Original subtitles

Sundance 518, taxi across runway 24 left.

Contact ground...

February 1, 1991.

Los Angeles International Airport--LAX.

246 heading two seven zero,

contact Los Angeles departure.

Thank you.

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

Cleared to land, 24 left, 1493.

Traveling at 150 miles per hour,

U.S. Air flight 1493 descends toward runway 24 left.

What the hell?

I pointed to the aircraft and yelled U.S. Air's crashing.

The aircraft was fully engulfed in flames.

But the full scope of this tragedy

is far bigger than anyone can imagine.

Ladies and gentlemen,

we are starting our approach.

We lost both engines!

Put the mask over your nose.

Emergency descent.

Mayday, mayday.

Brace for impact!

I think I lost one.

Investigation starting...

He's gonna crash!

At one of the busiest airports in the world,

a Boeing 737 has just exploded into 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 re-examine every detail of the last 15 minutes.

U.S. Air flight 1493

cruises toward Los Angeles International Airport.

LAX is a central hub for international travelers.

Just confirm the visual approach

for U.S. Air 1493 is 24 left.

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.

And I went from the business meetings

to the Columbus Airport

and got on a U.S. Air flight

that was non-stop to Los Angeles.

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

U.S. Air 1493, expedite your descent

through 4,000 as much as practical, if 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 four, U.S. 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 of four.

U.S. Air 1493.

Thanks for your help.

Contact Los Angeles tower, 133.9.

Good night.

Good night.

Gear down.

Alright, 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 Brann

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,

the type of aircraft, route of flight.

I issue the clearance to the pilot

and then I pass the strips, the flight information

to the next controller.

Brann 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 Wascher

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.

U.S. Air 23, taxi into position

and hold runway 24 left.

Position and hold, 24 left, U.S. Air 23.

49740 echo.

246, are you still holding short of 47?

246, affirmative.

Alright, you're next.

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

Roger, hold short.

U.S. Air flight 1493 is about eight miles from LAX.

The pilots configure their plane for landing.

Speed brakes.

♪ still workin' for a livin' ♪

Alright.

Flaps a-goin' one.

Flaps.

Now the pilots radio the LAX tower

for landing instructions.

U.S. Air 1493, inside roman.

Wings, 5006, ground--tower.

Robin Wascher is busy with other planes.

She doesn't respond to their radio call.

Skywest 569, taxi into position

and hold runway 24 left.

Traffic will cross downfield.

Ok, 24 left, position and hold, Skywest 569.

Wings West 5006, tower.

2166, going to approach, 164.5.

30.

Green light.

Detent.

Gear.

Flaps.

Landing clearance remains.

Just four miles from the airport,

the U.S. Air jet still doesn't have the ok to land.

Sundance 518, taxi across runway 24 left,

contact ground, .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 Wascher's permission to land.

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

246 heading 270, contact Los Angeles departure.

Good night.

But she's still focused on other planes.

Out of a thousand feet.

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, U.S. Air 1493,

you're cleared to land 24 left.

Cleared to land, 24 left, 1493.

Looks real good.

You're coming out of 500.

What the hell?

The U.S. Air 737 has barely touched down.

It erupts in flames and crashes

through Los Angeles International Airport.

I saw U.S. Air touch down,

and as he got about mid,

about a 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.

And 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, very chaotic.

I remember just thinking to myself, oh, god,

please get some more people out here.

Get me fire, get me officers, get me somebody,

because this is not good.

In the tower

there's no time to dwell on what's happening.

Other aircraft are still coming in to land.

Controllers must direct them to safety.

Wings west 5212, winds 240 at eight,

you are cleared to land, runway 24 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, in the aisle, not moving.

I thought to myself,

there must be an opening in the front of the plane

that allowed for this tremendous quantity of smoke

to roll into the plane so quickly.

And so I stumbled forward to 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 passengers were 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 arrive 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, 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, uh, 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.

We've got a 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, taxi into position,

hold runway 24 left.

Ok, 24 left, position and hold.

Skywest 569.

Staff can account for all 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 U.S. 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 runways,

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 4 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, 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 U.S. 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,

is out on a runway that's going to be used

for a takeoff 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.

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 scene was safe.

With airplane parts littering the airport,

LAX is running at half capacity.

Two of the four runways are shut down...

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.

First and foremost

we look at the communications.

Then we also look at the procedures within the facility

and how those were applied.

And were they indeed followed?

To learn more, the NTSB collects the audiotapes

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 Macintosh gets some bad news

about the Skywest Metroliner.

No voice recorder?

Great.

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.

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.

246 east, holding short of 47.

The investigation into the deadly collision

on runway 24 left

focuses on Robin Wascher'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 crossing downfield.

We use 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, 24 left, position and hold, Skywest 569.

Ok, stop it right 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 Wascher'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's it been there?

One minute and seven seconds.

The air traffic control tapes reveal

that Robin Wascher 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 Wascher 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,

Wascher began to lose track of some of those flights.

Is that for Philippine 102?

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.

Wascher 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?

Wings West 5006, on frequency again.

Changed radios, sorry about that.

They advised her that they had inadvertently been

on another frequency.

5006, you're back with me.

Yeah, we didn't mean to switch radios .

We're on now.

And that created a distraction

for the local controller.

Ok, I thought I lost you.

Sorry, we thought we lost you.

We apologize.

Not a problem.

But investigators discover that that flight

wasn't the only aircraft Robin Wascher was fixated on

in the moments before the crash.

Tower, Wings West 5072 is ready for takeoff.

Wings West 5072?

With U.S. Air 1493

less than a minute from touchdown,

Wascher hears from another Wings West aircraft,

flight 5072.

When Wings West 5702 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.

Ok, hold short.

Roger, holding short.

Investigators need to hear from Wascher herself.

I couldn't find the flight progress strip.

They hope to learn why

she didn't recognize 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,

U.S. Air flight 1493 crashed into the back of the Metroliner.

What the hell?

NTSB investigators now know that human error

played a major role in the collision at LAX.

Remarkably, when she cleared the U.S. Air flight to land,

Robin Wascher 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, it's,

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, Wascher 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 LAX.

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.

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 Wascher 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 learn

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 Wascher's chances of discovering her error were slim.

Investigators turn their attention

to the cockpit of the U.S. 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?

Ok, 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 the anti-collision beacon on the tail.

NTSB investigators then use a helicopter

to put themselves in the position of the U.S. 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,

what we thought might be the condition of obscuration.

They positioned a Metroliner on the runway

in the same spot where the collision occurred.

And sure enough, we could not see that,

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 color and brightness as the runway lights.

The plane may have been all but invisible

to the pilots of U.S. 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 U.S. Air flight 1493

and a Skywest Metroliner alarms the public.

The accident seems to prove

that controllers can not safely handle the increasing traffic

at Los Angeles International Airport.

The NTSB investigation points to Robin Wascher'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, 3 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 90's and even into the 2000's,

I would describe it as a common event.

LAX certainly was one of the worst Airports we had

for 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 takeoff 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.

The runway status lights illuminate red,

it 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 lights

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.