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Safety Recommendation Details

Safety Recommendation A-91-113
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 FEDERAL AVIATION ADMINISTRATION: DIRECT THE GENERAL AVIATION COMMUNITY AND THE AIRLINES TO TAKE STEPS TO ENSURE THAT PILOT TRAINING PROGRAMS, INCLUDING COCKPIT RESOURCE MANAGEMENT TRAINING AND FLIGHT OPERATIONS PROCEDURES, PLACE SUFFICIENT EMPHASIS ON THE NEED FOR PILOTS TO MAINTAIN VIGILANCE IN MONITORING AIR TRAFFIC CONTROL RADIO COMMUNICATION FREQUENCIES FOR POTENTIAL TRAFFIC CONFLICTS WITH THEIR AIRCRAFT, ESPECIALLY WHEN ON ACTIVE RUNWAY AND/OR WHEN CONDUCTING A FINAL APPROACH TO A LANDING.
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: 8/10/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Crew Resource Management, Flightcrew, General Aviation, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 8/10/1993
Response: THE BOARD NOTES THAT THE FAA SENT A LETTER TO ALL FLIGHT INSTRUCTOR REFRESHER CLINIC SPONSORS REQUESTING THAT THEY EMPHASIZE IN THEIR PROGRAM PRESENTATIONS THE NEED FOR PILOTS TO MAINTAIN VIGILANCE IN MONITORING ATC COMMUNICATION FREQUENCIES. ADDITIONALLY, THE FAA PUBLISHED AN ARTICLE IN THE FAA AVIATION NEWS ENTITLED "STOP, LOOK & LISTEN" & SENT A LETTER TO ALL FLIGHT STANDARDS DIVISIONS REQUESTING THAT INFORMATION CONCERNING THIS RECOMMENDATION BE PROVIDED TO ALL KNOWN OPERATORS OF PILOT SCHOOLS & FAA-APPROVED PILOT SCHOOL CERTIFICATE HOLDERS. THE BOARD FURTHER NOTES THAT ON 3/17/93, THE FAA ISSUED ACOB 8-93-2, "MONITORING AIR TRAFFIC CONTROL COMMUNICATIONS FOR POTENTIAL TRAFFIC CONFLICTS," WHICH ADDRESSES THE ISSUES IDENTIFIED IN A-91-113. BASED ON THIS INFO, THE BOARD CLASSIFIES A-91-113 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 5/25/1993
Response: THE FAA AGREES WITH THIS RECOMMENDATION AND HAS TAKEN SEVERAL ACTIONS TO ADDRESS THIS ISSUE. ON MARCH 3, 1992, THE FAA SENT A LETTER TO ALL FLIGHT INSTRUCTOR REFRESHER CLINIC SPONSORS REQUESTING THAT THEY EMPHASIZE IN THEIR PROGRAM PRESENTATIONS THE NEED FOR PILOTS TO MAINTAIN VIGILANCE IN MONITORING AIR TRAFFIC CONTROL COMMUNICATION FREQUENCIES. THE FAA WILL PLACE ADDITIONAL EMPHASIS ON RADIO COMMUNICATION AND AIR TRAFFIC CONTROL PROCEDURES DURING THE NEXT REVISION CYCLE OF THE PRACTICAL TEST STANDARDS; AND WILL INCLUDE ADDITIONAL QUESTIONS IN THE WRITTEN TEST BOOKS CONCERNING RADIO COMMUNICATIONS, AIR TRAFFIC CONTROL PROCEDURES, AND AIRPORT SIGNS AND AIRPORT MARKING AIDS.

From: NTSB
To: FAA
Date: 4/8/1993
Response: THE BOARD NOTES THAT THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION & WILL ISSUE AN AIR CARRIER OPERATIONS BULLETIN (ACOB) TO ADDRESS THESE ISSUES. ADDITIONALLY, THE FAA WILL REQUEST THAT THE SPONSORS OF FLIGHT INSTRUCTOR REFRESHER CLINICS STRESS THE NEED FOR PILOTS TO MAINTAIN VIGILANCE IN MONITORING ATC COMMUNICATION FREQUENCIES & PUBLISH AN ARTICLE IN THE FAA AVIATION NEWS TO EMPHASIZE THE SUBJECT OF THIS RECOMMENDATION. THEREFORE, THE BOARD CLASSIFIES RECOMMENDATION A-91-113 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 1/13/1993
Response:

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA AGREES WITH THE INTENT OF THIS SAFETY RECOMMENDATION AND WILL ISSUE AN AIR CARRIER OPERATIONS BULLETIN TO ADDRESS THE ISSUES OF THIS SAFETY RECOMMENDATION. THE FAA WILL ALSO (1) REQUEST THAT THE SPONSORS OF FLIGHT INSTRUCTOR REFRESHER CLINICS STRESS THE NEED FOR PILOTS TO MAINTAIN VIGILANCE IN MONITORING AIR TRAFFIC CONTROL COMMUNICATION FREQUENCIES FOR POTENTIAL TRAFFIC CONFLICT; (2) REVIEW THE PRACTICAL TEST STANDARDS DURING THE NEXT REVISION CYCLE TO DETERMINE WHETHER OR NOT ADDITIONAL EMPHASIS IS NEEDED IN RELATION TO RADIO COMMUNICATIONS AND AIR TRAFFIC CONTROL PROCEDURES; (3) PUBLISH AN ARTICLE IN THE FAA AVIATION NEWS TO EMPHASIZE THE SUBJECT OF THIS SAFETY RECOMMENDATION; AND (4) REQUEST THAT FAA-APPROVED PILOT SCHOOL CERTIFICATE HOLDERS REVIEW THEIR PILOT TRAINING CURRICULA TO ENSURE APPROPRIATE EMPHASIS IS GIVEN TO THIS SUBJECT.

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.