Original subtitles

February the 1st, 1991.

Los Angeles International Airport, LAX.

Thank you, US Air 1493, you're cleared to land, 24L.

Cleared to land, 24L.

Traveling at 240 kilometers per hour.

US Air Flight 1493 descends towards runway 24 left.

What the hell?

I pointed to the aircraft and yelled, US Air is crashing.

The aircraft was fully engulfed in flames.

But the full scope of this tragedy is far greater than anyone can imagine.

At one of the busiest airports in the world A Boeing 737 has just exploded in

flames upon landing.

I think the thought process in the tower was, it was 1991, it was one of the

first nights of the first Gulf War.

And I think the thing that was foremost in our mind was maybe it was a bomb that

went off on the aircraft.

As firefighters bring the blaze under control, rescuers begin searching for

survivors.

About five minutes after the incident occurred, we got a call from an

emergency vehicle.

Amid the wreckage, they have made an alarming discovery, one that forces

everyone involved to reexamine every detail of the last 15 minutes.

U.S. Air Flight 1493 cruises towards Los Angeles International Airport.

LAX is a central hub for international travelers.

Just confirm the visual approach for U.S. Air 1493 is 24L.

That's correct, U.S. Air 1493.

For the approach captain Colin Shaw is managing radio communications First

officer David Kelly is at the controls

With 89

passengers on board the flight isn't quite full

Well, I'd been on a business trip to Columbus, Ohio

I went from the business meetings to Columbus Airport and got on a U.S. Air

flight that was nonstop to Los Angeles.

I planned a lot of good things and good times for that weekend.

U.S. Air 1493, expedite your descent through 4000 as much as practical as you

would. There will be traffic pass above you on the south side.

As the Boeing 737 nears Los Angeles...

The approach controller tells the pilots to make a quick descent.

They will need to stay clear of a flight passing above them.

OK, I'll expedite through 4.

US Air 1493.

Landing at LAX can be a challenge for pilots.

The airspace around the airport is often thick with traffic.

On average, a plane arrives or departs every 50 seconds.

Each of its four runways handles both takeoffs and landings.

Taxiways intersect the runways at dozens of locations.

The airport can be a maze of stops and starts for pilots following instructions

issued by controllers.

You got the left side in sight?

Yeah.

We're out at four.

Good night.

You're down?

All right. You gave three bells?

Yes, I did.

Perched 12 stories above the ground, tower controllers have a hawk's eye view

of traffic coming and going from the airport.

It was a busy night. There was a lot of airplanes.

We had numerous arrivals and departures.

during that time of the night, so it was a typical day.

Elliot Brown is the clearance delivery controller.

The primary duties of the clearance delivery controller is issuing the

routes of flight and the flight plans to the pilots as they come out of the

computer.

A flight strip is printed out, so you get a piece of paper with the call sign,

type aircraft, route of flight. I issue the clearance to the pilot, and then I

pass the strips, the flight information, to the next controller.

Brand shares flight information with four other controllers.

Two ground controllers, who handle planes moving between the gates and the

runways, and two local controllers, who are responsible for planes taking off

and landing.

Tonight, local controller Robin Washer is overseeing the two north runways at

LAX, 24 left and 24 right.

She uses the flight strips to keep track of flights departing and arriving.

US Air 23, taxi into position and hold runway 24L.

Position and hold 24L, US Air 23.

246, you still holding short of 47?

46, affirmative.

Right, you're next.

Skywest 569, taxi up and hold short of runway 24L.

Roger, hold short.

US Air Flight 1493 is about 13 kilometers from LAX.

The pilots configure their plane for landing.

Speed brakes.

Still working for a living.

All right.

Flaps are going one.

Flaps. Now the pilots radio the LAX tower for landing instructions.

U.S. Air 1493, inside, roger.

Wings, 5006, ground, tower.

Robin Washer is busy with other planes.

She doesn't respond to their radio call.

Skywest 569, taxi to position hold, runway 24L.

Traffic will cross downfield.

Okay, 24L. Position and hold, Skywest 569.

30 green lights to 10 here flaps landing

clearance remains Just six kilometers from the airport the US

air jet still doesn't have the okay to land

Sundance 518, taxi across runway 24L. Contact ground 0.65 when you're off the

runway. Good night.

Captain Shaw contacts the tower for the second time in less than a minute.

He needs washer's permission to land.

US Air 1493 for the left side.

246 heading 270, contact Los Angeles departure.

But she's still focused on other planes.

Flight 1493 is now one minute from the runway.

It's what pilots call short final.

Sometimes due to other priorities that take place, an aircraft might not get a

landing clearance until short final.

Thank you, US Air 1493. You're cleared to land. 2-4 left.

Cleared to land. 2-4 left.

1493.

Looks

real

good.

You're coming out of 500.

What the hell?

The US Air 737 has barely touched down.

It erupts in flames and crashes through Los Angeles International Airport.

I saw US Air touch down.

And as he got about mid, about third way down the runway at taxiway 45, the

aircraft was fully engulfed in flames.

The supervisor ran past me to pick up the crash phone and alert the emergency

vehicles to respond.

Aboard the flight, sheer terror.

There was a tremendous crunching sensation.

There was this extraordinary shower of sparks that shot by my window.

Good God.

Rosa Reynoso is a plainclothes officer with the airport police.

We see the aircraft engulfed in fire.

My partner and I were probably about 500 yards.

from it alert 33 runway 24l affirmative alert 33.

the initial moments were very scary um very chaotic i remember just thinking to

myself oh god please get some more people out here get me fired get me

officers get me somebody because uh this is not good

in the tower there's no time to dwell on what's happened

Other aircraft are still coming in to land.

Controllers must direct them to safety.

Wings 2-4-0 at 8. You are cleared to land.

Runway 2-4 right.

Use caution.

We just had an aircraft go off the runway in flames.

The cabin of flight 1493 is filling with toxic smoke.

Some passengers rush to a door at the rear of the plane.

I probably got seven or eight rows down the aisle, and then I encountered a

cluster of passengers standing in the aisle, not moving.

I thought to myself, there must be an opening in the front of the plane.

allowed for this tremendous quantity of smoke to roll into the plane so quickly

and so i stumbled forward to the the cockpit area and there

was tremendous fire on both sides of the plane i said to myself my gosh

there's no way you're going to get out of this airplane david you're trapped

outside some have escaped the plane

Rosa Reynoso is the first emergency responder to arrive at the scene.

The fire was intense.

It was very, very hot. I mean, almost singeing us.

She needs to act fast to help passengers away from the burning wreckage.

The passenger was trying to escape the plane from the emergency exit doors.

However, the fire had engulfed the doors, so some of the people that were

fine. Jumped out of the plane and into the fire.

More emergency personnel arrived within minutes.

Most passengers are jumping out of that door.

Some people were on fire.

Some of them were scratched, cut up.

Some of them had broken legs.

It was pretty traumatic.

And I think you just start operating on knowing that you have to do the right

thing and try and save these people.

David Koch is still inside.

I suddenly saw a crack of light, and my God, it was a miracle.

The crack opened up, and I suddenly realized that I had opened the galley

door.

But now he faces another hurdle.

He can't even see the ground through the fire and smoke.

And I said to myself,

What the hell? And jumped out.

I landed on the ground and then started crawling on my hands and knees away from

the airplane.

I had a great sense of guilt.

Why did I not go back into the airplane and say, follow me?

And I think if I'd gone back into the cabin, I might have...

passed out and fallen on the floor and died.

And that's how I've come to terms with the fact that I got out but didn't help

anybody else out.

As the search for survivors continues, firefighters make a stunning find.

This is Rescue 1.

The propeller down here in the wreckage.

The discovery of a propeller has horrifying implications.

There's two planes down here.

As soon as we found out that information, we started actively looking

to see what aircraft, if any, were missing.

So we started looking at the flight strips that were already departed.

And then we looked at the ones that were still pending.

And then we called the departure control, radar controller, to find out

which ones they've talked to in the last five, six minutes.

What about SkyWest 5569?

No, we haven't heard from them.

SkyWest 569 taxiing to position hold runway 24L.

Okay, 24L position. And hold SkyWest 569.

Staff can account for all of the aircraft except for SkyWest 5569, a

Fairchild Metroliner bound for Palmdale, California.

Emergency personnel find parts of the smaller plane strewn across runway 24

left.

There were 12 people on board the flight.

None have survived.

What's left of their plane is crushed between US Air 1493 and an abandoned

building near the runway.

My first thought was, oh my God, there's someone else under there, and we didn't

even realize it.

There's even more loss of life on board the larger plane.

20 are dead, two others are mortally wounded.

First Officer Kelly has survived, but Captain Shaw has not.

The disaster thrusts LAX into the media spotlight.

America's runway is, according to the nation's pilots, the most dangerous part

of the flight.

In the months and years leading up to the crash, increasing traffic was

becoming a safety concern at Los Angeles International Airport.

The most close calls, Los Angeles International Airport.

33 near collisions over the last four years.

That's one every month and a half.

The accident confirms safety issues need to be addressed.

The National Transportation Safety Board sends its GO team to LAX to investigate.

It was kind of a horrific scene.

The front end of the airplane was impaled on the captain's side against

the building.

And with close inspection, we could see parts of another aircraft underneath.

Investigators can see that the two planes collided at an intersection on

runway 24 left.

The scenario of the accident resulted in two planes being on the runway at the

same time.

The runway was occupied.

And that's something that should never happen when a landing clearance is

granted.

Reducing collisions on US runways is a priority for investigators from the

NTSB. We had runway incursions on the most wanted list from 1990 here at the

safety board.

And it's a major concern for the whole industry.

A runway incursion is simply when an inappropriate object is out on a runway

that's going to be used for a take-off or landing.

Some of the world's worst airline disasters have taken place on runways.

In March 1977, on the island of Tenerife,

583 people died when two Boeing 747s collided on the runway.

In January 1990, a Beechcraft King Air 100 was struck by a Boeing 727

attempting to land in Atlanta.

Later that year in Detroit, another Boeing 727 smashed straight into a DC-9

carrying 44 people.

Runway incursions occur due to some failure in the

existing system.

Something has happened. Some directive has not been followed. Some inattention

is present in the scenario of a runway incursion.

Which one of these planes was cleared for 24 left?

Investigators need to find out why there were two planes on runway 24 left at the

same time.

One of the principal objectives was to immediately see if we could find out

what error had taken place that would allow that situation to occur.

Part of that answer may lie in the wreckage.

But 24 hours after the crash, the investigation is at a near standstill.

There's too much fuel on board the 737.

Crawling through the wreckage would be dangerous.

The aircraft had about 6,000 pounds, maybe 1,000 gallons

of fuel on board.

How long is this going to take?

The Saturday was spent defueling the aircraft, and that's a

very slow process. That took almost all day before the fire department could

declare that the...

the the scene was safe with airplane parts littering the airport lax is

running at half capacity two of the four runways are shut down that's causing

chaos for travelers

when

the ntsb team finally gets access to the wreckage they're under enormous pressure

to act quickly

They must gather all the information they need so the airport can be fully

reopened Their investigation has a dual purpose

They must figure out what caused the collision They also want to know why

so many passengers got trapped and died in the burning aircraft

We're not sure what went on, we don't have a recording of it, but there were

some altercations with people trying to get ahead of other people.

Making matters worse, one of the emergency exit doors is inside the

plane, partially blocking the exit.

If you follow the instructions on the card, the exit card, it will tell you to

throw that exit out.

This did not take place, so the right over the wing exit was, I would say,

partially obstructed by that large hatch.

The NTSB concludes that a reduced number of exit doors made it impossible for

many of the passengers to escape.

With no way out, they were overcome by toxic smoke as it filled the cabin.

While some investigators analyze wreckage at the crash site, others focus

on air traffic control.

Well, first and foremost, we look at the communications, then we also look at the

procedures within the facility and how those are applied and were they indeed

followed.

To learn more, the NTSB collects the audio tapes of the controllers'

communications with the planes.

Investigators wonder what instructions were given to the pilots in the moments

leading up to the crash They also want to know what the flight crews were

saying during those crucial seconds Did the pilots follow their instructions?

The cockpit voice recorders should provide investigators with the answer

But then Bob McIntosh gets some bad news about the SkyWest Metroliner.

No voice recorder.

Great.

We recognized looking at the onboard equipment that SkyWest 569 did not have

a CVR flight recorder installed.

And that was disappointing to us.

At the time of the crash, commuter planes were not required to carry

cockpit voice recorders.

This means the only SkyWest conversations caught on tape are radio

communications recorded in the control tower.

The two cockpit crew members would have exchanged

words, would have been listening to the air traffic information that was coming

into their cockpit all the time.

And we recognized that that was a valuable piece of data that we had lost.

Using the air traffic control tapes and just one CVR, investigators try to find

out which of the two aircraft in the collision was actually cleared to use

runway 24 left.

The answer will raise alarming questions about the safety of all passengers

flying to and from LAX.

The investigation into the deadly collision on runway 24 left focuses on

Robin Washer's conversations with the two planes involved.

Investigators begin with the smaller plane.

Minutes before the accident, the pilots of the Metroliner waited for permission

to take off.

Skywest 569, taxi into position and hold runway 24 left.

Traffic will be cropping downhill.

We used the tapes to try to visualize, like a local controller would, where the

aircraft would be on the runway.

The pilots of the SkyWest Metroliner turned their plane onto the runway and

stopped at intersection 45.

They had to wait for another plane to cross the runway downfield.

OK, 24L, position and hold, SkyWest 569.

OK. Stop her out there.

From the air traffic control tapes, the NTSB can tell that the pilots of the

Metroliner followed all their instructions correctly.

All right, let's keep going.

Responsibility for the accident must lie elsewhere.

Investigators probe the tapes further.

They look at Washer's communications with the U.S. Air pilots.

U.S. Air 1493, for the left side, 24 left.

Thank you, U.S. Air 1493, you're cleared to land, 24 left.

U.S. Air 1493 was cleared to land on the same runway during the time that SkyWest

569 was still sitting in position on that same runway.

Cleared to land, 24 left, 1493.

SkyWest 569, right at intersection 45.

How long has it been there?

One minute, seven seconds.

The air traffic control tapes reveal that Robin Washer instructed both the

SkyWest Metroliner and the U.S. Air Flight to use runway 24 left at the same

time.

What the hell?

When we're examining the recorded voice communications, what we try to do is to

put ourselves in the position of the controller.

What would she have seen?

What would she have heard?

What would she have done?

Investigators need to know what Robin Washer was doing at the time of the

crash.

They look at the other flights that she had under her control.

Wings West 5006, taxi across runway 24 left.

They learn that in the moments before the collision, Washer began to lose

track of some of those flights.

No,

sir, hold short.

Wings West 5006, taxi across runway 24 left.

Wings West 5006 was an aircraft that was on the north side of runway 24 left

who wanted to cross to the south side.

Wings West 5006, ground tower.

And when she was ready to cross the aircraft, the crew did not respond.

Washer spent nearly a full minute of her time trying to re-establish radio

contact with the flight crossing the runway.

Can I hear the rest of that exchange?

They advised her

they had inadvertently been on another frequency.

5006, you're back with me.

And that created a distraction for the local controller.

OK, I thought I lost you.

Sorry, we thought we lost you. We apologise.

Not a problem.

But investigators discover that that flight wasn't the only aircraft Robin

Washer was fixated on in the moments before the crash.

Tower, Wings West 5072 is ready for takeoff.

Wings West 5072?

With US Air 1493 less than a minute from touchdown, Washer hears from another

Wings West aircraft, Flight 5072.

When Wings West 5072 called to say that he was ready for departure, it was

obvious to us that she didn't understand who this aircraft was.

Wings West 5072, are you at 47 or full length?

We're at full length.

Okay, hold short.

Investigators need to hear from Washer herself.

I couldn't find the flight progress strip.

They hope to learn why she didn't recognise a flight that was under her

control.

I couldn't find the strip, so I asked my supervisor to help me.

Francita?

I need a strip for Wings West 5072.

She explains that as the pilots of the Metroliner waited on the runway for

permission to take off, she was searching for another flight's progress

strip.

Before she could get back on track, US Air Flight 1493 crashed into the back of

the Metroliner.

NTSB investigators now know that human error played a major role in the

collision at LAX.

Remarkably, when she cleared the US Air flight to land, Robin Washer simply

forgot about the Metroliner waiting on the runway.

This situation that occurred is a situation that no controller wants to go

through.

You train...

your whole career for this not to happen. And when it does happen, you

can't even describe the feelings that you go through.

A situation like this could potentially happen to anybody.

We are all human.

After the accident, Washer left her job at LAX and never worked as an air

traffic controller again.

But investigators believe there are likely more causes to this accident than

one person's fatal error.

Any time that you do an investigation, it's easy to point the blame at one

individual. What you want to do is to say, why did this occur and what can we

do to prevent a reoccurrence?

Answers to those questions begin to emerge as the NTSB examines the daily

routine in the control tower in the weeks before the accident.

It was one of those, you don't know you have a problem until you have a problem.

It turns out another disaster was narrowly averted seven months before the

collision. A landing DC-10 flew just over an Airbus waiting on the runway to

take off at LAS.

Los Angeles Airport has always been known as one of the number one runway

incursion airports in the system, and changes were overdue.

Controllers at LAX produced documentation showing that immediately

after that close call, they alerted officials that the control tower was

understaffed.

They also explained that regions around the northern runways were invisible to

controllers. because their view was blocked by a light tower.

We went up in the tower climbed the stairs and asked the air traffic

controllers to step aside while we sat in their chairs and looked out the

window.

The view that the air traffic controller was presented with had an obstruction,

a light pole that produced a glare, and it was a light that lit up the

airport ramp.

Robin Washer may not have been able to see the SkyWest Metroliner as it sat out

on the runway.

NTSB investigators look at other tools she could have used to detect the

forgotten plane.

Surface radar is generally used during periods of low visibility.

It is a tool by which the local controller, should they so choose, be

able to visually confirm on that scope that an aircraft is indeed where it says

it is.

Ground radar displays all aircraft and ground vehicles moving around the

airport.

But on the night of the accident, that system wasn't working.

You're holding short, is that correct, sir?

Yes, ma'am, we're holding short.

It was in constant out-of-service, in-service, out-of-service, in-service,

and gave the management a lot of trouble.

The system was not very reliable and we did lodge complaints to have it fixed

and to upgrade the system as soon as we could.

Investigators learned that just four days before the accident, officials at

LAX had formally asked the FAA to treat the failing ground radar with the

highest priority.

The radar drive and some of the drive mechanism had some ring gears and

spur gears that they had to go to machine shops and literally make that

part because it would wear out on a regular basis trying to rotate the

antenna.

We looked into this particular problem and learned that Los Angeles had been

slated to receive a new system in 1988.

However, that date had slipped, and at that time, they were not sure when they

were going to get a new radar system.

With the ground radar system out of commission, and with her view of the

runway impeded by blinding lights,

Robin Washer's chances of discovering her error were slim.

Investigators turned their attention to the cockpit of the US Air flight.

They wonder why the pilots didn't see the Metroliner out on the runway and

abort their landing.

Well, most of us in the pilot community would recognize that it's our job to

scan that runway and find aircraft that might be out there or anything else

prior to landing.

Like all planes, the Metroliner is equipped with lights to make it more

visible at night.

There are strobe lights on the wingtips and the tail.

navigation lights on the wings, and a colored anti-collision beacon on top of

the vertical stabilizer.

We were concerned about the SkyWest lighting and had to look at the flight

operations manual, and we found that the operating procedure for that company was

to turn on the strobe lights only after clearance for takeoff.

So no other lights were required?

Okay, thank you.

The Metroliner wasn't yet cleared for takeoff.

So the only lights that would have been lit while it waited on the runway were

the navigation lights on the wings and tail, and the anti-collision beacon on

the tail.

NTSB investigators then use a helicopter to put themselves in the position of the

US air pilots as they were making the approach to runway 24 left.

We went up and we actually flew that final approach in order to verify what

we thought might be the condition of obscuration.

They positioned a metro liner on the runway in the same spot where the

collision occurred.

And sure enough... We could not see that aircraft parked out there at spot

45 and 47.

You just couldn't see it.

Looks real good.

The investigation determines the lights on the Metroliner were the same colour

and brightness as the runway lights.

The plane may have been all but invisible to the pilots of US Air 1493.

You're coming out of 500.

The anti-collision beacon in particular would have been lost in a sea of lights.

When the National Transportation Safety Board releases its report, controller

error is determined to be a cause of the runway collision.

We're in the business of determining why something happened. You may call it a

cause or causes or contributing factors, but our job ends when the next accident

is prevented.

Preventing accidents on the runways of LAX would prove to be a much greater

challenge than investigators could imagine.

The collision between US Air Flight 1493 and a SkyWest Metroliner alarms the

public.

The accident seems to prove that controllers cannot safely handle the

increasing traffic at Los Angeles International Airport.

The NTSB investigation points to Robin Washer's failure to maintain awareness

of the flights under her control as one cause of the accident.

But the report also points to a failing system in the air traffic control

facilities at LAX.

In the months and years following the accident, improvements are made to air

traffic facilities in an attempt to make the airport a safer place.

The failing ground radar system is finally replaced with a newer model.

Today at Los Angeles Tower we have the newest system out there. Each arrival or

departure they're taxiing on the taxiways or on the runways have a call

sign and type aircraft associated with it so you have positive identification

of all aircraft at all times.

New policies governing the way flight progress strips are handled in the tower

are put in place.

Ground controllers now organize the strips before they make their way to the

local controller.

The extra set of eyes reduces the local controller's workload.

Five years after the crash, a new air traffic control tower is built at LAX.

The tower is 16 stories higher, three times larger, and offers controllers

clear, unobstructed sight lines.

New regulations concerning aircraft lighting are also put in place.

It becomes mandatory for pilots to turn on all their lights before they move out

onto a runway.

But despite the improvements, the rate of runway incursions at LAX only goes

up.

Throughout the 90s and even into the 2000s, I would describe it as a common

event.

LAX certainly was one of the worst airports we had for a number of

incursions. Ten years after the accident, more serious runway incursions

were happening at LAX than at any other airport in the United States.

They had...

double-digit runway incursions and serious runway incursions almost every

year and in fact in 2007 they actually had 21 runway incursions.

In an attempt to reduce the problem once and for all, the Federal Aviation

Administration begins work on a new system of runway lights to keep planes

apart on the ground.

The runway status light system is a series of

Runway entrance lighting that we put at taxiways or take-off hold lighting that

we actually put on the runway itself.

The system is fully automatic.

It uses a series of red lights embedded in the runways and taxiways.

The lights warn pilots if there is conflicting traffic.

Runway status lights illuminate red tells a pilot that it is unsafe, or a

vehicle driver, that it is unsafe to either cross or enter that runway.

And it triggers because there is an aircraft landing or departing. There's

some other traffic on the runway.

The runway status light seems to be one of the most effective systems we have

for preventing runway incursions and certainly the serious runway incursions.

In April 2009,

The technology was installed at Los Angeles International Airport.

Prototypes of the system have also been installed at Dallas-Fort Worth and San

Diego.

By 2011 runway status lights will be a key feature at dozens of airports across

the United States.

The equipment we're using at Los Angeles Tower today is much better than the

equipment that we used back in 1991.

It's been upgraded, it's much more reliable, and it gives the controllers

the tools they need to make sure that the runways are clear and to keep the

aircraft moving.

Though new technology can never guarantee 100% safety, the improvements

at LAX have restored public confidence in the airport.

even among those who survived flight 1493.

I spent a couple of days in intensive care at a local hospital, and I had

nightmares, by the way, following my release from the hospital for quite a

number of days.

But I'm doing fine now. I have no problem with getting on airplanes and

flying, and I've got great confidence in the airline system.