USAir Flight 1493: Boeing 737 Crashes Onto Runway Due To Mistake | Mayday | On The Move

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[Music] february the 1st 1991 los angeles international airport lax 246 heading 270 contact los angeles park here thank you usa 1493 you're cleared to land two four left where the land two four left 1493 traveling at 240 kilometers per hour usf like 1493 descends towards runway 24 left what the hell i pointed to the aircraft and yelled the 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 hey 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 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 [Music] amid the wreckage they have made an alarming discovery one that forces everyone involved to re-examine every detail of the last 15 minutes [Music] [Music] us air flight 1493 cruises towards los angeles international airport [Music] lax is a central hub for international travelers just confirm the visual approach for us air 1493 is too far left that's correct for the approach captain colin shaw is managing radio communications [Music] first officer david kelly is at the controls [Music] with 89 passengers on board the flight isn't quite full [Music] well i'd been on a business trip to columbus ohio and 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 usair 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 okay 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 inside yeah we're out of four usair 1493 thanks for your help contact los angeles tower 133 decimal nine good night good night [Music] you're down all right you gave three bells yes i did [Music] perched 12 stories above the ground tower controllers have a hawks eye view of traffic coming and going from the airport it was a busy night there was a lot of airplanes um we had numerous arrivals and departures uh during that time of the night so it was a typical day elliot bran is the clearance delivery controller the primary duties of the clearance delivery controller is issuing the uh 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 usr 23 taxi into position and hold runway two four left position [Music] two four six you still holding short of 47 46 affirmative all right you're next sky west 569 taxi up and home short and runway four left roger [Applause] us air flight 1493 is about 13 kilometers from lax [Music] the pilots configure their plane for landing speed brakes still working for a living all right the laps are going one reps now the pilots radio the lax tower for landing instructions usaid 1493 inside robin wings 5006 robin washer is busy with other planes she doesn't respond to their radio call skywest 569 tracks in the position 30 green lights to 10. gear flaps landing clearance remains [Music] just six kilometers from the airport the us air jet still doesn't have the okay to land sundance 518 taxi across runway two four left contact ground point six five 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 you're there 1493 for the left side 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 a short final thank you user 1493 you're cleared to land two four left clear to land 14.93 looks real good you're coming out of 500. what the hell [Music] the usa 737 has barely touched down it erupts in flames and crashes through los angeles international effort i saw us air touch down and as he got about mid about third way down the runway a taxiway 45 the aircraft was fully engulfed in flames [Music] 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 plain clothes 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 24 l 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 [Applause] 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 at eight you are cleared to land runway two four 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 rushed to a door at the rear of the plane i probably got seven or eight rows down the aisle and uh 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 is very very hot i mean almost singing [Music] she needs to act fast to help passengers away from the burning wreckage the passengers trying to escape the plane um from the emergency exit doors however the fire had engulfed the doors so some of the people that were fined jumped out of the plane and into the fire more emergency personnel arrive within minutes most passengers are coming 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 coke is still inside i suddenly saw a crack of light and my god was a miracle the 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 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 uh passed out and fallen on the floor and died and that's how i've come to terms with the fact that i i got out but didn't help anybody else out as the search for survivors continues firefighters make a stunning find this is rescue one we've got a propeller down here in the wreckage the discovery of a propeller has horrifying there's two implications 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 uh what about skywest 5569 no we haven't heard from them skywest 569 tax into position holds runway two four left okay two four left position 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 twenty 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 [Music] 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 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 uh resulted in two planes uh 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 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 in january 1990 a beachcraft king air 100 was struck by a boeing 727 attempting to land in atlanta [Music] 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 has is present in in the scenario of a runway incursion which one of these planes was cleared for too far [Music] 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 six thousand pounds maybe a thousand gallons of fuel on board how long is this going to take the the the saturday was spent uh defueling the aircraft and that's a very slow process that took almost all day uh 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 travellers [Music] 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 were applied and were they indeed followed to learn more the ntsb collects the audio tapes of the controller's 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 [Music] but then bob mcintosh gets some bad news about the sky west metro liner 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 sky west 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 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 [Music] the answer will raise alarming questions about the safety of all passengers flying to and from lax 246 are you still holding short of 47 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 23 taxi into position minutes before the accident the pilots of the metro liner waited for permission to take off skywest 569 taxi into position and hold runway 2-4 left traffic will be crossing downhill 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 sky west metro liner turned their plane onto the runway and stopped at intersection 45. they had to wait for another plane to cross the runway downfield okay two for left position and hold skywest 569. okay stop right there from the air traffic control tapes the ntsb can tell that the pilots of the metro liner 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 washers communications with the us air pilots user 1493 for the left side two four left thank you usair 1493 you're cleared to land two four left a us 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 2-4 left 1493. skywest 569 right at intersection 45. how long's it been there [Music] one minute seven seconds the air traffic control tapes reveal that robin washer instructed both the sky west metroliner and the u.s air flight to use runway 24 left at the same time contact brown 0.51 what the hell [Music] 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 two four left they learned that in the moments before the collision washer began to lose track of some of those flights is that for philippine 102. no sir hold short wings west 5006 taxi across runway two four left wings west 5006 was an aircraft that was on the north side of runway 2-4 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 [Music] 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 they had inadvertently been on another frequency 5006 you're back with me and that created a distraction for the local controller okay i thought i lost you sorry we thought we lost you we apologized 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 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 was 50-72 are you at 47 or full length we're at full length okay hold short roger investigators need to hear from washer herself [Music] i couldn't find the flight progress trip they hoped 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 francina i need to strip for wingsworth's 5072. she explains that as the pilots of the metro liner 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 u.s air flight to land robin washer simply forgot about the metroliner waiting on the runway this is this situation that occurred is a con 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 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 anytime 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 [Music] 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 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 [Music] robin washer may not have been able to see the sky west 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 uh constant uh 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 the some of the drive mechanism had some ring gears and 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 was slim investigators turned their attention to the cockpit of the u.s air flight they wonder why the pilots didn't see the metro liner 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 coloured anti-collision beacon on top of the vertical stabilizer we were concerned about the the sky west lighting and 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 [Music] 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 uh 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 [Music] the investigation determines the lights on the metro liner were the same color 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 [Music] we're in the in the business of determining uh 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 sky west 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 [Music] 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 uh 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 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 the 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 one-way increases 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 uh my release from from the hospital for uh quite a number of days but i'm doing fine now i have no problem with getting on airplanes and and flying and i i've got great confidence in the airline system [Music] you
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Channel: On The Move
Views: 329,576
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Keywords: on the move, cars, planes, trains, documentary, documentaries, full length documentaries, plane documentary, mayday series, mayday, plane disasters, airport, runway, plane pilot, pilot, hd documentary, 2021 documentary, united airlines, plane crash, air accident, air crash, air disaster, plane accident, air emergency, plane disaster, plane emergency
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Length: 47min 3sec (2823 seconds)
Published: Tue Sep 14 2021
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