- Date
- February 1, 1991, 18:07 local (Feb 2, 1991, 02:07 UTC)
- Place
- Los Angeles, CA
- Injuries
- 34 fatal, 13 serious, 17 minor, 37 uninjured
- Phase of flight
- Landing
- Weather
- Visual (VMC) · Dusk
- Status
- Completed · report August 5, 1993
- Report
- Board-adopted at Board Meeting
- Investigation class
- Class 1
- NTSB office
- Major Investigations Division
- Safety recommendations
- Yes
- FAA reports
- 19910201001381A19910201001382A
- Case key
- 15944
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.
On this page
Probable cause
The failure of the Los Angeles air traffic facility management to implement procedures that provided redundancy comparable to the requirements contained in the national operational position standards and the failure of the FAA air traffic service to provide adequate policy direction and oversight to its air traffic control facility managers. These failures created an environment in the Los Angeles air traffic control tower that ultimately led to the failure of the local controller 2 (LC2) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the usair and skywest aircraft. Contributing to the cause of the accident was the failure of the FAA to provide effective quality assurance of the ATC system. (NTSB report AAR-91/08)
Sequence of events
NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.
Analysis
SKW5569, N683AV, had been cleared to rwy 24L, at intersection 45, to position and hold. The local controller, because of her preoccupation with another airplane, forgot she had placed SKW5569 on the runway and subsequently cleared USA1493, N388US, for landing. After the collision, the two airplanes slid off the runway into an unoccupied fire station. The tower operating procedures did not require flight progress strips to be processed through the local ground control position. Because this strip was not present, the local controller misidentified an airplane and issued a landing clearance. The technical appraisal program for air traffic controllers is not being fully utilized because of a lack of understanding by supervisors and the unavailability of appraisal histories.
Aircraft · 2
- Registration
- N388US
- Reported as
- Boeing 737-300
- Category
- Airplane
- Engine
- GE CFM56-3-B1, 20,000 lbs thrust, turbo fan
- Damage
- Destroyed
- Fire
- On-Ground
- Flight
- Part 121
- Operator
- Usair
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · January 2, 2000
- Departed
- CMH · Columbus, OH
- Flight plan
- IFR
- Airport
- LAX · Los Angeles International, runway 24L, 10,285 × 150 ft, concrete
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
- Registration
- N683AV
- Reported as
- Fairchild SA-227-AC
- Category
- Airplane
- Engine
- Garrett TPE-331, 680 horsepower, turbo prop
- Damage
- Destroyed
- Fire
- On-Ground
- Flight
- Part 135
- Operator
- Skywest Airlines, Inc.
- Airworthiness certificate
- Standard, Utility; Standard, Aerobatic; Special, Special flight (Special); Standard, Normal
- Last inspection
- Unknown · January 2, 2000
- Destination
- PMD · Palmdale, CA
- Flight plan
- IFR
- Airport
- LAX · Los Angeles International, runway 24L, 10,285 × 150 ft, concrete
Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.
Flight crew · 2
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot, aircraft N388US
- Age
- 48
- Certificate
- Airline transport
- Airplane ratings
- Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Valid Medical--w/ waivers/lim
- Seat
- Left
- Toxicology
- Performed
- Flight hours
- 16,300 total · 4,300 in this make and model · 43 in the last 30 days
- Role
- Pilot, aircraft N683AV
- Age
- 32
- Certificate
- Airline transport
- Airplane ratings
- Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Valid Medical--no waivers/lim.
- Seat
- Left
- Toxicology
- Performed
- Flight hours
- 8,808 total · 2,107 in this make and model
Weather
- Conditions
- Visual (VMC) · Dusk
- Wind
- 260° at 6 knots
- Visibility
- 15 statute miles
- Lowest ceiling
- None
- Temperature
- 57 °F, dew point 43 °F
- Altimeter
- 30.00 inHg
- Observed at
- LAX, 1 nm away
FAA reports on this event · 2
The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.