# NTSB LAX91IA297: Boeing 747-200, Los Angeles, CA, August 13, 1991

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: August 12, 1991, 20:21 local (Aug 13, 1991, 03:21 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: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 298 uninjured
- Status: Completed, report May 5, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27032
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91IA297
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27032/pdf
- Page: https://openairdocs.org/ntsb/LAX91IA297

## 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

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

- Near collision between aircraft, takeoff - roll/run
  - light condition - dark night (contributing factor)
  - object - aircraft moving on ground
  - airport facilities,runway safety area - inadequate (cause)
  - atc clearance procedure - inadequate (cause)
  - identification of aircraft visually - misjudged, atc personnel(lcl/gnd/clnc)
  - insufficient standards/requirements, faa(organization) (contributing 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 (not matched to a registry record)
- Reported make and model: BOEING 747-200
- Category: Airplane
- Engines: P&W JT9D-7R4G2 54750 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.

- Pilot; 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

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.

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