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Safety Recommendation Details

Safety Recommendation A-91-115
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: DEVELOP FOR INCLUSION IN THE AIRMAN'S INFORMATION MANUAL AND THE AIR TRAFFIC CONTROL HANDBOOK (7110.65F) SPECIFIC PHRASEOLOGY TO BE USED BY PILOTS WHEN REQUESTING AN INTERSECTION DEPARTURE AND SPECIFIC PHRASEOLOGY TO BE USED BY CONTROLLERS WHEN ISSUING A POSITION-AND-HOLD CLEARANCE FOR AN INTERSECTION DEPARTURE.
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: 4/16/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/16/1993
Response: THE BOARD NOTES THAT THE FAA HAS REVISED THE AIR TRAFFIC CONTROL HANDBOOK TO PROVIDE SPECIFIC PHRASEOLOGY FOR IDENTIFYING AN INTERSECTION WHEN ANY CLEARANCE IS REQUESTED OR PROVIDED FOR A DEPARTURE FROM A POINT ON THE RUNWAY OTHER THAN AT THE DEPARTURE END. FURTHERMORE, THE AIM WAS REVISED TO INCLUDE AN EXAMPLE OF THE PHRASEOLOGY THAT PILOTS SHOULD USE WHEN REQUESTING AN INTERSECTION DEPARTURE. BASED ON THIS INFO, THE BOARD CLASSIFIES A-91-115 AS "CLOSED--ACCEPTABLE ACTION."

From: NTSB
To: FAA
Date: 4/8/1993
Response: THE BOARD NOTES THAT THE FAA AGREES WITH THE INTENT OF THIS RECOMMENDATION & WILL DEVELOP A CHANGE TO ORDER 7110.65 & A CHANGE TO THE AIM. PENDING FURTHER INFO, RECOMMENDATION A-91-115 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/24/1993
Response: THE FAA AGREES WITH THIS SAFETY RECOMMENDATION AND HAS REVISED PARAGRAPH 3-106 OF ORDER 7110-65G. THIS CHANGE PROVIDES SPECIFIC PHRASEOLOGY FOR IDENTIFYING AN INTERSECTION WHEN ANY CLEARANCE IS REQUESTED OR PROVIDED FOR A DEPARTURE FROM A POINT ON THE RUNWAY OTHER THAN AT THE DEPARTURE END. ADDITIONALLY, THE FAA REVISED PARAGRAPH 4-60 OF THE AIRMAN'S INFORMATION MANUAL (AIM) TO INCLUDE AN EXAMPLE OF THE PHRASEOLOGY THAT PILOTS SHOULD USE WHEN REQUESTING AN INTERSECTION DEPARTURE. A COPY OF THE REVISION TO ORDER 7110.65G AND A COPY OF THE REVISION TO THE AIM FOR THE BOARD'S INFORMATION.

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA AGREES WITH THE INTENT OF THIS SAFETY RECOMMENDATION AND WILL DEVELOP A CHANGE TO ORDER 7110.65 AND A CHANGE TO THE AIM. THESE CHANGES WILL PROVIDE SPECIFIC PHRASEOLOGY FOR IDENTIFYING AN INTERSECTION WHEN ANY CLEARANCE IS REQUESTED OR PROVIDED FOR A DEPARTURE FROM A POINT ON THE RUNWAY OTHER THAN AT THE DEPARTURE END.

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.