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Safety Recommendation Details

Safety Recommendation A-91-109
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. REQUIRE THAT INTERIM EVALUATIONS OF CONTROLLER PERFORMANCE, SUCH AS THOSE OF THE TECHNICAL APPRAISAL PROGRAM, BE RETAINED FOR 2 YEARS AND UTILIZED IN CONJUCTION WITH OTHER PERFORMANCE APPRAISALS TO TRACK THE PERFORMANCE AND TRAINING NEEDS OF AIR TRAFFIC CONTROLLERS.
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): Air Traffic Control, Records, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 5/14/1998
Response: A-91-109 ASKED THE FAA TO REQUIRE THAT INTERIM EVALUATIONS OF CONTROLLER PERFORMANCE, SUCH AS THOSE OF THE TECHNICAL APPRAISAL PROGRAM, BE RETAINED FOR 2 YEARS & UTILIZED IN CONJUNCTION WITH OTHER PERFORMANCE APPRAISALS TO TRACK THE PERFORMANCE & TRAINING NEEDS OF AIR TRAFFIC CONTROLLERS. BASED ON THE FAA'S ACTIONS, THE BOARD CLASSIFIES A-91-109 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 1/6/1998
Response: (Letter Mail Controlled 1/12/98 3:45:58 PM MC# 980030) 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 TRAINING DISCUSSIONS BETWEEN AIR TRAFFIC CONTROLLERS & THEIR FIRST-LEVEL SUPERVISORS. THESE DISCUSSIONS WILL FOCUS ON TECHNICAL TRAINING NEED AS IDENTIFIED. THESE DISCUSSIONS WILL BE DOCUMENTED & RETAINED PERMANENTLY ON THE EMPLOYEE'S TRAINING & PROFICIENCY RECORD, FAA FORM 3120-1. THE FAA IS ALSO REVISING ORDER 3120.4, AIR TRAFFIC TECHNICAL TRAINING ORDER, TO INCLUDE A FULL-PERFORMANCE LEVEL CONTROLLER SKILL ENHANCEMENT TRAINING. THIS NEW SKILL ENHANCEMENT TRAINING WILL PROVIDE INCREASED TECHNICAL TRAINING FOCUSED ON THE CONTROLLER'S INDIVIDUAL PERFORMANCE.

From: NTSB
To: FAA
Date: 3/7/1997
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 EFFORTS 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'S NEW ORDER WILL REQUIRE FIRST-LINE SUPERVISORS TO RETAIN EACH WRITTEN 6-MONTH REVIEW FOR 1 YEAR. THE BOARD CONTINUES TO BELIEVE THAT FIRST-LINE SUPERVISORS SHOULD BE REQUIRED TO RETAIN EACH WRITTEN 6-MONTH REVIEW FOR 2 YEARS. THE RETENTION OF THESE REVIEWS FOR A 2-YEAR PERIOD PROVIDES THE FIRST-LINE SUPERVISOR WITH A TOOL TO IDENTIFY PERFORMANCE TRENDS THAT MAY REQUIRE CORRECTIVE ACTION. THE 2-YEAR PERIOD REQUESTED BY THE BOARD IS IN LINE WITH FAA ORDER 7210.3, "FACILITY OPERATION & ADMINISTRATION," WHICH REQUIRES THAT DOCUMENTATION OF CONTROLLER PERFORMANCE THAT WAS IDENTIFIED AS A CAUSAL FACTOR/S IN AN OPERATIONAL ERROR BE RETAINED FOR A PERIOD OF 2 & HALF YEARS. THE BOARD URGES THE FAA TO RECONSIDER ITS POSITION BEFORE FINALIZING THE PROVISIONS OF ITS NEW ORDER. THEREFORE, THE BOARD CLASSIFIES A-91-109 "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 6/7/1996
Response: THE FAA DOES NOT AGREE WITH THIS RECOMMENDATION & GOES ON TO SAY THAT THEY BELIEVE ANY REVIEWS RETAINED BEYOND THE 1 YEAR REQUIREMENT WOULD BE OUT OF DATE & NOT A VALID REPRESENTATION OF THE EMPLOYEE'S TECHNICAL PERFORMANCE.

From: NTSB
To: FAA
Date: 11/14/1995
Response: THE NTSB REQUESTS THAT THE FAA REQUIRE THAT THESE PERIODIC EVALUATIONS BE RETAINED FOR REFERENCE FOR 2 YEARS TO ENHANCE THE EFFECTIVENESS OF THE NEW OPERATIONAL ASSESSMENT PROGRAM BY HAVING SUCH DOCUMENTS AVAILABLE FOR USE WITH OTHER PERFORMANCE APPRAISALS TO TRACK A CONTROLLER'S PERFORMANCE & TRAINING NEEDS. THEREFORE, THE BOARD CLASSIFIES A-91-109 "OPEN--UNACCEPTABLE RESPONSE," & REQUESTS THAT THE FAA ADDRESS THIS ISSUE IN FUTURE CORRESPONDENCE.

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 CONDUCT A DETAILED REVIEW AND ANALYSIS OF CONFORMANCE OF OFFICE OF PERSONNEL MANAGEMENT REGULATIONS, DEPARTMENT OF TRANSPORTATION POLICY, AND UNION CONTRACTS CONCERNING THE RETENTION AND USE OF PERFORMANCE EVALUATIONS. HOWEVER, THE BOARD NOTES THAT THE REVIEW WILL BEGIN AFTER THE CONTRACT NEGOTIATIONS BETWEEN THE FAA AND THE CONTROLLERS UNION ARE COMPLETED. BASED ON THIS INFORMATION, THE BOARD CLASSIFIES RECOMMENDATION A-91-109 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 4/23/1993
Response: THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION AND WILL CONDUCT A DETAILED REVIEW AND ANALYSIS OF CONFORMANCE TO OFFICE OF PERSONNEL MANAGEMENT REGULATIONS, CONCERNING THE RETENTION AND USE OF PERFORMANCE EVALUATIONS. THIS REVIEW, HOWEVER, WILL BEGIN AFTER THE CONTROLLERS UNION NEGOTIATIONS ARE COMPLETED. THE FAA ANTICIPATES COMPLETION OF THE CONTRACT NEGOTIATIONS BY SEPTEMBER 1993.

From: NTSB
To: FAA
Date: 4/8/1993
Response: THE BOARD NOTES THAT THE FAA IS CONDUCTING A REVIEW & ANALYSIS CONCERNING THE RETENTION & USE OF PERFORMANCE EVALUATIONS. PENDING FURTHER INFORMATION, A-91-109 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA IS CONDUCTING A DETAILED REVIEW AND ANALYSIS OF CONFORMANCE TO OFFICE OF PERSONNEL MANAGEMENT REGULATIONS, DEPARTMENT OF TRANSPORTATION POLICY, AND UNION CONTRACTS CONCERNING THE RETENTION AND USE OF PERFORMANCE EVALUATIONS. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.