NTSB · Safety Recommendation
Safety Recommendation A-91-105
Recommendation
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: UNDERTAKE A THOROUGH RISK-BASED EVALUATION OF AIR TRAFFIC CONTROL PROCEDURES AT THE LOS ANGELES INTERNATIONAL AIRPORT, EVALUATE WHETHER CHANGES ARE REQUIRED, AND IMPLEMENT NECESSARY CHANGES. THE EVALUATION SHOULD CONSIDER AT LEAST THE FOLLOWING ISSUES: (A) RUNWAY INTERSECTION TAKEOFFS; (B) POSITION-AND-HOLD CLEARANCES; (C) DISPLACED RUNWAY THRESHOLDS; (D) HAZARDS ASSOCIATED WITH RUNWAY CROSSING TRAFFIC; (E) LOCAL ASSIST CONTROLLER; (F) AIRPORT SURFACE DETECTION EQUIPMENT (ASDE) USE AND MAINTENANCE.
Safety Issue and Context
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.
Response History
April 8, 1993 · NTSB Correspondence · FAA
THE BOARD IS PLEASED TO NOTE THAT THE FAA HAS TAKEN ACTION TO ADDRESS EACH CONCERN CITED IN THIS RECOMMENDATION. DURING A VISIT TO THE LAX ATC FACILITIES, THE BOARD WAS INFORMED THAT AN OPERATIONAL ASSESSMENT IS CONDUCTED DAILY TO DETERMINE THE SAFEST WAY TO PROVIDE SERVICE TO THE USER. MOREOVER, ONLY TWO INTERSECTIONS (36U & 8J) WILL BE DESIGNATED AS USABLE FOR DEPARTURE. PILOTS WILL BE REQUIRED TO SOLICIT INTERSECTION DEPARTURES DIRECTLY FROM THE GROUND CONTROLLER, WHO IN TURN WILL APPROVE OR DISAPPROVE THE REQUEST & A FLIGHT PROGRESS STRIP WILL THEN BE MARKED TO INDICATE THAT SUCH A REQUEST HAS BEEN APPROVED.
THESE ACTIONS, IN ADDITION TO THOSE OUTLINED IN THE FAA'S LETTER, MEET THE INTENT OF THIS RECOMMENDATION, & THE BOARD CLASSIFIES A-91-105 AS "CLOSED--ACCEPTABLE ACTION."
March 2, 1992 · Recipient Response · FAA
THE FAA HAS REVIEWED ITS AIR TRAFFIC CONTROL PROCEDURES AND PROVIDES THE FOLLOWING: (A) THE LOS ANGELES TOWER HAS IMPLEMENTED THE NATIONAL PROCEDURE OF NOT USING "TAXI INTO POSITION AND HOLD" FOR INTERSECTION DEPARTURES DURING PERIODS OF DARKNESS OR FROM INTERSECTIONS NOT VISIBLE FROM THE TOWER. (B) THE LOS ANGELES TOWER IS IN COMPLIANCE WITH NATIONAL DIRECTIVES REGARDING POSITION AND HOLD CLEARANCES. (C) THE FAA IS EVALUATING THE CONCEPT OF ESTABLISHING DISPLACED THRESHOLDS FOR RUNWAYS OF SUFFICIENT LENGTH WHICH ARE USED FOR SIGNIFICANT VOLUMES OF ARRIVALS AND DEPARTURES.
(D) CURRENT PROCEDURES REQUIRE THE LOCAL CONTROLLER TO RETAIN CONTROL OF AIRCRAFT CROSSING AN INBOARD RUNWAY IN ORDER TO USE AN OUTBOARD RUNWAY OR PROCEED TO TAXIWAY. (E) THE LOCAL ASSIST CONTROLLER PROVIDES AN EXTRA SET OF EYES AND EARS TO MONITOR THE TRAFFIC SITUATION. (F) THE CURRENT ASDE AT LOS ANGELES INTERNATIONAL AIRPORT IS A ONE-OF-A-KIND SYSTEM WHICH WAS PURCHASED BY THE CITY OF LOS ANGELES DEPARTMENT OF AIRPORTS AND INSTALLED IN 1972. THE ONE-OF-A-KIND SYSTEM HAS GENERATED SUPPORT PROBLEMS WHICH HAVE RESULTED IN LENGTHY OUTAGES. PREVIOUS AIR TRAFFIC PROCEDURES CALLED FOR OPERATION OF THE UNIT DURING HOURS OF DARKNESS REGARDLESS OF WEATHER CONDITIONS.
THE PROCEDURES WERE REVISED IN MID-AUGUST AND NOW REQUIRE THAT THE ASDE BE OPERATED ONLY WHEN WEATHER CONDITIONS WARRANT ITS USE.