Cerritos Crash Tied to Traffic Control System
The failure of the nation’s air traffic control system to adequately protect aircraft was the chief cause of the collision between an Aeromexico jet and a private plane over Cerritos last August, the National Transportation Safety Board ruled Tuesday.
The board concluded that the smaller plane’s unauthorized intrusion into the restricted airspace surrounding Los Angeles International Airport and the “limitations” of the time-honored “see-and-avoid” concept, under which pilots are presumed capable of spotting other aircraft in time to take evasive action, were contributing factors.
The final report on the crash, which killed 82 people, cited “systemic problems” and “does not point the finger at individuals,” board chairman Jim Burnett said.
Separate Statement
However, Burnett said he will issue a separate statement declaring that he believes the pilot of the private plane should share some blame because he should have had time to see the DC-9 passenger jet and avoid the collision.
The report, adopted on a 5-0 vote after an 11-month investigation, charged that the collision demonstrated that the Federal Aviation Administration relies too heavily on procedures that are increasingly inadequate in the crowded skies around airports.
The board said the air traffic control system puts too much emphasis on the “see-and-avoid” approach, and noted that the FAA does not require air traffic controllers to advise aircraft that they are guiding about the presence of nearby unsupervised aircraft operating under visual flight rules. The Aeromexico jet received no warning from controllers about the smaller plane.
“At some point you have to stop patching the system and address its basic design,” Burnett said. “You’re going to have to consider systemic problems and not point fingers at individuals.”
The board urged strengthening of air traffic control procedures to require controllers to issue more warnings about nearby small planes and urged that airliners be equipped with electronic anti-collision devices to provide timely warnings of danger.
In addition, the board recommended that the FAA expand tracking and enforcement actions against pilots who intrude into restricted airspace and require small planes operating around some airports to carry sophisticated altitude-reporting equipment.
The FAA declined immediate comment on the board’s findings and recommendations.
The NTSB’s findings were immediately applauded by Aeromexico. Los Angeles attorney Frank Silane, representing the airline, said the ruling “confirms the fact that the flight crew and the airline have done nothing wrong and are fully vindicated.”
Aeromexico Flight 498 en route from Tijuana was preparing for its final approach to LAX when it collided with a Piper Cherokee Archer II, which had taken off from Torrance Airport on a flight to Big Bear Lake.
The two planes slammed together at an altitude of about 6,500 feet, virtually head-on at 11:52 a.m. The nose wheel of the Piper struck the vertical stabilizer at the tail of the big jet, and the DC-9’s tail sheared off the top of the smaller plane.
NTSB investigators concluded that the pilot of the smaller plane, William K. Kramer, 53, of Rancho Palos Verdes, probably had about an even chance of seeing the jetliner in time to take effective evasive action. They said it was unlikely the Aeroexico crew could have seen the smaller plane until a few seconds before the collision.
Both planes plummeted earthward. The jetliner plunged in an inverted attitude and crashed into a residential neighborhood in Cerritos, igniting a pyre that claimed most of the 15 victims on the ground. The smaller plane fluttered to the ground about two blocks away.
The board said it was unable to determine the answer to one key question: why Kramer flew into the restricted airspace without permission.
Kramer, an executive at a Torrance-based metals company, was described by the board staff as a “a very cautious, concerned general aviation pilot” who, while he had little experience flying in the Los Angeles area, had consulted other pilots about airspace restrictions, had taken a familiarization flight and had bought a chart showing the restricted area.
While an autopsy indicated that Kramer suffered from heart disease, Burnett said there was no evidence he had suffered a heart attack before the collision.
While the four-member board majority laid the primary blame on the air traffic control system, no blame was found for Walter R. White, 35, the air controller who was directing the Aeromexico flight’s approach to LAX.
Taped data showed that radar at the control facility was tracking the path of Kramer’s plane, but White has maintained that he never saw the small plane on his radarscope.
Investigators said that even though air traffic was light at the time, White, a six-year FAA veteran with a good work record, might not have noticed the Piper on his radar screen because he had to deal unexpectedly with a second private plane that had strayed into the restricted airspace.
The controller “reoriented his priorities” to deal with the other small plane, said David R. Kelley, chief of the board’s operational factors division.
The board staff said it was possible that White may not have noticed the Piper because the radar signal from the plane could have been very dim on his screen.
Witnesses at the NTSB hearings on the crash last December contended that not all radar data is displayed properly on the screen, saying the problem is “inherent in the system.”
However, Dick Morrison, a special projects officer for the FAA’s Western Region, told reporters two months later that the failure to see planes properly on the radar screen is probably due more to procedures that controllers follow than to some problem with the equipment.
NTSB board member John K. Lauber called White “one of the most tragic characters” in the accident and said he was a “conscientious performer” who was carrying out his primary responsibility to separate aircraft under air traffic control that were authorized to be in the controlled airspace.
“The controller was clearly acting in accordance with existing directives,” Lauber said. When they follow those directives, Lauber said, controllers are “doing . . . what they have been conditioned to do for so long . . . not make the primary concern the total protection of the participating aircraft from all other aircraft in the system,” Lauber said.
“We have got to change the state of priorities,” he said, “If we don’t, we will continue to have these accidents.”
White declined to comment on Tuesday’s findings by the NTSB, saying that he is worried about potential lawsuits and concerned that any comments might be improperly interpreted.
About 30 suits filed as a result of the disaster have been consolidated in federal court in Los Angeles. The first hearing on the case is scheduled for July 15.
Meanwhile, 15 of the 17 homes destroyed or damaged in the crash have been restored.
But Barry A. Rabbitt, a member of the Cerritos City Council, said Tuesday that every time he drives by the neighborhood destroyed by the crash he is “reminded of what happened there, the loss of life and property.”
Penny Pagano reported from Washington. Eric Malnic reported from Los Angeles.
