Safety Board Blames FAA for LAX Collision


Last February’s disastrous runway collision at Los Angeles International Airport was caused by the Federal Aviation Administration’s failure to run the airfield control tower properly, according to the official government report released on Wednesday.

Rather than place primary responsibility for the crash on Robin Lee Wascher, the controller whose error led to the accident, the National Transportation Safety Board instead blamed FAA management at the LAX tower and FAA officials who oversee that management. Wascher’s error, the board said, resulted from a poor work environment created by FAA mismanagement.

The board’s report came as something of a surprise, because attention had focused on Wascher since she admitted that she became confused in the dark of nightfall and mistakenly cleared a USAir jetliner to land on a runway where she had already positioned a SkyWest commuter plane for takeoff.


The Boeing 737 jetliner struck the smaller commuter plane and both aircraft exploded in a ball of fire on Feb. 1, killing 22 on the jet and all 12 aboard the smaller plane.

The safety board released only a 12-page summary of its final, official report on Wednesday, and details were relatively few. But Ted Lopatkewicz, a spokesman for the board, said the problems outlined in the report are the same ones discussed during last April’s hearing on the crash. These include:

* The failure of the tower management to move swiftly to provide authorized assistants who could have helped controllers such as Wascher keep track of the planes they are handling.

* The failure of management to promptly correct glare problems that made it difficult for controllers to see planes in some areas of the airport.

* Management’s failure to provide controllers handling planes on the ground with paper slips containing basic information about individual aircraft under their control. Investigators say the slips might help ground controllers account for the planes and minimize confusion when aircraft are handed off to flight controllers such as Wascher.

* The failure of FAA officials in Washington to provide a properly functioning radar system that would help controllers keep track of the planes on the ground.


* Inadequate review of LAX tower operations by national and regional FAA officials and the failure to take prompt corrective action when needed.

FAA Administrator James P. Busey in Washington and FAA officials in Los Angeles declined comment on the FAA report.

Wascher--who previously accept blame for the crash and is working at a desk job at the FAA’s regional headquarters in Hawthorne--said Wednesday that she did not want to talk to the news media.

But Jim Morin, general counsel for the National Air Traffic Controllers Assn. in Washington, said, “We’re talking about poor FAA management in general.

“Wascher was, in fact, a victim of the system,” he said. “It could have happened to virtually any air traffic controller working in Los Angeles.”

The report said the accident occurred after FAA management failed to provide adequate supervision, “policy direction and oversight. . . .


“This created an environment in the LAX tower that ultimately led to the failure of (Wascher) to maintain an awareness of the traffic situation, culminating in the inappropriate clearances and subsequent collision of the USAir and SkyWest aircraft,” the report said. “Contributing to the . . . accident was the failure of the FAA to provide effective quality assurance of the air traffic control system.”

Karl Grundman, a Los Angeles-area controller who serves as the regional representative to the controllers’ organization here, said: “Obviously, the FAA officials are going to have to look at their management at the Los Angeles tower. If they find they need to change some of the management personnel here, then they should do it.”

FAA officials in Los Angeles said they already have taken steps to rectify some of the problems identified by the safety board.

Officials said the assistant controller positions are being filled gradually. Tower Manager Leonard Mobley said the positions, although authorized by the FAA in 1988, had not been filled earlier because some controllers resisted having assistants looking over their shoulders.

Richard Lein, the FAA’s regional air traffic chief in Los Angeles, said the glare problems have been solved by redesigning and moving some light fixtures surrounding some of the terminal buildings.

He said the strip-handling process at the LAX tower is being reviewed in the aftermath of the accident. (Although flight data strips pass from controller to controller with the movement of the aircraft at most airports, the strips hopscotch over ground controllers at LAX. Lein said this is because ground controllers are too busy to handle the strips.)


Wascher testified during the safety board hearings on the crash that the 20-year-old ground radar system used to track planes on the ground is frequently inoperable and was not working at the time of the crash. Jim Lougheed, a local FAA equipment manager, said the agency has finally resolved most of the problems with a new replacement system, but testing is not complete.

The final report also recommended that the FAA:

* Review air traffic control procedures at LAX.

* Check the lighting at all tower-controlled airports in the United States to reduce glare.

* Assure that anti-collision lights on all aircraft are visible to the other aircraft. (David Kelly, the surviving co-pilot of the USAir jet, said he never saw the commuter plane on the runway below him as he came in for a landing.)

* Make sure all pilots are trained to listen for radio broadcasts that might suggest other aircraft could pose a hazard. (Seconds before the LAX collision, Wascher was talking to both planes on the same frequency, but Kelly said he did not hear her direct the SkyWest turboprop onto the runway ahead of him.)

* Review policies to make sure that flight attendants direct passengers to the nearest emergency exits. (One flight attendant said that another stewardess died when she attempted to reach a pre-assigned exit, instead of the nearest one.)

* Alert pilots to the hazards of misusing prescription and over-the-counter drugs. (Tests showed that Colin F. Shaw, the USAir pilot who died in the crash, had traces of phenobarbital, a barbiturate, in his system. The safety board said there was not enough of the drug to impair his ability to fly.) While declining comment on the NTSB’s causal findings, the FAA did respond to the recommendations, saying it had taken them under “immediate review.


“Each of the recommendations will be given expedited consideration, and, where applicable, will be implemented as soon as possible,” the FAA said.

The FAA said it is already conducting research at New York’s John F. Kennedy Airport on use of traffic “stop lights” to control the flow of taxiing aircraft.