On the evening of February 1, 1991, USAir Flight 1493, a
Boeing 737-300, collided with SkyWest Airlines Flight 5569, a
Fairchild Swearingen Metroliner turboprop aircraft, upon landing at
Los Angeles International Airport
Los Angeles International Airport , commonly referred to as LAX (with each letter pronounced individually), is the primary international airport serving Los Angeles, California and its surrounding metropolitan area. LAX is located in the W ...
(LAX).
Though air traffic was not heavy at LAX, as Flight 1493 was on
final approach
In aeronautics, the final approach (also called the final leg and final approach leg) is the last leg in an aircraft's approach to landing, when the aircraft is lined up with the runway and descending for landing.Crane, Dale: ''Dictionary of ...
, the
local controller was distracted by a series of abnormalities, including a misplaced
flight progress strip
A flight progress strip is a small strip of paper used to track a flight in air traffic control (ATC). While it has been supplemented by more technologically advanced methods of flight tracking since its introduction, it is still used in modern ...
and an aircraft that had inadvertently switched off the tower frequency. The SkyWest flight was told to taxi into takeoff position, while the USAir flight was landing on the same
runway
According to the International Civil Aviation Organization (ICAO), a runway is a "defined rectangular area on a land aerodrome prepared for the landing and takeoff of aircraft". Runways may be a man-made surface (often asphalt concrete, as ...
.
Upon landing, the 737 collided with the twin-engined turboprop, continued down the runway with the turboprop crushed beneath it, exited the runway, and caught fire. All 12 people aboard the smaller plane were killed, as well as an eventual total of 23 of the 89 occupants of the
Boeing 737
The Boeing 737 is a narrow-body aircraft produced by Boeing at its Renton Factory in Washington.
Developed to supplement the Boeing 727 on short and thin routes, the twinjet retains the 707 fuselage width and six abreast seating with two un ...
. Rescue workers were on the scene of the fire within minutes and began the evacuation of the plane. Because of the intense fire, three of the 737's six exits could not be used. Neither of the front exits was usable, which caused the front passengers to try to use the
overwing exits. However, only one of the overwing exits was usable, which caused a backlog to form. Most of those who died aboard the 737 succumbed to
asphyxiation
Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects primarily the tissues and organs. There are many circumstances that can i ...
in the post-crash fire.
The
National Transportation Safety Board
The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incid ...
(NTSB) found that the probable cause of the accident was the procedures in use at the LAX control tower, which provided inadequate redundancy, leading to a loss of
situational awareness
Situational awareness or situation awareness (SA) is the perception of environmental elements and events with respect to time or space, the comprehension of their meaning, and the projection of their future status. An alternative definition is tha ...
by the local controller, and inadequate oversight by the
Federal Aviation Administration
The Federal Aviation Administration (FAA) is the largest transportation agency of the U.S. government and regulates all aspects of civil aviation in the country as well as over surrounding international waters. Its powers include air traffic m ...
(FAA) for failing to supervise the control tower managers.
The crash led directly to the NTSB's recommendation of using different runways for takeoffs and landings at LAX.
Background
Aircraft and crew
USAir
US Airways (formerly USAir) was a major United States airline that operated from 1937 until its merger with American Airlines in 2015. It was originally founded in Pittsburgh as a mail delivery airline called All American Aviation, which soon b ...
Flight 1493 was a scheduled service from
Syracuse, New York
Syracuse ( ) is a City (New York), city in and the county seat of Onondaga County, New York, Onondaga County, New York, United States. It is the fifth-most populous city in the state of New York following New York City, Buffalo, New York, Buffa ...
, making stops at
Washington, DC
)
, image_skyline =
, image_caption = Clockwise from top left: the Washington Monument and Lincoln Memorial on the National Mall, United States Capitol, Logan Circle, Jefferson Memorial, White House, Adams Morgan ...
,
Columbus, Ohio
Columbus () is the state capital and the most populous city in the U.S. state of Ohio. With a 2020 census population of 905,748, it is the 14th-most populous city in the U.S., the second-most populous city in the Midwest, after Chicago, and t ...
, and LAX, before continuing to San Francisco.
On February 1, 1991, Flight 1493 was operated using a Boeing 737-300 (
registration ); after a crew change in Washington, DC,
[ it was under the command of ]Captain
Captain is a title, an appellative for the commanding officer of a military unit; the supreme leader of a navy ship, merchant ship, aeroplane, spacecraft, or other vessel; or the commander of a port, fire or police department, election precinct, e ...
Colin Shaw (48), a highly experienced pilot with around 16,300 total flight hours (including more than 4,300 hours on the Boeing 737), and First Officer David Kelly (32), who had about 4,300 total flight hours, with 982 hours on the Boeing 737.[ Flying into LAX, the aircraft had 89 people on board (83 passengers, four flight attendants, and the two pilots).
On February 1, 1991, SkyWest Airlines Flight 5569 was operated using a twin-engined Fairchild Metroliner (registration ). The flight was scheduled to depart LAX on the final leg of a multicity schedule, and was bound for ]Palmdale, California
Palmdale is a city in northern Los Angeles County in the U.S. state of California. The city lies in the Antelope Valley region of Southern California. The San Gabriel Mountains separate Palmdale from the Los Angeles Basin to the south.
On Aug ...
, with 10 passengers and two pilots aboard.[ The aircraft did not carry a cockpit voice recorder (CVR) or a flight data recorder (FDR), as it was not required to do so at the time.] Both of Flight 5569's pilots had significant experience; Captain Andrew Lucas (32), had roughly 8,800 flight hours (with 2,101 of them on the Metroliner), and First Officer Frank Prentice (45), had over 8,000 flight hours, including 1,363 hours on the Metroliner.[
]
Airport
LAX has four parallel
Parallel is a geometric term of location which may refer to:
Computing
* Parallel algorithm
* Parallel computing
* Parallel metaheuristic
* Parallel (software), a UNIX utility for running programs in parallel
* Parallel Sysplex, a cluster of IBM ...
runways, with the two runways and associated taxiways north of the terminal
Terminal may refer to:
Computing Hardware
* Terminal (electronics), a device for joining electrical circuits together
* Terminal (telecommunication), a device communicating over a line
* Computer terminal, a set of primary input and output devic ...
called the North Complex.[ Aircraft that landed on the outer runway – 24R – would cross the inner runway – 24L – in order to reach the terminal.
]
Air traffic control
The air traffic controller (ATC) in charge of takeoffs and landings in the LAX tower (the local controller) was Robin Lee Wascher. She had been working in the role since 1982, and began working at LAX in 1989.["NTSB Reports Show Controller’s Troubled History, Pilot’s Drug Use"]
– Association Press, May 7 1991 The clearance delivery
Air traffic control (ATC) is a service provided by ground-based air traffic controllers who direct aircraft on the ground and through a given section of controlled airspace, and can provide advisory services to aircraft in non-controlled airs ...
controller in charge of taxiing aircraft was Francita Vandiver, who had previously served as an ATC in the US Navy
The United States Navy (USN) is the maritime service branch of the United States Armed Forces and one of the eight uniformed services of the United States. It is the largest and most powerful navy in the world, with the estimated tonnage of ...
. She had been working at LAX since 1988.
Accident details
Flight
Skywest 5569 was cleared by ATC Wascher in the LAX tower to taxi to Runway 24L, moving from gate 32 to the runway via taxiways Kilo, 48, Tango, and 45.[ The plane was briefly not visible from the tower on taxiway 48 between Kilo and Tango in the area known as "no man's land".
Immediately prior to SkyWest 5569 reaching runway 24L, a ]Wings West
Wings West Airlines was an American regional airline headquartered at McChesney Field (SBP), unincorporated San Luis Obispo County, California. The airline initially began scheduled passenger service as an independent commuter air carrier and th ...
aircraft had landed on 24R and was awaiting permission to cross 24L and taxi to the terminal. The local controller attempted to contact the Wings West aircraft, but the crew had changed frequencies and did not answer, distracting Wascher as she attempted to reestablish communications.[ Shortly after 6 PM local time, as USAir 1493 was on final approach to LAX, the Metroliner was cleared by the local controller to taxi into its takeoff position on 24L at the intersection of taxiway 45, some up from the runway threshold.][Kilroy, Chris. . Retrieved on December 16, 2009.] After four attempts by the local controller, the Wings West aircraft finally responded to the tower and apologized for switching frequencies. Wascher then cleared the USAir flight to land on 24L, even though the SkyWest Metroliner was still holding in takeoff position on the runway:
: Wascher: "USAir fourteen ninety-three cleared to land runway two four left."
: Captain Shaw (radio): "Cleared to land two four left fourteen ninety-three."
With this activity ongoing, another Wings West aircraft, a Metroliner similar to SkyWest 5569, called the tower reporting they were ready for takeoff. Wascher queried this aircraft about their position, and they told her they were holding on a taxiway short of 24L. The flight progress strip
A flight progress strip is a small strip of paper used to track a flight in air traffic control (ATC). While it has been supplemented by more technologically advanced methods of flight tracking since its introduction, it is still used in modern ...
for this flight had not yet been given to Wascher by controller Vandiver (another distraction), and Wascher mistakenly thought this Metroliner was SkyWest 5569, thus the runway was clear of aircraft. The first officer of the USAir flight recalled hearing this conversation, but did not remember anyone being cleared to hold on the runway.
The USAir plane touched down near the runway threshold. Just as the nose was being lowered, the first officer noticed SkyWest 5569 on the runway and applied maximum braking, but it was too late. The following was recorded on the CVR:
: Kelly: " nintelligiblelooks real good nintelligible"
: Shaw: "Ahhh, you're coming outta five hundred feet bug plus twelve, sink is seven."
: ound of click: Kelly: "Lights (on)."
: Voice unidentified: wo unintelligible words: Voice unidentified: nintelligible remark: ound of impact: End of recording
The USAir plane slammed into the Metroliner, crushing it beneath its fuselage. The 737 proceeded to skid down the runway, then veered off the left side and came to rest on the far side of the taxiway against a closed fire station building, where it eventually caught fire. Large debris from the Metroliner – including its tail, wings, and right engine – were found on the runway and between the runway and the abandoned fire station.
The accident was witnessed from a plane carrying the Vancouver Canucks
The Vancouver Canucks are a professional ice hockey team based in Vancouver. They compete in the National Hockey League (NHL) as a member of the Pacific Division of the Western Conference, and play their home games at Rogers Arena. Bruce B ...
, who were arriving for an National Hockey League
The National Hockey League (NHL; french: Ligue nationale de hockey—LNH, ) is a professional ice hockey league in North America comprising 32 teams—25 in the United States and 7 in Canada. It is considered to be the top ranked professional ...
game against the Los Angeles Kings.
The captain of that charter aircraft, having just landed, powered up the engines to get away from the fireball of the accident. The team was unsure if the USAir 737 was going to stop before it collided with their plane. The Canucks were shaken by the experience and lost to the Kings by a score of 9–1, their worst loss of the 1990–91 season.
Fatalities and injuries
The 35 dead included all 12 people (10 passengers and both crew members) on SkyWest 5569, and 23 of the 89 aboard the USAir 1493 (21 passengers, Captain Shaw, and one flight attendant). Two of the USAir fatalities were passengers who initially survived the crash, but died from burn injuries three and 31 days after the crash.
Captain Shaw was killed when the nose of the aircraft struck the abandoned fire station, crushing the section of the cockpit where his seat was located. Of the remaining passengers and crew aboard USAir 1493, two crew members and 10 passengers sustained serious injuries, 2 crew members and 15 passengers sustained minor injuries, and 37 passengers received no injuries. Billionaire
A billionaire is a person with a net worth of at least one billion (1,000,000,000, i.e., a thousand million) units of a given currency, usually of a major currency such as the United States dollar, euro, or pound sterling. The American busin ...
businessman David H. Koch
David Hamilton Koch ( ; May 3, 1940 – August 23, 2019) was an American businessman, political activist, philanthropist, and chemical engineer. In 1970, he joined the family business: Koch Industries, the second largest privately held c ...
was among the survivors.
The majority of fatalities aboard USAir 1493 occurred to those seated in the front of the plane, where the postcrash fire originated in the forward cargo hold, fed by a combination of fuel from the wreckage of SkyWest 5569 and gaseous oxygen from the 737's damaged crew oxygen system. Everyone seated in row 6 or forward was either killed or sustained major injuries, while everyone aft of row 17 escaped, some with minor injuries. Only two passengers and one crew member managed to escape from the forward service (R1) door, while the main cabin (L1) door was inoperable due to damage. Only two passengers used the left over-wing exit before the fire became too intense outside the aircraft. The majority of the survivors exited via the right over-wing exit, with the rest of the surviving cabin occupants escaping through the rear service (R2) door. The rear passenger (L2) door was briefly opened during the course of the accident, but was quickly closed due to the spreading fire on that side of the aircraft. Multiple issues slowed the evacuation from the right over-wing door, including a passenger seated in the exit row who could not open the door, a brief scuffle between two men at the exit, and the seatback of the exit window seat being folded forward, partially obstructing the exit.[
From the location of the bodies, only two victims on USAir 1493 were found in their seats, while authorities believe that 17 had unbuckled their seat belts and died from smoke inhalation while making their way to the exits. According to James Burnett, who headed the ]National Transportation Safety Board
The National Transportation Safety Board (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incid ...
(NTSB) investigation team, "I can't think of a recent accident where this many people have been up and out of their seats and didn't make it out." The captain was one of the few people who died of blunt force trauma, a blow to the head when the bulkhead collapsed as the aircraft collided with the firehouse. The first officer was rescued through the cockpit windows by some of the first firefighters to arrive on the accident scene.
Shaw was found to have traces of phenobarbital in his blood. The Federal Aviation Administration
The Federal Aviation Administration (FAA) is the largest transportation agency of the U.S. government and regulates all aspects of civil aviation in the country as well as over surrounding international waters. Its powers include air traffic m ...
prohibits use of the sedative
A sedative or tranquilliser is a substance that induces sedation by reducing irritability or excitement. They are CNS depressants and interact with brain activity causing its deceleration. Various kinds of sedatives can be distinguished, but t ...
before flying. The drug was prescribed for irritable bowel syndrome by Shaw's physicians, who said they had warned him not to use the medication while flying.[
]
Investigation
First Officer David Kelly, who was flying the USAir 1493 during the accident leg, reported that he did not see SkyWest 5569 until he lowered the nose of his aircraft onto the runway after landing. Kelly also said that he applied the brakes, but did not have enough time for evasive action. Statements made by passengers who survived the crash were consistent with this testimony.["LAX Runway Collision"]
Retrieved on December 16, 2009.
Local controller Wascher, who cleared both aircraft to use the same runway, testified before the NTSB and accepted blame for causing the crash. She said she originally thought the landing USAir plane had been hit by a bomb, then "realized something went wrong... I went to the supervisor and I said, 'I think this (the SkyWest plane) is what USAir hit.'" She testified that rooftop lights in her line of sight caused glare in the tower, making seeing small planes difficult at the intersection where the SkyWest plane was positioned. Just before the accident, she confused the SkyWest plane with another commuter airliner that was on a taxiway near the end of the runway. Making matters more difficult, the ground radar at LAX was not working on the day of the accident.
The NTSB's investigation of the crash revealed that the cockpit crew of the landing USAir jet could not see the commuter plane, which blended in with other airport lights. The NTSB cited LAX's procedures which placed much of the responsibility for runways on the local controllers, which directly led to the loss of situational awareness by the local controller. The NTSB also noted that during the previous performance review, a supervisor had noted four deficiencies in the local controller who ultimately worked the accident aircraft. These deficiencies were not addressed prior to the accident, and two of the deficiencies were apparent in the accident sequence—her loss of situational awareness and aircraft misidentification.
The NTSB's investigation of the crash revealed a failing system in the air- and ground-traffic control facilities at LAX: the ground radar system worked intermittently, and was not functioning at the time of the incident; the blind spot, from the control tower, when looking at the spot where SkyWest 5569 was waiting on the runway; the system for ground controllers in the tower to pass flight progress strips to the local controller did not support the local controller's workload; aircraft on runways were not required to turn on all their external lights until rolling for takeoff. All these issues were rectified at LAX following this incident.
At the time of the accident, ATCs at LAX used all four runways (North Complex runways 24L and 24R, South Complex runways 25L and 25R) for mixed takeoffs and landings. One of the NTSB recommendations was that the runways be segregated with only landings or departures taking place on an individual runway. This recommendation was implemented, but not until after another incident, when on August 19, 2004, a Boeing 747
The Boeing 747 is a large, long-range wide-body airliner designed and manufactured by Boeing Commercial Airplanes in the United States between 1968 and 2022.
After introducing the 707 in October 1958, Pan Am wanted a jet times its size, t ...
landing on 24L passed only above a 737 holding on the same runway.
Aftermath
LAX now prioritizes the use of the outboard runways (24R and 25L) for landings and the inboard runways (24L and 25R) for takeoffs, though mixed operations may occur in certain situations. Additionally, a new control tower was built at LAX, in a more central location, significantly taller and with a better vantage point, allowing visibility of all runways and critical taxiways at the airport.
Before this accident, the FAA issued a ruling that required airlines to upgrade the flammability standards of materials on board, but the USAir plane had been built before the effective date of those requirements and had not yet been modernized. It was scheduled to be upgraded within the next year. By 2009, all aircraft operating in the United States were compliant.
Dramatization
The story of the disaster was featured in a 9th-season episode of the Discovery Channel Canada / National Geographic
''National Geographic'' (formerly the ''National Geographic Magazine'', sometimes branded as NAT GEO) is a popular American monthly magazine published by National Geographic Partners. Known for its photojournalism, it is one of the most widely ...
series ''Mayday
Mayday is an emergency procedure word used internationally as a distress signal in voice-procedure radio communications.
It is used to signal a life-threatening emergency primarily by aviators and mariners, but in some countries local organiza ...
''. The episode, titled "Cleared for Disaster", explores the events surrounding the crash and its investigation, including interviews with NTSB investigators, first responders, survivors, and witnesses.
It is featured in season 1, episode 3, of the TV show '' Why Planes Crash'', in an episode called "Human Error".
See also
* Tenerife airport disaster – in 1977, the deadliest runway incursion in history, involving two 747s in dense fog
* Madrid runway disaster
The Madrid runway disaster was on 7December 1983 when a departing Iberia Boeing 727 struck an Aviaco McDonnell Douglas DC-9 at Madrid-Barajas Airport, causing the deaths of 93 passengers and crew.
Crash
On 7 December 1983, a Boeing 727 of Iber ...
– a 1983 fatal runway incursion involving a DC-9
The McDonnell Douglas DC-9 is an American five-abreast single-aisle aircraft designed by the Douglas Aircraft Company. It was initially produced by the developer company as the Douglas DC-9 until August 1967 and then by McDonnell Douglas.
After ...
and a 727
* 1990 Wayne County Airport runway collision
The 1990 Wayne County Airport runway collision involved the collision of two Northwest Airlines jetliners at Detroit Metropolitan Wayne County Airport on December 3, 1990. Flight 1482, a scheduled Douglas DC-9-14 operating from Detroit to Pitts ...
– a 1990 fatal runway incursion involving both a DC-9 and a 727
* Linate Airport disaster - a 2001 fatal runway incursion involving an MD-87 and a Cessna Citation CJ2
The Cessna CitationJet/CJ/M2 (also known as the Model 525) are a series of light business jets built by Cessna, and are part of the Citation family.
Launched in October 1989, the first flight of the Model 525 was on April 29, 1991. Federal Avi ...
Notes
References
External links
*
{{DEFAULTSORT:Usair Flight 1493
1991 in Los Angeles
Aviation accidents and incidents in the United States in 1991
Aviation accidents and incidents caused by air traffic controller error
Airliner accidents and incidents involving ground collisions
1493
Year 1493 ( MCDXCIII) was a common year starting on Tuesday (link will display the full calendar) of the Julian calendar.
Events
January–December
* January 19 – Treaty of Barcelona: Charles VIII of France returns Cerdagne a ...
Accidents and incidents involving the Boeing 737 Classic
Accidents and incidents involving the Fairchild Swearingen Metroliner
Airliner accidents and incidents in California
Los Angeles International Airport
February 1991 events in the United States
Aviation accidents and incidents in 1991