAL SUPERVISORS COURSE WILL BE DELAYED UNTIL AFTER THE IMPLEMENTATION OF ORDER 3430.X. BASED ON THIS INFORMATION, THE BOARD CLASSIFIES RECOMMENDATION A-91-108 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 4/23/1993
Response: THE FAA AGREES WITH THIS RECOMMENDATION AND IS ISSUING ORDER 3430.X, TECHNICAL APPRAISAL PROGRAM. THE FAA ORIGINALLY PLANNED TO HAVE THE NEW ORDER IMPLEMENTED BY SEPTEMBER 30, 1992. HOWEVER, CONTRACT NEGOTIATIONS BETWEEN THE FAA AND THE CONTROLLERS UNION HAVE DELAYED THE IMPLEMENTATION OF THIS ORDER. THE FAA ANTICIPATES COMPLETION OF THE CONTRACT NEGOTIATIONS BY SEPTEMBER 1993. ONCE THE NEGOTIATIONS ARE COMPLETED, THE FAA CAN PROCEED WITH THE ISSUANCE OF THE NEW ORDER. THE FAA ALSO TOLD THE BOARD THAT IT WAS DEVELOPING A 32-HOUR RESIDENT COURSE ENTITLED OPERATIONAL SUPERVISORS COURSE FOR OJT/TPR ADMINISTRATION (COURSE 50317). THE FAA HAD PLANNED TO IMPLEMENT THIS COURSE IN THE FOURTH QUARTER OF FISCAL YEAR 1992. CONTRACT NEGOTIATIONS BETWEEN THE FAA AND THE CONTROLLERS UNION HAVE ALSO DELAYED THIS EFFORT SINCE THE NEW ORDER IS THE BASIS FOR THIS COURSE. THE FAA WILL PROCEED WITH THIS TRAINING COURSE AS SOON AS THE CONTRACT NEGOTIATIONS ARE COMPLETED.

From: NTSB
To: FAA
Date: 4/8/1993
Response: THE BOARD NOTES THAT THE FAA IS REWRITING THE TECHNICAL APPRAISAL PROGRAM AS THE TECHNICAL PERFORMANCE REVIEW, ORDER 3430.X, & THE FAA ACADEMY HAS DEVELOPED A 32-HOUR RESIDENT COURSE ENTITLED OPERATIONAL SUPERVISORS COURSE FOR OJT/TPR ADMINISTRATION. PENDING RECEIPT OF THE REVISED FAA ORDER 3430.X, THE BOARD CLASSIFIES RECOMMENDATION A-91-108 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE TECHNICAL APPRAISAL PROGRAM IS BEING REWRITTEN AS THE TECHNICAL PERFORMANCE REVIEW, ORDER 3430.X. IT IS ANTICIPATED THAT THE NEW ORDER WILL BE IMPLEMENTED BY SEPTEMBER 30, 1992. ALL AIR TRAFFIC PERSONNEL, INCLUDING FIRST-LEVEL SUPERVISORS, WILL BE INSTRUCTED ON THE APPLICATION OF THE PROGRAM PRIOR TO IMPLEMENTATION. INITIAL INSTRUCTION WILL BE PROVIDED TO REGIONAL PERSONNEL BY HEADQUARTERS PERSONNEL FAMILIAR WITH THE DESIGN AND INTENT OF THE NEW PROGRAM. A CADRE TRAINING APPROACH WILL BE USED TO COMPLETE THIS INSTRUCTION DOWN TO THE SPECIALIST LEVEL. IN ADDITION, THE FAA ACADEMY HAS DEVELOPED A 32-HOUR RESIDENT COURSE ENTITLED OPERATIONAL SUPERVISORS COURSE FOR OJT/TPR ADMINISTRATION (COURSE 50317). A DEVELOPMENTAL TRYOUT WILL BE CONDUCTED PRIOR TO THE PROTOTYPE CLASS SCHEDULED FOR LATE APRIL. IT IS ANTICIPATED THAT THIS COURSE WILL BE IMPLEMENTED IN THE FOURTH QUARTER OF FISCAL YEAR 1992.