Date: February 1, 1991
Type: Boeing 737-300 and Fairchild Metroliner SA-227-AC
Registration: N388US and N683AV
Operator: USAir and Skywest
Where: Los Angeles International Airport, Los Angeles, California
Report No. NTSB/AAR-91/08
Report Date: October 22, 1991
Pages: 161

[This is the Executive Summary, not the Abstract.  New format.]

On February 1, 1991, at 1807 Pacific standard time, USAir flight 1493,
N388US, a Boeing 737-300, collided with Skywest flight 5569, N683AV, a
Fairchild Metroliner (SA-227-AC), while the USAir airplane was landing
on runway 24 left at Los Angeles International Airport, Los Angeles,
California.  The Skywest Metroliner was positioned on the same runway,
at intersection 45, awaiting clearance for takeoff.  As a result of
the collision, both airplanes were destroyed.  All 10 passengers and 2
crewmembers aboard the Metroliner and 20 passengers and 2 crewmembers
aboard the USAir airplane were fatally injured.

The National Transportation Safety Board determines that the probable
cause of the accident was 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.  The 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
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.

The safety issues raised in this report include:

        Air traffic management and equipment at Los Angeles
        International Airport.

        Aircraft exterior lighting and conspicuity.

        Pilot situation awareness during takeoff and landing and
        operation on airport surfaces.

        Air traffic controller workload, performance, and supervision.

        Air transport accident survivability, evacuation standards and
        procedures, interior furnishing flammability standards, and
        survival devices.

Recommendations concerning these issues were addressed to the Federal
Aviation Administration.