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Safety Recommendation Details

Safety Recommendation A-91-111
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: REDEFINE THE AIRPLANE CERTIFICATION COVERAGE COMPLIANCE STANDARDS FOR ANTICOLLISION LIGHT INSTALLATIONS TO ENSURE THAT THE ANTICOLLISION LIGHT(S) OF AN AIRRAFT IN POSITION ON A RUNWAY ARE CLEARLY VISIBLE TO THE PILOT OF ANOTHER AIRCRAFT PREPARING TO LAND OR TAKE OFF ON THAT RUNWAY.
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: 7/21/1997
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/21/1997
Response: THE BOARD RECOGNIZES THAT THE FAA IS ADDRESSING THIS SAFETY ISSUE UNDER THE REVISED RUNWAY INCURISON PROGRAM; THESE EFFORTS DO NOT ADDRESS THE ISSUE OF CERTIFICATION STANDARDS FOR ANTICOLLISON LIGHTS FOR AIRCRAFT VISIBILITY. BECAUSE THE FAA DOES NOT INTEND TO TAKE FURTHER ACTION, THE BOARD CLASSIFIES A-91-111 "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 3/31/1997
Response: THE FAA BELIEVES THAT THE CURRENT ANTI-COLLISION LIGHT DESIGN STANDARDS ARE ADEQUATE & ENSURE THAT AN AIRPLANE IS CONSPICUOUS FROM THE REAR IN BOTH THE HORIZONTAL PLANE & AT VERTICAL ANGLES. ALSO, THE FAA BELIEVES THAT OPERATIONAL EXPERIENCE HAS VALIDATED THE ADEQUACY OF THE CURRENT INTENSITY & COVERAGE REQUIREMENTS OF ANTICOLLISON LIGHTS. THE FAA DOES NOT INTEND TO CONTINUE A PROGRAM TO REDEFINE AIRPLANE CERTIFICATION COVERAGE COMPLIANCE AS AN INDEPENDENT EFFORT.

From: NTSB
To: FAA
Date: 4/27/1995
Response: THE BOARD NOTES THAT THIS MATTER HAS BEEN REFERRED TO AVIATION RULEMAKING ADVISORY COMMITTEE. THE BOARD BELIEVES THAT A SPECIFIC TIME FRAME SHOULD BE ESTABLISHED BY THE FAA TO ENABLE EVALUATION OF COMMITTEE ACTION. THE BOARD IS DISAPPOINTED THAT THE FAA'S RESPONSE COMES MORE THAN 3 YEARS AFTER A-91-111 WAS ISSUED & SUGGESTS THAT THE FAA RESPOND TO THIS LETTER WITHIN 90 DAYS OF RECEIPT. THE RESPONSE SHOULD INCLUDE AN ANTICIPATED DATE FOR COMPLETION OF THE ACTIONS NECESSARY TO FULFILL THE INTENT OF THIS RECOMMENDATION. IN THE MEANTIME, THE BOARD CLASSIFIES A-91-111 "OPEN--UNACCEPTABLE RESPONSE" PENDING A FORECASTED TIME FRAME FOR COMPLETED ACTION."

From: FAA
To: NTSB
Date: 9/23/1994
Response: THE FAA IS CONTINUING ITS EFFORT TO REVISE 14 CFR 23.1401 TO REQUIRE THAT ANTICOLLISION LIGHT BE CLEARLY VISIBLE FROM THE REAR OF THE AIRCRAFT & TO PILOTS OF AIRCRAFT PREPARING TO LAND OR TAKEOFF ON THE RUNWAY. THE PROJECT HAS BEEN ACCEPTED BY THE AVIATION RULEMAKING ADVISORY COMMITTEE WHICH WILL DEVELOP A REGULATORY PACKAGE & ASSOCIATED ADVISORY MATERIAL. THE ARAC WILL ALSO ENSURE THAT ANY RULEMAKING WHICH RESULTS IS HARMONIED WITH THE JOINT AIRWORTHINESS AUTHORITY.

From: NTSB
To: FAA
Date: 1/19/1994
Response: THE BOARD NOTES THAT THE FAA IS CONSIDERING AN AMENDMENT TO 14 CFR 23.1401 TO REQUIRE THAT THE ANTICOLLISION LIGHT BE CLEARLY VISIBLE FROM THE REAR OF THE AIRCRAFT AND TO THE PILOTS OF AIRCRAFT PREPARING TO LAND OR TAKE OFF ON THAT RUNWAY. PENDING FURTHER INFO CONCERNING THIS AMENDMENT, THE BOARD CLASSIFIES A-91-111 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 6/30/1993
Response: The Federal Aviation Administration (FAA) has reviewed these safety recommendations further and is considering a regulatory action to address these issues. Improvements to the anticollision light requirements were made, but blockage aft of the airplane is still allowed for airplanes certificated under current 14 CFR Part 23. The FAA believes that the safety issue is where the blockage is allowed versus the amount of blockage allowed. If the FAA eliminated the blockage allowances for engines, winglets, and other protrusions, the manufacturers would have to use multiple lights instead of the one or two that currently provide coverage. The FAA's proposed action is to continue allowing reasonable blockage but require that the anticollision light be seen from the rear. Accordingly, the FAA is considering an amendment to 14 CFR 23.1401 to require that the anticollision light be seen from the rear of the aircraft so that the light is clearly visible to the pilot of another aircraft preparing to land or take off on that runway. Additionally, the FAA will inform operators of the circumstances surrounding this accident and recommend that they upgrade their airplanes to the current standards if grandfathered under previous standards. I will keep the Board apprised of the FAA's progress on these safety recommendations.

From: NTSB
To: FAA
Date: 4/8/1993
Response: THIS RECOMMENDATION ASKED THE FAA TO REEVALUATE & REDEFINE THE PERMISSIBLE AREAS IN WHICH THE ILLUMINATION OF AN ANTICOLLISION LIGHT IS OBSTRUCTED BY AIRCRAFT STRUCTURE. THE BOARD CONTINUES TO BELIEVE THAT A .5 STERADIAN OF BLOCKAGE IS UNACCEPTABLE & AGAIN ASKS THE FAA TO RECONSIDER ITS POSITION. CONSEQUENTLY, RECOMMENDATION A-91-111 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA HAS REVIEWED THE APPLICABLE ANTICOLLISION LIGHT DESIGN STANDARDS AND HAS DETERMINED THAT THE CURRENT REGULATIONS PROVIDE ADEQUATE COVERAGE. THE FAA BELIEVES THAT THE CURRENT REGULATIONS ENSURE THAT THE AIRPLANE IS CONSPICUOUS FROM THE REAR BOTH IN THE HORIZATIONAL VISION PLANE AND AT VERTICAL ANGLES WELL BEYOND NORMAL LANDING APPROACH ANGLES. SUBSEQUENT TO THE INITIAL CERTIFICATION OF THE METROLINER INVOLVED IN THIS ACCIDENT, THE FAA HAS MADE SEVERAL IMPROVEMENTS TO THE ANTICOLLISION LIGHT REQUIREMENTS. THESE IMPROVEMENTS INCLUDE INCREASING THE EFFECTIVE INTENSITY FOR ANTICOLLISION LIGHTS BY FOUR TIMES THE ORIGINAL VALUE IN AMENDMENT 23-11 EFFECTIVE AUGUST 11, 1971. ADDITIONALLY, THE VERTICAL COVERAGE WAS INCREASED IN AMENDMENT 23-30, EFFECTIVE SEPTEMBER 1, 1977, FROM +/- 30 DEGREES TO 75 DEGREES ABOVE AND BELOW THE HORIZON. OPERATIONAL EXPERIENCE HAS VALIDATED THE ADEQUACIES OF THE CURRENT INTENSITY AND COVERAGE REQUIREMENTS OF THE ANTICOLLISION LIGHTS.

From: NTSB
To: FAA
Date:
Response: At the 1990 Board meeting addressing the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL), the Board voted to place Safety Recommendations A-86-33, A-86-40 and A-86-42 on the Federal MWL under the issue category “Runway Incursions/ Ground Collisions of Aircraft.” On November 8, 2007 at the Board meeting addressing the Federal Most Wanted List of Transportation Safety Improvements the category’s name was changed to “Improve Runway Safety.” Since 1990, the Board has voted to include Safety Recommendations A-91-29, A-91-30, A-91-54 through A-91-58, A-91-110 through A-91-115, A-95-86, A-95-92, A-95-93, A-95-97, A-00-66, A-0067, A-00-68, and A-07-57 is this category as well.