1991 Los Angeles runway collision
USAir Boeing 737-300 and SkyWest Airlines Fairchild SA-227-AC · Runway incursion caused by ATC error
Event
- NTSB case
- DCA91MA018
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Completed
- Event fatalities
- 35 · all aircraft and ground
- Ground fatalities
- 0
- Occupants
- 101
- Survivors
- 66
- InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
- 29
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- Airline
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Visual Meteorological Cond
Aircraft 1 · Boeing 737-300
- Flight
- US1493
- Aircraft type
- Boeing 737
- Category
- Airplane
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N388US
- Operator
- USAir
- Onboard fatalities
- Unknown
- Occupants
- 89
- Survivors
- 66
- InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
- 29
- Route
- From John Glenn Columbus International Airport (CMH), Columbus, OHTo San Francisco International Airport (SFO)
- Aircraft age
- Not recorded
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 121: Air Carrier
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- Landing · landing roll
- First occurrenceThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- On ground/water collision with object
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Destroyed
Aircraft 2 · Fairchild SA-227-AC
- Flight
- OO5569
- Aircraft type
- Fairchild SA-227
- Category
- Airplane
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N683AV
- Operator
- SkyWest Airlines
- Onboard fatalities
- Unknown
- Occupants
- 12
- Survivors
- 0
- InjuriesFatal: death within 30 days. Serious: over 48 hours in hospital within a week, most broken bones, severe bleeding, nerve or organ damage, or serious burns. Minor: anything less. Glossary
- None · no survivors
- Route
- From Los Angeles International Airport (LAX)To Palmdale Regional Airport / USAF Plant 42 Airport (PMD), Palmdale, CA
- Aircraft age
- Not recorded
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 135: Air Taxi & Commuter
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- Standing
- First occurrenceThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- On ground/water collision with object
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Destroyed
Cause areas
- Atc personnel(lcl/gnd/clnc) › Atc clearance, improper
- Atc personnel(supervisor) › Supervision, inadequate
Approximate · Coordinates from the Wikipedia article; not checked against an investigation report.
From the Wikipedia article
On the evening of Friday, 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 (LAX). As Flight 1493 was on final approach, the local controller was distracted, though air traffic was not heavy at LAX, by a series of abnormalities, including a misplaced flight progress strip 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.
Upon landing, the 737 collided with the smaller turboprop Metroliner, which was crushed beneath the larger USAir jet as it continued down the runway, caught fire, and veered into an airport fire station. Rescue workers arrived in minutes and began to evacuate the 737, but because of the intense fire, three of the 737's six exits were unusable, including both front exits; front passengers could only use one of the two overwing exits, causing a bottleneck. All 12 people aboard the smaller plane were killed, along with an eventual total of 23 of the 89 occupants of the 737, with 20 on the 737 caused by asphyxiation in the fire. One passenger from the 737 died from injuries 31 days later.
The National Transportation Safety Board (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 by the local controller, and inadequate oversight by the Federal Aviation Administration (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.
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.
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. 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 2200 ft up from the runway threshold. 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:
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 for this flight had not yet been given to Wascher by controller Vandiver (another distraction), and Wascher mistakenly thought this Metroliner was SkyWest 5569, and thus that 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. Meanwhile, Wascher was busy handling other flights:
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:
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.
Investigation and cause
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.
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 landing on 24L passed only 200 ft above a 737 holding on the same runway.
Text from the Wikipedia article “1991 Los Angeles runway collision” (revision 1369109045, retrieved 2026-09-18) by its authors, under CC BY-SA 4.0. Extracted as plain text: references, tables, images and some sections are left out. Read the article
NTSB narrative
SKW5569, N683AV, HAD BEEN CLEARED TO RWY 24L, AT INTERSECTION 45, TO POSITION AND HOLD. THE LOCAL CONTROLLER, BECAUSE OF HER PREOCCUPATION WITH ANOTHER AIRPLANE, FORGOT SHE HAD PLACED SKW5569 ON THE RUNWAY AND SUBSEQUENTLY CLEARED USA1493, N388US, FOR LANDING. AFTER THE COLLISION, THE TWO AIRPLANES SLID OFF THE RUNWAY INTO AN UNOCCUPIED FIRE STATION. THE TOWER OPERATING PROCEDURES DID NOT REQUIRE FLIGHT PROGRESS STRIPS TO BE PROCESSED THROUGH THE LOCAL GROUND CONTROL POSITION. BECAUSE THIS STRIP WAS NOT PRESENT, THE LOCAL CONTROLLER MISIDENTIFIED AN AIRPLANE AND ISSUED A LANDING CLEARANCE. THE TECHNICAL APPRAISAL PROGRAM FOR AIR TRAFFIC CONTROLLERS IS NOT BEING FULLY UTILIZED BECAUSE OF A LACK OF UNDERSTANDING BY SUPERVISORS AND THE UNAVAILABILITY OF APPRAISAL HISTORIES.
Probable cause
THE FAILURE OF THE LOS ANGELES AIR TRAFFIC FACILITY MANAGEMENT TO IMPLEMENT PROCEDURES THAT PROVIDED REDUNDANCY COMPARABLE TO THE REQUIREMENTS CONTAINED IN THE NATIONAL OPERATIONAL POSITION STANDARDS AND THE FAILURE OF THE FAA AIR TRAFFIC SERVICE TO PROVIDE ADEQUATE POLICY DIRECTION AND OVERSIGHT TO ITS AIR TRAFFIC CONTROL FACILITY MANAGERS. THESE FAILURES CREATED AN ENVIRONMENT IN THE LOS ANGELES AIR TRAFFIC CONTROL TOWER THAT ULTIMATELY LED TO THE FAILURE OF THE LOCAL CONTROLLER 2 (LC2) TO MAINTAIN AN AWARENESS OF THE TRAFFIC SITUATION, CULMINATING IN THE INAPPROPRIATE CLEARANCES AND THE SUBSEQUENT COLLISION OF THE USAIR AND SKYWEST AIRCRAFT. CONTRIBUTING TO THE CAUSE OF THE ACCIDENT WAS THE FAILURE OF THE FAA TO PROVIDE EFFECTIVE QUALITY ASSURANCE OF THE ATC SYSTEM. (NTSB REPORT AAR-91/08)
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
Wikipedia article: 1991 Los Angeles runway collision
- Revision
- 1369109045 · 2026-08-12 · retrieved 2026-09-18
- Wikidata
- Q949020
- Licence
- Text CC BY-SA 4.0, by the article's authors; Wikidata CC0; town positions GeoNames (CC BY 4.0)
NTSB record DCA91MA018
- Event ID
- 20001212X16433
- Case number
- DCA91MA018
- Dataset
- historical-pre2008
- Source SHA-256
- 89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Where each value comes from
- Record
- Wikipedia article "1991 Los Angeles runway collision" (page 1278063, revision 1369109045); merged with NTSB case DCA91MA018 (events / aircraft)
- Date
- NTSB record DCA91MA018: NTSB API eventDate, eventTimeUtc and eventTimeUtcOffsetHours (local date)
- Place and country
- Wikipedia infobox: site; country from NTSB record DCA91MA018
- Map position
- Wikipedia: Wikipedia article coordinates
- Aircraft, operator and route
- NTSB record DCA91MA018: aircraft; gaps from Wikipedia infobox: aircraft type, registration, operator, origin and destination; route airports from the linked airport articles' Wikidata codes (OurAirports)
- Operation
- NTSB record DCA91MA018: operated under Part 121: Air Carrier, Part 135: Air Taxi & Commuter
- Fatalities
- Reviewed (2026-09-19): NTSB final report AAR-91/08 (table: 34 fatal = 12 on SkyWest + 22 on USAir; text: another USAir passenger died of burns 31 days later and was classed as 'serious' under 49 CFR 830.2), https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9108.pdf
- Ground fatalities
- Reviewed (2026-09-19): NTSB final report AAR-91/08 (table: 34 fatal = 12 on SkyWest + 22 on USAir; text: another USAir passenger died of burns 31 days later and was classed as 'serious' under 49 CFR 830.2), https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9108.pdf
- Summary
- Wikipedia infobox: summary
Source notes (4)
- One occurrence in two sources, merged: the Wikipedia article "1991 Los Angeles runway collision" and NTSB case DCA91MA018, matched by the same aircraft registration and date. For this US event the NTSB's values are used where the two differ; each value names its source.
- Death toll settled: the NTSB record (DCA91MA018) gives 34 and the Wikipedia article 35; NTSB final report AAR-91/08 (table: 34 fatal = 12 on SkyWest + 22 on USAir; text: another USAir passenger died of burns 31 days later and was classed as 'serious' under 49 CFR 830.2) gives 35. Later death. The NTSB's 34 leaves out a USAir passenger who died of his burns 31 days after the crash; the report names him but counts him as seriously injured under the 30-day rule. Wikipedia's 35 includes him.
- Filled from the NTSB case API where the bulk record had no value: local date, investigation status. Values present in the bulk record are kept.
- The date is the local date; the NTSB stores the UTC date 1991-02-02.