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Los Angeles runway disaster
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{{short description|1991 runway collision between two airplanes}}{{Use mdy dates |date=May 2020}}- the content below is remote from Wikipedia
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Background
Aircraft and crew
USAir Flight 1493 was a scheduled service from Syracuse, New York, making stops at Washington, DC, Columbus, Ohio, and LAX, before continuing to San Francisco.BOOK,weblink Aviation Accident Report: Runway Collision of USAir Flight 1493, Boeing 737 and Skywest Flight 5569 Fairchild Metroliner, Los Angeles International Airport, Los Angeles, California, February 1, 1991, October 22, 1991, National Transportation Safety Board, NTSB/AAR-91/08, January 21, 2016, - Copy at EmbryâRiddle Aeronautical University.{{rp|1}} On February 1, 1991, Flight 1493 was operated using a Boeing 737-300 (registration {{Airreg|N|388US}}); after a crew change in Washington, DC,{{rp|1}} it was under the command of Captain Colin Franklin 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 T. Kelly (32), who had about 4,300 total flight hours, with 982 hours on the Boeing 737.{{rp|82}} Flying into LAX, the aircraft had 89 people on board (83 passengers, four flight attendants, and the two pilots).{{efn|name="count discrepancy footnote"|The executive summary of the NTSB report describes "89 passengers, 4 flight attendants, and 2 flight crewmembers" aboard Flight 1493.{{rp|1}} However, this does not match the contents of the report. The body of the report describes a total of "89 persons aboard the B-737".{{rp|30}} In addition, the report's section on injuries to persons describes a total of 101 persons involved in the accident, including 12 aboard the Metroliner and 89 aboard the Boeing 737.{{rp|8}} In addition, shortly after the accident, USAir officials reported to the press that 83 passengers and 6 flight crew were on board Flight 1493.NEWS,weblink Pilots Dead, Many Missing In Fiery Los Angeles Crash, Reinhold, Robert, The New York Times, February 3, 1991, March 25, 2016, Of the 83 passengers and 6 crew members aboard USAir Flight 1493, on the way from Columbus, Ohio, to Los Angeles, 19 were still unaccounted for this afternoon, said airline officials., }}On February 1, 1991, SkyWest Airlines Flight 5569 was operated using a twin-engined Fairchild Metroliner (registration {{Airreg|N|683AV}}). The flight was scheduled to depart LAX on the final leg of a multicity schedule, and was bound for Palmdale, California, with 10 passengers and two pilots aboard.{{rp|1}} 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.{{rp|20â21}} 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.{{rp|83}}Airport
LAX has four parallel runways, with the two runways and associated taxiways north of the terminal called the North Complex.{{rp|13}} Aircraft that landed on the outer runway â 24R â would cross the inner runway â 24L â in order to reach the terminal.{{Citation needed|date=November 2023}}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.NEWS, May 7, 1991, NTSB Reports Show Controller's Troubled History, Pilot's Drug Use, Associated Press,weblink dead,weblink February 8, 2023, The clearance delivery controller in charge of taxiing aircraft was Francita Vandiver, who had previously served as an ATC in the US Navy. She had been working at LAX since 1988.{{rp|83}}Accident details
Flight
(File:USAir Flight 1493 traffic movements.svg|thumb|right|Diagram showing movement of the aircraft involved in the accident)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.{{rp|5}}{{efn|name="taxiway footnote"|Taxiway names Kilo, 48, Tango, and 45 were in use at the time of the accident; these taxiways were redesignated as Charlie, Sierra, Delta, and Delta10 after 1991.{{citation needed|date=January 2016}}}} 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".{{Citation needed|date=November 2023}}Immediately prior to SkyWest 5569 reaching runway 24L, a Wings West 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.{{rp|5}} Shortly after 6 PM local time, as USAir 1493 was on final approach to LAX, the SkyWest Metroliner was cleared by the local controller to taxi into position and hold on Runway 24L at the intersection of taxiway 45, some {{convert|2200|ft|m}} up from the runway threshold.Kilroy, Chris. {{usurped|weblink" title="web.archive.org/web/20091011065232weblink">AirDisaster.Com: Special Report: USAir Flight 1493}}. 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:{| class="wikitable"Fatalities and injuries
thumb|right|Seating chart of US Airways Flight 1493 from the NTSB, revealing locations of passengers, lack of injury, the severity of injuries, and deathsThe 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 Lead flight attendant Deanna Bethea ). Two of the USAir fatalities were passengers who initially survived the crash, but died from burn injuries three and 31 days after the crash.{{efn|name="fatality footnote"|Although the NTSB's final report only lists 22 "fatal" injuries aboard USAir 1493, a total of 23 people died as a result of the crash. One fatality, a passenger who initially survived the crash but died 31 days later due to burn injuries, was officially recorded by the NTSB as a "serious" injury. In its final report, the NTSB explained that at the time, 49 CFR 830.2 defined "fatal injury" as an injury that results in death within 3 days of an accident. In accordance with regulation, the NTSB counted this deceased passenger among the 12 "serious" injuries.{{rp|8}} The regulation has since been revised, and {{as of|2016|October|lc=y}}, any injury resulting in death within 30 days is now deemed a "fatal injury".{{CodeFedReg|49|830|2}}}}Captain Shaw was killed when the nose of the aircraft struck the abandoned fire station, crushing the section of the cockpitWEB, Klein, Dan, Cockpit voice recorder of USAir 1493,weblink July 17, 2013, dead,weblink" title="web.archive.org/web/20140417220524weblink">weblink April 17, 2014, 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 businessman David H. Koch was among the survivors.NEWS, Koch, David H., 1991-03-07, Opinion {{!, 'Last in Line for the Exit'|language=en-US|work=The New York Times|url=https://www.nytimes.com/1991/03/07/opinion/last-in-line-for-the-exit.html|access-date=2020-08-12|issn=0362-4331}}NEWS, 2014-12-15, David Koch on the Plane Crash That Helped Change His Life, ABC News,weblink 2020-08-12, 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.{{rp|37}}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 (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."NEWS,weblink The Fire This Time, People (magazine), People, February 25, 1991, January 21, 2016, July 16, 2010,weblink" title="web.archive.org/web/20100716210710weblink">weblink dead, 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.{{Citation needed|date=November 2023}}Shaw was found to have traces of phenobarbital in his blood. The Federal Aviation Administration prohibits use of the sedative 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.{{rp|7}}"LAX Runway Collision". Retrieved on December 16, 2009.{{Better source needed|date=December 2017}}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.NEWS, Malnic, Eric, Connell, Rich,weblink Controller Says Her Error Caused Runway Collision, Los Angeles Times, May 8, 1991, January 21, 2016, NEWS, Stein, Mark,weblink Controller Was Stricken by Grief, Tears After Crash : Disaster: Co-workers spent hours after the accident counseling her and hid her from publicity for days., February 9, 1991, Los Angeles Times, March 29, 2020, 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.NEWS,weblink FAA releases tower tapes of the crash on L.A. runway, The Baltimore Sun, Carroll, James R., March 26, 1991, January 21, 2016, December 23, 2010,weblink" title="web.archive.org/web/20101223061057weblink">weblink dead, 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 sequenceâher 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.{{Citation needed|date=November 2023}}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 landing on 24L passed only {{convert|200|ft|m}} above a 737 holding on the same runway.WEB,weblink Aircraft Incident Report, B737 and B744 runway incursion, Los Angeles CA, August 19, 2004, August 19, 2004, National Transportation Safety Board, LAX04IA302,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.{{Citation needed|date=November 2023}}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.NEWS,weblinkweblink" title="web.archive.org/web/20090228050315weblink">weblink dead, February 28, 2009, Surviving Crashes: How Airlines Prepare for the Worst, Time (magazine), Time, Harrell, Eben, February 26, 2009, January 21, 2016, Air traffic controller Wascher, who bore the immediate responsibility for the crash, was adjudged to have made an error in adverse circumstances that any air traffic controller could have made and was not prosecuted or fired. She declined an offer to return to air traffic control and took a desk job at the FAA's western regional office.WEB,weblink 2024-01-02, 2022-11-12, Cleared to Collide: The crash of USAir flight 1493 and SkyWest flight 5569, or the Los Angeles Runway Disaster, Kyra, Dempsey, Admiral Cloudberg,Dramatization
The story of the disaster was featured in a 9th-season episode of the Discovery Channel Canada / National Geographic series Mayday. 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.EPISODE, Cleared for Disaster, Mayday (Canadian TV series), Mayday, Discovery Channel Canada / National Geographic Society, National Geographic, 9, 4, 2010, It is featured in season 1, episode 3, of the TV show Why Planes Crash, in an episode called "Human Error".TLC also aired a segment on the crash in the 1990's special called Terror in the Sky. It featured an interview with billionaire David Koch who survived the accident, as well as footage of the aftermath of the collision.{{YouTube|6JKCJwPYacY|"Terror in the Sky"}}See also
- Tenerife airport disaster â in 1977, the deadliest runway incursion in history, involving two 747s in dense fog
- Madrid runway disaster â a 1983 fatal runway incursion involving a DC-9 and a 727
- 1990 Wayne County Airport runway collision â a 1990 fatal runway incursion involving both a DC-9 and a 727
- Linate Airport disaster â a 2001 fatal runway incursion involving an MD-87 and a Cessna Citation CJ2
- 1996 Quincy Airport disaster â a 1996 fatal runway incursion involving a Beechcraft 1900C and a King Air plane.
- 2024 Haneda Airport runway collision â a 2024 fatal runway incursion on runway 16L/34R at Haneda Airport involving an A350 and a coast guard DHC-8
Notes
{{notelist}}References
{{NTSB}}{{reflist}}External links
- {{ASN accident |id=19910201-0}}
- content above as imported from Wikipedia
- "Los Angeles runway disaster" does not exist on GetWiki (yet)
- time: 10:50pm EDT - Sat, May 04 2024
- "Los Angeles runway disaster" does not exist on GetWiki (yet)
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