Mayday (2013) s09e04 Episode Script
Cleared for Disaster
(RADIO COMMUNICATION) NARRATOR: February 1, 1991, Los Angeles International Airport - LAX.
246 heading 270, contact Los Angeles Departure.
Travelling at 240km/h, USAir Flight 1493 descends towards runway 24 Left.
MAN: What the hell?! MAN: 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.
It was 1991.
It was one of the first nights of the first Gulf War.
And I think the thing that was foremost in my 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.
After 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.
USAir Flight 1493 cruises towards Los Angeles International Airport.
LAX is a central hub for international travellers.
Just confirm the visual approach for USAir 1493 is 24 Left.
MAN: (OVER RADIO) That's correct, USAir 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.
MAN: 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.
OK.
I'll expedite through 4,000.
USAir 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 take-offs 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 intersect? Yeah.
We're out at 4,000.
USAir 1493, thanks for your help.
Contact Los Angeles tower 133.
9.
Goodnight.
Goodnight.
- Gear down? - Alright.
- You gave it three belts? - Yes, I did.
Perched 12 storeys above the ground .
.
tower controllers have a hawk's-eye view of traffic coming and going from the airport.
Elliot Brann is the clearance delivery controller.
MAN: The primary duties of the clearance delivery controller is issuing the routes of flights 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 with 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.
USAir 23, taxi into position and hold.
Runway 24 Left.
MAN: (OVER RADIO) Position and hold.
24 Left.
USAir 23.
(RADIO COMMUNICATION) 246, are you still holding short of 47? MAN: (OVER RADIO) 246, affirmative.
Alright, you're next.
SkyWest 569, taxi up and hold short of runway 24 Left.
Roger.
Hold short.
(RADIO COMMUNICATION) USAir Flight 1493 is about 13km from LAX.
The pilots configure their plane for landing.
Speed, brakes.
(SINGS) # Still working for a livin' # (CHUCKLES) Alright.
Flaps are go on one.
Flaps.
Now the pilots radio the LAX tower for landing instructions.
USAir 1493.
Inside roaming.
Wings 5006 ground, er, tower.
Robin Wascher is busy with other planes.
She doesn't respond to their radio call.
SkyWest 569, taxi into position, hold.
Runway 24 Left.
Traffic will cross downfield.
OK, 24 Left.
Position and hold.
SkyWest 569.
Wings West 5006, tower.
(RADIO COMMUNICATION) 30.
Green light.
To 10.
Gear.
Flaps.
Landing clearance remains.
Just 6km from the airport, the USAir jet still doesn't have the OK to land.
Sundance 518, taxi across runway 24 Left.
Contact ground 0.
65 when you're off the runway.
Goodnight.
Captain Shaw contacts the tower for the second time in less than a minute.
He needs Wascher's permission to land.
USAir 1493 for the Left side.
24 Left.
246 heading 270, contact Los Angeles Departure.
Goodnight.
But she's still focused on other planes.
Down to 1,000ft.
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, USAir Flight 1493.
You're cleared to land.
24 Left.
Cleared to land! 24 Left.
(RADIO COMMUNICATION) It looks real good.
Ah.
You're coming out of 500.
What the hell?! The USAir 737 has barely touched down.
It erupts in flames and crashes through Los Angeles International Airport.
(EXPLOSION) I saw USAir touch down and as he got about third-way down the runway, at taxiway 45, the aircraft was fully engulfed in flames.
And the supervisor ran past me to pick up the crash phone and alert the emergency vehicles to respond.
Aboard the flight - sheer terror.
(SCREAMING) There was a tremendous crunching sensation and there was this extraordinary shower of sparks that shot by my window.
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.
"'Cause 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 West 5212.
Wings 240 at 8.
You are cleared to land.
Runway 24 Right.
Use caution.
We just had an aircraft go off the runway in flames.
(SCREAMING) The cabin of Flight 1493 is filling with toxic smoke.
Some passengers rush to a door at the rear of the plane.
DAVID: I've 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 "that allowed for this tremendous quantity of smoke "to roll into the plane so quickly.
" (SCREAMING, PANICKED CRIES) And so, I stumbled forward to the cockpit area and there was tremendous fire on both sides of the plane.
Outside, some have escaped the plane.
Rosa Reynoso is the first emergency responder to arrive at the scene.
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 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 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 realised 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 I 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.
The discovery of a propeller has horrifying implications.
MAN: (ON PHONE) There's two planes down here.
BRANN: 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 radar controller to find out which ones they've talked to in the last five, six minutes.
What about SkyWest 5569? MAN: (OVER RADIO) No.
We haven't heard from them.
SkyWest 569, taxi into position.
Hold.
Runway 24 Left.
MAN: (OVER RADIO) OK.
24 Left.
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 USAir 1493 and an abandoned building near the runway.
My first thought was, "Oh, my God.
There is someone else under there.
"And we didn't even realise it.
" There's even more loss of life on board the larger plane.
20 are dead, 2 others are mortally wounded.
First Officer Kelly has survived but Captain Shaw has not.
The disaster thrusts LAX into the media spotlight.
REPORTER: America's runways, according to the nation's pilots, are 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 1.
5 months.
The accident confirmed safety issues need to be addressed.
The National Transportation Safety Board sends its go team to LAX to investigate.
MAN: 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 appropriate 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.
Some directive has not been followed.
Some inattention is present in the scenario of a runway incursion.
Investigators need to find out why there were two planes on runway 24 Left at the same time.
One of the principle 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 onboard the 737.
Crawling through the wreckage would be dangerous.
The aircraft had about 6,000 pounds, maybe 1,000 gallons of fuel onboard.
How long is this going to take? The Saturday was spent de-fuelling 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.
That's causing chaos for travellers.
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 analyse wreckage at the crash site, others focus on air traffic control.
MAN: 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 audiotapes 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.
But then Bob McIntosh gets some bad news about the SkyWest Metroliner.
No voice recording? Great.
We recognised, 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.
OK, 24 Left, position hold SkyWest 569.
The two cockpit crew members would have exchanged words, would've been listening to the air traffic information that was coming into their cockpit all the time and we recognised 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.
ROBIN WASCHER: (ON TAPE) 246, are you still 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.
23, taxi into position.
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 used the tapes to try to visualise, 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.
MAN: (ON TAPE) OK, 24 Left position and hold, SkyWest 569.
OK.
Stop her right there.
From the air traffic control tapes, the NTSB can tell that the pilots of the Metroliner followed all their instructions correctly.
Investigators probe the tapes further.
They look at Wascher's communications with the USAir pilots.
USAir 1493 for the left side, 24 Left.
USAir 1493, you're cleared to land 24 Left.
A USAir 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.
The air traffic control tapes reveal that Robin Wascher instructed both the SkyWest Metroliner and the USAir flight to use runway 24 Left at the same time.
Left contact ground .
65 when you are.
What the hell?! When we were 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? They look at the other flights that she had under her control.
WASCHER: 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.
MAN: (OVER RADIO) Philippine, 102.
No, sir.
Hold short.
Wings West 5006, taxi across runway 24 Left.
WENTWORTH: Wings West 5006 was an aircraft that was on the north side of runaway 24 Left who wanted to cross to the south side.
Wings West 5006, groundtower.
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 a flight crossing the runway.
MAN: (OVER RADIO) Wings West 5006 on frequency again.
Changed radios.
Sorry about that.
They advised her 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 had created a distraction for the local controller.
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 take-off.
Wings West 5072? With USAir 1493 less than a minute from touchdown, Wascher 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.
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 recognise a flight that was under her control.
I couldn't find the strip so I asked my supervisor to help me.
Francetta .
.
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, USAir 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 USAir 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 happened 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.
WENTWORTH: 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?" 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 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.
MACINTOSH: 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 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.
WENTWORTH: 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? MAN: (OVER RADIO) 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.
BRANN: 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 turned their attention to the cockpit of the USAir 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 recognise 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 wing tips and the tail, navigation lights on the wings and a coloured anti-collision beacon on top of the vertical stabiliser.
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 take-off.
So no other lights were required? OK, thank you.
The Metroliner wasn't yet cleared for take-off so the only lights that would've 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 USAir 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 Metroliner 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 USAir 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 USAir 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 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.
BRANN: 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 organise 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 storeys higher, 3 times larger and offers controllers clear, unobstructed sightlines.
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.
MAN: 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 number of incursions.
10 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.
Runway status lights 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 illuminated 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.
Runway status lights seems to be one of the most effective systems we have for preventing runway incursions and, certainly, the serious runway incursions.
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 Towers 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.
Now I have no problem with getting on airplanes and flying and I've got great confidence in the airline system.
246 heading 270, contact Los Angeles Departure.
Travelling at 240km/h, USAir Flight 1493 descends towards runway 24 Left.
MAN: What the hell?! MAN: 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.
It was 1991.
It was one of the first nights of the first Gulf War.
And I think the thing that was foremost in my 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.
After 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.
USAir Flight 1493 cruises towards Los Angeles International Airport.
LAX is a central hub for international travellers.
Just confirm the visual approach for USAir 1493 is 24 Left.
MAN: (OVER RADIO) That's correct, USAir 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.
MAN: 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.
OK.
I'll expedite through 4,000.
USAir 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 take-offs 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 intersect? Yeah.
We're out at 4,000.
USAir 1493, thanks for your help.
Contact Los Angeles tower 133.
9.
Goodnight.
Goodnight.
- Gear down? - Alright.
- You gave it three belts? - Yes, I did.
Perched 12 storeys above the ground .
.
tower controllers have a hawk's-eye view of traffic coming and going from the airport.
Elliot Brann is the clearance delivery controller.
MAN: The primary duties of the clearance delivery controller is issuing the routes of flights 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 with 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.
USAir 23, taxi into position and hold.
Runway 24 Left.
MAN: (OVER RADIO) Position and hold.
24 Left.
USAir 23.
(RADIO COMMUNICATION) 246, are you still holding short of 47? MAN: (OVER RADIO) 246, affirmative.
Alright, you're next.
SkyWest 569, taxi up and hold short of runway 24 Left.
Roger.
Hold short.
(RADIO COMMUNICATION) USAir Flight 1493 is about 13km from LAX.
The pilots configure their plane for landing.
Speed, brakes.
(SINGS) # Still working for a livin' # (CHUCKLES) Alright.
Flaps are go on one.
Flaps.
Now the pilots radio the LAX tower for landing instructions.
USAir 1493.
Inside roaming.
Wings 5006 ground, er, tower.
Robin Wascher is busy with other planes.
She doesn't respond to their radio call.
SkyWest 569, taxi into position, hold.
Runway 24 Left.
Traffic will cross downfield.
OK, 24 Left.
Position and hold.
SkyWest 569.
Wings West 5006, tower.
(RADIO COMMUNICATION) 30.
Green light.
To 10.
Gear.
Flaps.
Landing clearance remains.
Just 6km from the airport, the USAir jet still doesn't have the OK to land.
Sundance 518, taxi across runway 24 Left.
Contact ground 0.
65 when you're off the runway.
Goodnight.
Captain Shaw contacts the tower for the second time in less than a minute.
He needs Wascher's permission to land.
USAir 1493 for the Left side.
24 Left.
246 heading 270, contact Los Angeles Departure.
Goodnight.
But she's still focused on other planes.
Down to 1,000ft.
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, USAir Flight 1493.
You're cleared to land.
24 Left.
Cleared to land! 24 Left.
(RADIO COMMUNICATION) It looks real good.
Ah.
You're coming out of 500.
What the hell?! The USAir 737 has barely touched down.
It erupts in flames and crashes through Los Angeles International Airport.
(EXPLOSION) I saw USAir touch down and as he got about third-way down the runway, at taxiway 45, the aircraft was fully engulfed in flames.
And the supervisor ran past me to pick up the crash phone and alert the emergency vehicles to respond.
Aboard the flight - sheer terror.
(SCREAMING) There was a tremendous crunching sensation and there was this extraordinary shower of sparks that shot by my window.
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.
"'Cause 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 West 5212.
Wings 240 at 8.
You are cleared to land.
Runway 24 Right.
Use caution.
We just had an aircraft go off the runway in flames.
(SCREAMING) The cabin of Flight 1493 is filling with toxic smoke.
Some passengers rush to a door at the rear of the plane.
DAVID: I've 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 "that allowed for this tremendous quantity of smoke "to roll into the plane so quickly.
" (SCREAMING, PANICKED CRIES) And so, I stumbled forward to the cockpit area and there was tremendous fire on both sides of the plane.
Outside, some have escaped the plane.
Rosa Reynoso is the first emergency responder to arrive at the scene.
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 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 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 realised 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 I 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.
The discovery of a propeller has horrifying implications.
MAN: (ON PHONE) There's two planes down here.
BRANN: 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 radar controller to find out which ones they've talked to in the last five, six minutes.
What about SkyWest 5569? MAN: (OVER RADIO) No.
We haven't heard from them.
SkyWest 569, taxi into position.
Hold.
Runway 24 Left.
MAN: (OVER RADIO) OK.
24 Left.
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 USAir 1493 and an abandoned building near the runway.
My first thought was, "Oh, my God.
There is someone else under there.
"And we didn't even realise it.
" There's even more loss of life on board the larger plane.
20 are dead, 2 others are mortally wounded.
First Officer Kelly has survived but Captain Shaw has not.
The disaster thrusts LAX into the media spotlight.
REPORTER: America's runways, according to the nation's pilots, are 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 1.
5 months.
The accident confirmed safety issues need to be addressed.
The National Transportation Safety Board sends its go team to LAX to investigate.
MAN: 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 appropriate 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.
Some directive has not been followed.
Some inattention is present in the scenario of a runway incursion.
Investigators need to find out why there were two planes on runway 24 Left at the same time.
One of the principle 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 onboard the 737.
Crawling through the wreckage would be dangerous.
The aircraft had about 6,000 pounds, maybe 1,000 gallons of fuel onboard.
How long is this going to take? The Saturday was spent de-fuelling 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.
That's causing chaos for travellers.
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 analyse wreckage at the crash site, others focus on air traffic control.
MAN: 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 audiotapes 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.
But then Bob McIntosh gets some bad news about the SkyWest Metroliner.
No voice recording? Great.
We recognised, 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.
OK, 24 Left, position hold SkyWest 569.
The two cockpit crew members would have exchanged words, would've been listening to the air traffic information that was coming into their cockpit all the time and we recognised 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.
ROBIN WASCHER: (ON TAPE) 246, are you still 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.
23, taxi into position.
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 used the tapes to try to visualise, 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.
MAN: (ON TAPE) OK, 24 Left position and hold, SkyWest 569.
OK.
Stop her right there.
From the air traffic control tapes, the NTSB can tell that the pilots of the Metroliner followed all their instructions correctly.
Investigators probe the tapes further.
They look at Wascher's communications with the USAir pilots.
USAir 1493 for the left side, 24 Left.
USAir 1493, you're cleared to land 24 Left.
A USAir 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.
The air traffic control tapes reveal that Robin Wascher instructed both the SkyWest Metroliner and the USAir flight to use runway 24 Left at the same time.
Left contact ground .
65 when you are.
What the hell?! When we were 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? They look at the other flights that she had under her control.
WASCHER: 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.
MAN: (OVER RADIO) Philippine, 102.
No, sir.
Hold short.
Wings West 5006, taxi across runway 24 Left.
WENTWORTH: Wings West 5006 was an aircraft that was on the north side of runaway 24 Left who wanted to cross to the south side.
Wings West 5006, groundtower.
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 a flight crossing the runway.
MAN: (OVER RADIO) Wings West 5006 on frequency again.
Changed radios.
Sorry about that.
They advised her 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 had created a distraction for the local controller.
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 take-off.
Wings West 5072? With USAir 1493 less than a minute from touchdown, Wascher 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.
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 recognise a flight that was under her control.
I couldn't find the strip so I asked my supervisor to help me.
Francetta .
.
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, USAir 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 USAir 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 happened 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.
WENTWORTH: 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?" 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 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.
MACINTOSH: 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 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.
WENTWORTH: 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? MAN: (OVER RADIO) 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.
BRANN: 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 turned their attention to the cockpit of the USAir 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 recognise 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 wing tips and the tail, navigation lights on the wings and a coloured anti-collision beacon on top of the vertical stabiliser.
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 take-off.
So no other lights were required? OK, thank you.
The Metroliner wasn't yet cleared for take-off so the only lights that would've 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 USAir 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 Metroliner 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 USAir 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 USAir 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 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.
BRANN: 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 organise 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 storeys higher, 3 times larger and offers controllers clear, unobstructed sightlines.
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.
MAN: 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 number of incursions.
10 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.
Runway status lights 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 illuminated 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.
Runway status lights seems to be one of the most effective systems we have for preventing runway incursions and, certainly, the serious runway incursions.
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 Towers 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.
Now I have no problem with getting on airplanes and flying and I've got great confidence in the airline system.