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Safety Recommendation Details

Safety Recommendation A-91-116
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: PROHIBIT THE USE, AFTER A SPECIFIED DATE, OF CABIN MATERIALS IN ALL TRANSPORT CATEGORY AIRPLANES THAT DO NOT COMPLY WITH THE IMPROVED FIRE SAFETY STANDARDS CONTAINED IN 14 CFR 25-853.
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: 9/19/1994
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/19/1994
Response: THE BOARD NOTES THAT THE FAA HAS CONCLUDED THAT THE POTENTIAL COSTS OF A MANDATORY RETROFIT PROGRAM WOULD FAR OUTWEIGH THE POTENTIAL BENEFITS. THE BOARD CONTINUES TO BELIEVE THAT A DATE SHOULD BE ESTABLISHED AFTER WHICH CABIN MATERIALS USED FOR ROUTINE REPLACEMENT OF FURNISHINGS IN TRANSPORT-CATEGORY AIRPLANES DUE TO NORMAL WEAR WOULD HAVE TO MEET THE IMPROVED FIRE SAFETY STANDARDS CONTAINED IN 14 CFR 25.853, REGARDLESS OF WHETHER THE NEW FURNISHINGS CONSTITUTE A SUBSANTIALLY COMPLETE REPLACEMENT OF THE CABIN INTERIOR. BASED ON THE FAA'S POSITION CONCERNING THIS ISSUE, THE BOARD CLASSIFIES A-91-116 "CLOSED--UNACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 12/2/1993
Response: PRIOR TO THE ADOPTION OF THE IMPROVED FIRE SAFETY STANDARDS IN JULY 1986 (AMENDMENTS 25-61 & 121-189), THE FAA CONSIDERED WHETHER OR NOT A MANDATORY RETROFIT PROGRAM COULD BE ADOPTED SIMILAR TO THAT FOR SEAT CUSHIONS. UNLIKE SEAT CUSHIONS WHICH ARE TYPICALLY REPLACED EVERY 3 YEARS DUE TO WEAR, THE LARGE SURFACE-AREA COMPONENTS TO WHICH THESE STANDARDS APPLY ARE MORE DURABLE & ARE NOT TYPICALLY REPLACED IN LESS THAN 8 YEARS. UNDER MANDATORY RETROFIT PROGRAM, ALL OF THE COSTS OF RETROFITTING THE LARGE SURFACE-AREA COMPONENTS WOULD THEREFORE BE ATTRIBUTABLE TO RULEMAKING RATHER THAN TO NORMAL WEAR, EVEN WITHOUT A MANDATORY RETROFIT REQUIREMENT, THE RULEMAKING WAS CONTROVERSIAL BECAUSE THE COST OF COMPLIANCE WAS GREATER THAN ORIGINALLY ANTICIPATED.

From: NTSB
To: FAA
Date: 4/8/1993
Response: THE BOARD CONTINUES TO BELIEVE THAT IT IS VITALLY IMPORTANT TO PASSENGER & CREW SAFETY THAT CABIN MATERIALS IN ALL TRANSPORT CATEGORY AIRPLANES COMPLY WITH THE IMPROVED FIRE SAFETY STANDARDS CONTAINED IN 14 CFR 25.853. A SPECIFIED DATE SHOULD BE ESTABLISHED, SUCH AS 9/1/95, AFTER WHICH THE REPLACEMENT OF ANY CABIN MATERIALS IN TRANSPORT CATEGORY AIRPLANES SHOULD MEET THE IMPROVED FIRE SAFETY STANDARDS. THE BOARD REQUESTS THAT THE FAA RECONSIDER ITS POSITION ON THIS RECOMMENDATION & CLASSIFIES A-91-116 "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/2/1992
Response: THE FAA HAS EVALUATED THIS SAFETY ISSUE AND HAS DETERMINED THAT IN THE CASE OF THIS ACCIDENT IT WAS UNLIKELY THAT IMPROVED MATERIALS WOULD HAVE RESULTED IN IMPROVED SURVIVABILITY. THE RELEASE OF ON BOARD GASEOUS OXYGEN FOR FLIGHTCREW USE RESULTED IN A FIRE MORE INTENSE THAT THE IMPROVED MATERIALS ARE DESIGNED TO RESIST. PRIOR TO THE ADOPTION OF AMENDMENTS 25-61 AND 121-189 IN JULY 1986 TO ESTABLISH NEW FLAMMABILITY STANDARDS FOR LARGE SURFACE AREA INTERIOR COMPONENTS, THE FAA CONSIDERED ADOPTING A MANDATORY RETROFIT PROGRAM FOR ALL AIRPLANES USED IN AIR CARRIER SERVICE. AT THAT TIME, THE FAA DETERMINED THAT IT WAS NOT ECONOMICALLY FEASIBLE TO IMPLEMENT A MANDATORY REQUIREMENT. THE FAA DID, BELIEVE THAT IF AN AIR CARRIER WAS ECONOMICALLY COMMITTED TO DOING A SUBSTANTIALLY COMPLETE REFURBISHMENT PROGRAM THAN THE INCREMENTAL COST OF INSTALLING IMPROVED MATERIALS WAS DEEMED JUSTIFIED BASED ON EXPECTED BENEFITS. CONSEQUENTLY, AMENDMENT 121-189 INCLUDED A PROVISION THAT IF AN AIRCRAFT IS SUBSTANTIALLY REFURBISHED IT MUST BE REFURBISHED WITH THE NEW MATERIALS.