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Safety Recommendation Details

Safety Recommendation A-91-112
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: EVALUATE AND IMPLEMENT, AS APPROPRIATE, SUITABLE MEANS FOR ENCHANCING THE CONSPICUITY OF AIRCRAFT ON AIRPORT SURFACES DURING NIGHT OR PERIODS OF REDUCED VISIBILITY. INCLUDE IN THIS EFFORT MEASURES, SUCH AS THE DISPLACEMENT OF AN AIRCRAFT AWAY FROM THE RUNWAY CENTERLINE, WHERE APPLICABLE, AND THE USE OF CONSPICUITY ENHANCEMENTS, SUCH AS HIGH-INTENSITY STROBE LIGHTING AND LOGO LIGHTING BY AIRCRAFT ON ACTIVE RUNWAYS, AND ENCOURAGE OPERATORS OF AIRPLANES CERTIFICATED PRIOR TO SEPTEMBER 1, 1977, TO UPGRADE THEIR AIRPLANES TO THE PRESENT HIGHER INTENSITY STANDARDS FOR ANTICOLLISION LIGHT INSTALLATIONS.
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: 4/27/1995
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/27/1995
Response: THE BOARD NOTES THAT THE FAA HAS NOT EVALUATED METHODS TO ENHANCE THE CONSPICUITY OF AIRCRAFT OR HAVE OPERATORS BEEN ENCOURAGE BY THE FAA TO UPGRADE THE LIGHTING SYSTEMS OF AIRCRAFT CERTIFICATED BEFORE 9/1/77, TO THE PRESENT HIGHER INTENSITY STANDARDS. THEREFORE, THE BOARD CLASSIFIES A-91-112 "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 9/23/1994
Response: THE FAA BELIEVES THAT THE PROPOSED AMENDMENT TO 14 CFR 23.1401 IN RESPONSE TO A-91-111 WILL ADDRESS THIS RECOMMENDATION COMPLETELY. THE AMENDMENT, IF ADOPTED, WILL IMPLEMENT, AS REQUESTED, SUITABLE MEANS FOR ENHANCING THE CONSPICUITY OF AIRCRAFT ON AIRPORT SURFACES DURING NIGHT OR PERIODS OF REDUCED VISIBILITY. ON 1/19/94 THE BOARD AGREED WITH THE FAA THAT THIS RULEMAKING DEFINING MORE STRINGENT ANTICOLLISION LIGHT VIEWING AREAS WOULD HAVE POSITIVE EFFECTS ON THE CONSPICUITY OF AIRCRAFT. HOWEVER, THE BOARD STATED THAT IN ADDITION TO RULEMAKING DEFINING MORE STRINGENT ANTICOLLISION LIGHT VIEWING AREAS, IT ANTICIPATED A RESPONSE WHICH WOULD ALSO INCLUDE PILOT TRAINING MATERIAL REGARDING ENHANCED CONSPICUITY. THE BOARD CLASSIFIED THIS RECOMMENDATION AS CLOSED UNACCEPTABLE ACTION & ASKED THAT THE FAA PROVIDE FURTHER INFO.

From: NTSB
To: FAA
Date: 1/19/1994
Response: THE BOARD NOTES THAT THE FAA WILL INFORM OPERATORS OF THE CIRCUMSTANCES SURROUNDING THE ACCIDENT FROM WHICH THIS RECOMMENDATION RESULTED & RECOMMEND THAT OPERATORS OF AIRPLANES CERTIFICATED PRIOR TO 9/1/77, UPGRADE THEIR AIRPLANES TO THE PRESENT HIGHER INTENSITY STANDARDS FOR ANTICOLLISION LIGHT INSTALLATION. THE BOARD AGREES THAT RULEMAKING DEFINING MORE STRINGENT ANTICOLLISION LIGHT VIEWING AREA WILL HAVE POSITIVE EFFECTS ON THE CONSPICUITY OF AIRCRAFT. HOWEVER, THE INTENT OF A-91-112 WAS BROADER IN SCOPE THAN THE AIRCRAFT LIGHTING REQUIREMENTS. THE BOARD ANTICIPATED A MORE COMPREHENSIVE RESPONSE, INCLUDING INCORPORATING INTO PILOT TRAINING PROGRAMS MATERIAL REGARDING ENHANCED CONSPICUITY. THE BOARD REQUESTS THAT THE FAA PROVIDE THE BOARD WITH A COPY OF THE EVALUATION & ANY ADDITIONAL ACTION THE FAA PLANS TO TAKE TO ENHANCE THE CONSPICUITY OF AIRCRAFT ON AIRPORT SURFACES. PENDING FURTHER INFO, THE BOARD CLASSIFIES A-91-112 "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: THE BOARD NOTES THAT THE FAA IS REVIEWING A COURSE OF ACTION TO ADDRESS RECOMMENDATION A-91-112; THEREFORE, THE BOARD CLASSIFIES IT "OPEN--AWAIT RESPONSE."

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA IS REVIEWING THIS SAFETY RECOMMENDATION. I WILL APPRISE THE BOARD OF THE FAA'S COURSE OF ACTION TO ADDRESS THIS ISSUE AS SOON AS THE REVIEW IS COMPLETED.

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.