LAX Runway Collision

This article is an abridged version of the article of the same name that appeared in Asia-Pacific Air Safety (Sept 1992)

On 1 February 1991 at 1807 hours pacific standard time, USAir flight 1493, a Boeing 737-300, collided with Skywest flight 5569, a Fairchld Metroliner, while the USAir aircraft was landing on runway 24 left at Los Angeles International Airport. The Metroliner was positioned on the same runway some 2200ft from the threshold at intersection 45, awaiting clearance for takeoff. Both aircraft were destroyed as a result of the collision. All 10 passengers and two crew members aboard the Metroliner and 20 passengers and two crew members aboard the Boeing were killed.

The story from the cockpit of USAir 1493

The first officer was flying the aproach to LAX. He saw an aircraft that appeared to be taxying towards him on taxiway Uniform. He looked down the runway, saw the runway lights but did not see an aircraft on the runway. As he lowered the nose of the aircraft onto the runway after landing, the first officer observed an aircraft on the runwat immediately in front of and below him. He said that the other aircraft had a position light and/or a red light on is tail. The landing lights of his aircraft were reflected off the propellers of the aircraft in front of him. The first offcier said that there was some application of braking before the collision but there was insufficient time for evasive action. He believed that the initial point of impact was directly on the nose of his aircraft and the tail of the unidentified aircraft. He said that the collision occurred simultaneous to his aircraft's nosewheel contacting the runway. The collision was marked by a flash of light followed by the nose of his aircraft dropping. There was an explosion and fire upon impact and the Metroliner became wedged between the left engine and the fuselage of the B-737.

The story from the cabin of USAir 1493

Several passengers noted that the landing appeared to be routine; however, within a few seconds of touchdown they recalled feeling the aircraft move up and down, consistent with heavy brake applications. They noticed an orange glow through the cabin windows on both sides of the aircraft; flight attendants were heard yelling repeated commands 'get down, stay down!'. After the collision, the aircraft skidded off the runway to the left, crossed taxiway Uniform, and collided with a disused fire station. The two rear flight attendants and several passengers had unbuckled their seat belts after the first impact and were thrown forward when the B-737 struck the building. As soon as the aircraft stopped the R-1 flight attendant departed his jump seat and went to the R- 1 door. After assessing the area outside the door for fire, he rotated the handle to the open position and attempted to open the door. He said that during this time the smoke inside the cabin became so intense that he could no longer see anything. After forcing the door, he was able to open it about 12 in (30 cm) and shortly thereafter he was able to open it fully. At that point, a passenger was standing by the door, and he pushed the passenger out of the aircraft. The distance from the door sill to the ground was about 5 ft (1.6 m). Another passenger then passed the R-1 flight attendant and jumped out. The flight attendant then attempted to enter the cabin near row one; however, the smoke and flames were too intense. Returning to the R-1 door, he jumped to the ground. Several passengers who had been seated in the cabin between rows 4 and 13, escaped via the two overwing emergency exits and the R-2 service door. Because of the intensity of the fire on the left side of the aircraft, only two passengers were able to escape from the left overwing emergency exit. They crawled along the left wing and jumped from the leading edge of the wing to the ground. About 37 passengers escaped via the right overwing emergency exit. Their egress was hampered by the passenger seated in seat 10-F who stated that she was very frightened and 'froze'. As a result she was unable to leave her seat or open the window exit next to her. The male passenger seated in 1 I-D climbed over the 10-E seat back and opened the overwing exit; he pushed the passenger seated in 10F out the window onto the wing and then followed her. During the subsequent evacuation through the right overwing exit, two male passengers had an altercation at the open exit that lasted several seconds.

Firefighter's Story

Immediately following the collision, the Los Angeles ATC tower notified the airport rescue and fire fighting (ARFF) services on the red phone circuit of an aircraft crash near runway 24 left (see figure 2). The senior ARFF officer immediately initiated a full response and the first ARFF trucks arrived at the scene less than 1 min after notification. Flames from an apparent pool of fuel under the aircraft engulfed the fuselage and were visible inside the forward passenger cabin. No fire was evident in the cockpit area. As the fire fighters began their initial fire attack, they observed 40 to 50 people outside the aircraft. The fire fighters also witnessed six or seven people evacuating through the right rear door and the right overwing exit. Using both roof and bumper turrets, the four crash units were able to extinguish most of the ground fire in about 1 min, but they were unable to extinguish it completely. While the initial attack on the fire was in progress, three fire fighters departed their vehicles and began rescue operations. One fire fighter removed the first officer of the B-737 through the sliding window on the right side of the cockpit and, assisted by another fire fighter, moved him to a safe area. One of the firefighters then returned to the cockpit area through the sliding window and attempted to rescue the captain. However, he was unable to do so because the captain was pinned in the wreckage. A fire fighter brought a foam-producing hand line to the cockpit to protect the captain. Around the same time, another fire fighter brought a hand line to the R-1 door. However, before fire fighters could attack the cabin fire through this door, the fire had intensified quickly and burned a large hole through the cabin roof. Despite the ventilation afforded by the opening in the roof, the fire fighter, who had entered the forward cabin, could only advance a few seat rows toward the rear because of the fire's intensity. However, fire fighters remained in the cabin until the interior fire was extinguished some 30 min after arriving at the scene. One fire fighter, using a foam-producing hand line under the B-737, found a propeller in the right engine of the B-737, and reported this discovery to his supervisor. His supervisor asked the tower whether a second aircraft was involved. The tower indicated that a 'Metroliner' might be involved and the Incident Commander then initiated a search of the runway for any survivors. They found five bodies and debris scattered along the path of the B-737. As the fire fighters extinguished the fire under the B-737, the fuselage of the Metroliner was found crushed under the left forward fuselage of the B-737. Of the 89 persons aboard the B-737, 20 passengers, one flight attendant and the captain were fatally injured. Autopsies of the 19 passengers and one flight attendant revealed that they died of asphyxia due to smoke inhalation. One person who evacuated the aircraft died as a result of thermal burns a few days later and 31 days after the accident the captain succumbed to multiple traumanc injuries. All of the 12 persons aboard the Metroliner were fatally injured. The captain, first officer and nine passengers, succumbed to multiple traumatic injuries. One passenger died as a result of smoke inhalation and burns.

The story from the tower

After Skywest 5569 had received the flight plan clearance from the controller at Clearance Delivery, the flight strip for the flight was forwarded directly to the aerodrome controller ('local controller' --LC2) position. Because the boarding gates for Skywest Airlines are on the south side of the airport at terminal 6, the flight crew received initial taxi instructions from the south complex ground controller (GCI). When the crew called the north complex ground controller (GC2) at the frequency changeover point, they were instructed to taxi for runway 24 left. Local procedures enabled aircraft to request intersection departures direct from the local controller instead of the ground controller. This relieved the ground controller from co-ordinating with the local controller and marking the flight progress strips, and was intended to reduce the ground controller's workload. However, its effect was to increase the local controller's workload by requiring him/her to determine the flight path intentions and rely on memory and observations of aircraft on the ground to identify and track the progress of aircraft. If, at any stage, a controller is unable to recall such details, or to recognise or observe an aircraft, however briefly, the possibility of error is greatly increased.
On its initial radio contact with the LC2 at 1803:38, the flight crew of Skywest 5569 advised, 'at [taxiway] 45 we'd like to go from here if we can'. In later testimony, the LC2 stated that she did not hear the 'at 45' portion of the transmission. The Safety Board was unable to determine conclusively whether the LC2 heard the flight crew of Skywest 5569 state that they wished to depart, 'at 45'. However, subsequent transmissions by the LC2 indicate that she was briefly aware of Skywest 5569's presence on runway 24 left at intersection 45. At 1804:44, the LC2 cleared the flight crew of Skywest 5569 to 'taxi into position and hold runway two four left, traffic will cross down field.' At 1805:02 she cleared the flight crew of SWA725 (a Southwest Airlines B-737), 'taxi up to and hold short of 24 left ... you'll follow the Metroliner'. The Metroliner referred to in this instruction must have been Skywest 5569. This transmission authorised SWA725 to hold short (taxi up to the holding point) of the active runway. The transmission could not have been intended for another Metroliner (Wings West 5072) which was holding short on taxiway Uniform. Such an instruction to Wings West 5072 would have positioned SWA725 in front of the aircraft that it had just been instructed to follow. Between 1804:11 and 1804:52, the LC2 made four transmissions in an attempt to clear Wings West 5006, which had landed on runway 24 right, to cross 24 left. At 1805:09 communication with Wings West 5006 was re-established. The LC2's repeated attempts to communicate with the flight crew of Wings West 5006 generated additional workload, and subsequent unnecessary and extraneous conversation with them created a distraction. The resultant effect on her performance was evident from the fact that at one point she identified Wings West 5006 as 'Sundance 518', an aircraft that she had cleared to the south complex (runway 25 right) almost 41/2: min earlier. The Safety Board believed that during her communication with Wings West 5006, the LC2 became preoccupied and forgot that Skywest 5569 was on the runway. At 1806:08, Wings West 5072 called ready for takeoff. The LC2 had no flight progress strip in front of her for this aircraft and queried the crew regarding their intended departure intersection, 'you at 47 or full length?' Instead of considering the ramifications of the flight crew's response to her query, 'we're full length; the LC2 initiated and participated in a search for the Wings West 5072 flight progress strip. This situation created another distraction from her task of scanning the runway. If the flight progress strip had been at the LC2 position, this diversion of attention would not have occurred. The missing strip was subsequently located at the clearance delivery position, misfiled as a yet-to-be- delivered departure clearance. As a result of the demanding workload and a lack of other memory aids such as the progress strip, the LC2 subsequently 'forgot' that Skywest 5569 was on the runway and misidentified Wings West 5072 as Skywest 5569. Observing the Metroliner, which she now thought was Skywest 5569, taxiing in front of her on taxiway Uniform, she developed a mental picture and a reasonable expectation that the runway was clear and issued the landing clearance to the flight crew of USAir 1493. The LC2 testified that following the accident, and after she was relieved from the operating position, she returned to the tower cab of her own volition because:
I realised there was something wrong. I went back over to local control to find out, ask him what strips he had in front of him .... I said see if you can find Skywest 569. I went to the ground control and I said see if you're in contact with Skywest 569. I went to the supervisor and I told her, I said this is what I believe USAir hit.

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