# NTSB DCA91MA018: Boeing 737-300, N388US, Los Angeles, CA, February 2, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 1 · Major · Final report
- Date: February 1, 1991, 18:07 local (Feb 2, 1991, 02:07 UTC)
- Place: Los Angeles, CA
- Location: 33.9425° N, 118.4080° W: Placed by OpenAirDocs at LOS ANGELES INTL (LAX), within about a mile (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=33.9425&lon=-118.4080&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 34 fatal, 13 serious, 17 minor, 37 uninjured
- Status: Completed, report August 5, 1993
- Report: Board-adopted at Board Meeting
- Investigation class: Class 1
- NTSB office: Major Investigations Division
- Safety recommendations: Yes
- NTSB case key (mKey): 15944
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA91MA018.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15944/pdf
- Board report AAR9108 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9108.pdf
- Page: https://openairdocs.org/ntsb/DCA91MA018

## Probable cause (aircraft 2)

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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- On ground/water collision with object, landing - roll
  - supervision - inadequate, atc personnel(supervisor) (cause)
  - inadequate substantiation process, faa(organization) (contributing factor)
  - atc clearance - improper, atc personnel(lcl/gnd/clnc) (cause)
  - object - aircraft parked/standing
- On ground/water collision with object, standing
  - supervision - inadequate, atc personnel(supervisor) (cause)
  - inadequate substantiation process, faa(organization) (contributing factor)
  - atc clearance - improper, atc personnel(lcl/gnd/clnc) (cause)
  - object - aircraft moving on ground

## Analysis (aircraft 2)

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 1

- Registration: [N388US](https://openairdocs.org/deregistered/N388US-1997-07-02), registration cancelled 1997-07-02, S/N 23310 (OpenAirDocs)
- Reported make and model: BOEING 737-300
- Registry model: [Boeing 737-3B7](https://openairdocs.org/model/boeing-737-3b7) (registry code 138447F) (OpenAirDocs)
- Category: Airplane
- Engines: GE CFM56-3-B1 20000 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

## Aircraft 2

- Registration: [N683AV](https://openairdocs.org/deregistered/N683AV-1994-10-13), registration cancelled 1994-10-13, S/N AC683 (OpenAirDocs)
- Reported make and model: FAIRCHILD SA-227-AC
- Registry model: [Fairchild SA227-AC](https://openairdocs.org/model/fairchild-sa227-ac) (registry code 3377509) (OpenAirDocs)
- Category: Airplane
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot, aircraft N388US; age 48; 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
- Pilot, aircraft N683AV; age 32; 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 (OpenAirDocs).

- [Accident 19910201001381A](https://openairdocs.org/incident/19910201001381A), Feb 1, 1991: Boeing 737300, Los Angeles, CA, Destroyed, 22 fatal. Cleared to land,collided with N683AV that was holding on same runway. ATC controller overlooked aircraft on runway.
- [Accident 19910201001382A](https://openairdocs.org/incident/19910201001382A), Feb 1, 1991: Swrngn SA227AC, Los Angeles, CA, Destroyed, 12 fatal. While holding on runway was struck from behind by landing N388US cleared to land same runway. Controller oversight.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

---
OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.