LAX91IA297

NTSB incident investigation · Boeing 747-200 · Los Angeles, CA · August 13, 1991

Incident · No injuriesIncident investigationFinal report
Date
August 12, 1991, 20:21 local (Aug 13, 1991, 03:21 UTC)
Place
Los Angeles, CA
Injuries
298 uninjured
Damage
No damage
Phase of flight
Takeoff
Aircraft
ZKNZWBoeing 747-200
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 5, 1993
Report
Approved by Office Director
Case key
27032

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The inadequate runway safety area inherent in the airport design, and, the ATC clearance procedures in use which failed to take into consideration the substandard runway safety area. Factors in the incident were the dark night time conditions and the inadequate standards used by ATC to determine clearance procedures at airports which do not meet current design criteria.

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.

Near collision between aircraftTakeoff - roll/run
Light condition - dark nightFactor
Object - aircraft moving on ground
Airport facilities,runway safety area - inadequateCause
Atc clearance procedure - inadequateCause
Identification of aircraft visually - misjudgedAtc personnel(lcl/gnd/clnc)
Insufficient standards/requirementsFaa(organization)Factor

Analysis

The flt crew of an air new zealand Boeing 747 rprtd a nr collision with the tail of a federal express Boeing 727 on tkof. Due to lack of a tail logo or strobe lgts, the 727 was not visible to the 747 crew til just bfr rotation. The 747 crew estd they vertically clrd the 727 tail by 100 ft. the 727 was being psnd fm a cargo ramp to a maint facility. The acft was being taxied by 2 mechanics with a clnc fm ATC. ATC tapes revealed the 727 was clrd across the rwy by the LCL ctlr, 32 sec bfr the 747'S tkof clnc. As the 727 crossed the rwy, the mechanics saw a united 767 turning onto a perpendicular twy drctly ahd & they stopped their acft til they could ctc gnd ctl & clarify the situation. Tapes showed the 767 had been told by gnd ctl to hold for the 727 drg the time the 727 was on the LCL ctl freq. The arpt design & layout did not meet current rwy safety area dimensional criteria concerning sepn of parallel twys fm the rwy. The ATC proc in use by the twr did not consider the inadqt rwy safety area demensions.

Aircraft

Registration
ZKNZW
Reported as
Boeing 747-200
Category
Airplane
Engine
P&W JT9D-7R4G2, 54,750 lbs thrust, turbo fan
Damage
No damage
Flight
Part 129
Operator
Air New Zealand
Registered owner
Air New Zealand
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 2, 2000
Departed
LAX · Los Angeles, CA
Destination
HNL · Honolulu, HI
Flight plan
IFR
Airport
LAX · Los Angeles International, runway 25, 12,091 × 150 ft, concrete

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Certificates
Airline transport, Foreign
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left

Weather

Conditions
Visual (VMC) · Night/dark
Wind
340° at 8 knots
Visibility
10 statute miles
Lowest ceiling
28,000 ft overcast
Temperature
73 °F, dew point 63 °F
Altimeter
30.00 inHg
Observed at
LAX, 1 nm away