Boeing 737-300 and Fairchild SA-227-AC accident near Los Angeles, California, February 2, 1991
On February 2, 1991 at about 2:07 am local time, 2 aircraft, Boeing 737-300 (N388US) and Fairchild SA-227-AC (N683AV), were involved in the same accident near Los Angeles, California (Los Angeles International airport). 34 people were killed, 13 people were seriously injured and 17 people had minor injuries; 37 others were unhurt. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
THE FAILURE OF THE LOS ANGELES AIR TRAFFIC FACILITY MANAGEMENT TO IMPLEMENT PROCEDURES THAT PROVIDED REDUNDANCY COMPARABLE TO THE REQUIREMENTS CONTAINED IN THE NATIONAL OPERATIONAL POSITION STANDARDS AND THE FAILURE OF THE FAA AIR TRAFFIC SERVICE TO PROVIDE ADEQUATE POLICY DIRECTION AND OVERSIGHT TO ITS AIR TRAFFIC CONTROL FACILITY MANAGERS. THESE FAILURES CREATED AN ENVIRONMENT IN THE LOS ANGELES AIR TRAFFIC CONTROL TOWER THAT ULTIMATELY LED TO THE FAILURE OF THE LOCAL CONTROLLER 2 (LC2) TO MAINTAIN AN AWARENESS OF THE TRAFFIC SITUATION, CULMINATING IN THE INAPPROPRIATE CLEARANCES AND THE SUBSEQUENT COLLISION OF THE USAIR AND SKYWEST AIRCRAFT. CONTRIBUTING TO THE CAUSE OF THE ACCIDENT WAS THE FAILURE OF THE FAA TO PROVIDE EFFECTIVE QUALITY ASSURANCE OF THE ATC SYSTEM. (NTSB REPORT AAR-91/08)
THE FAILURE OF THE LOS ANGELES AIR TRAFFIC FACILITY MANAGEMENT TO IMPLEMENT PROCEDURES THAT PROVIDED REDUNDANCY COMPARABLE TO THE REQUIREMENTS CONTAINED IN THE NATIONAL OPERATIONAL POSITION STANDARDS AND THE FAILURE OF THE FAA AIR TRAFFIC SERVICE TO PROVIDE ADEQUATE POLICY DIRECTION AND OVERSIGHT TO ITS AIR TRAFFIC CONTROL FACILITY MANAGERS. THESE FAILURES CREATED AN ENVIRONMENT IN THE LOS ANGELES AIR TRAFFIC CONTROL TOWER THAT ULTIMATELY LED TO THE FAILURE OF THE LOCAL CONTROLLER 2 (LC2) TO MAINTAIN AN AWARENESS OF THE TRAFFIC SITUATION, CULMINATING IN THE INAPPROPRIATE CLEARANCES AND THE SUBSEQUENT COLLISION OF THE USAIR AND SKYWEST AIRCRAFT. CONTRIBUTING TO THE CAUSE OF THE ACCIDENT WAS THE FAILURE OF THE FAA TO PROVIDE EFFECTIVE QUALITY ASSURANCE OF THE ATC SYSTEM. (NTSB REPORT AAR-91/08)
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- February 2, 1991 · about 2:07 am local time
- Place
- Los Angeles, California · Los Angeles International
- Type
- Accident · collision on the ground
- Injuries
- 34 people were killed, 13 people were seriously injured and 17 people had minor injuries; 37 others were unhurt.
- Weather
- visual conditions (good weather)
- Aircraft 1
- Boeing 737-300 · all 737-300s on the register
- Registration
- N388US · no longer on the register
- Damage
- Destroyed
- Flight
- Flight of an unrecorded kind · scheduled airline rules (Part 121)
- Aircraft 2
- Fairchild SA-227-AC · all SA-227-ACs on the register
- Registration
- N683AV · no longer on the register
- Damage
- Destroyed
- Flight
- Flight of an unrecorded kind · charter and air-taxi rules (Part 135)
The NTSB's narrative for the Boeing 737-300 final · quoted from the NTSB record
SKW5569, N683AV, HAD BEEN CLEARED TO RWY 24L, AT INTERSECTION 45, TO POSITION AND HOLD. THE LOCAL CONTROLLER, BECAUSE OF HER PREOCCUPATION WITH ANOTHER AIRPLANE, FORGOT SHE HAD PLACED SKW5569 ON THE RUNWAY AND SUBSEQUENTLY CLEARED USA1493, N388US, FOR LANDING. AFTER THE COLLISION, THE TWO AIRPLANES SLID OFF THE RUNWAY INTO AN UNOCCUPIED FIRE STATION. THE TOWER OPERATING PROCEDURES DID NOT REQUIRE FLIGHT PROGRESS STRIPS TO BE PROCESSED THROUGH THE LOCAL GROUND CONTROL POSITION. BECAUSE THIS STRIP WAS NOT PRESENT, THE LOCAL CONTROLLER MISIDENTIFIED AN AIRPLANE AND ISSUED A LANDING CLEARANCE. THE TECHNICAL APPRAISAL PROGRAM FOR AIR TRAFFIC CONTROLLERS IS NOT BEING FULLY UTILIZED BECAUSE OF A LACK OF UNDERSTANDING BY SUPERVISORS AND THE UNAVAILABILITY OF APPRAISAL HISTORIES.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The NTSB's narrative for the Fairchild SA-227-AC final · quoted from the NTSB record
SKW5569, N683AV, HAD BEEN CLEARED TO RWY 24L, AT INTERSECTION 45, TO POSITION AND HOLD. THE LOCAL CONTROLLER, BECAUSE OF HER PREOCCUPATION WITH ANOTHER AIRPLANE, FORGOT SHE HAD PLACED SKW5569 ON THE RUNWAY AND SUBSEQUENTLY CLEARED USA1493, N388US, FOR LANDING. AFTER THE COLLISION, THE TWO AIRPLANES SLID OFF THE RUNWAY INTO AN UNOCCUPIED FIRE STATION. THE TOWER OPERATING PROCEDURES DID NOT REQUIRE FLIGHT PROGRESS STRIPS TO BE PROCESSED THROUGH THE LOCAL GROUND CONTROL POSITION. BECAUSE THIS STRIP WAS NOT PRESENT, THE LOCAL CONTROLLER MISIDENTIFIED AN AIRPLANE AND ISSUED A LANDING CLEARANCE. THE TECHNICAL APPRAISAL PROGRAM FOR AIR TRAFFIC CONTROLLERS IS NOT BEING FULLY UTILIZED BECAUSE OF A LACK OF UNDERSTANDING BY SUPERVISORS AND THE UNAVAILABILITY OF APPRAISAL HISTORIES.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record for the Boeing 737-300 from the NTSB's investigation tables, in plain English
Pilot
- Certificate: airline transport pilot
- Ratings: multi-engine land; instrument: airplane
- Flight time: 16,300 hours in all; 4,300 in this make and model; 43 in the last 30 days
- Medical certificate: Class 1 (valid medical--w/ waivers/lim.)
- Seat: left
The aircraft
- Last inspection: continuous airworthiness programme, January 2, 2000
- Maximum gross weight: 125,000 lb
- Seats: 128
- Landing gear: retractable
- Engine: Ge CFM56-3-B1 (turbofan); 0 hours total
- Fire on the ground
The flight
- Departed from: CMH Columbus OH at 9:17 pm
- Flight plan: IFR
- Runway 24L, 10,285 ft by 150 ft
- A second pilot was aboard
Weather at the time
- Light: dusk
- Wind: from 260° at 6 knots
- Visibility: 15 statute miles
- Sky: scat at 30,000 ft
- Temperature: 57°F (14°C), dew point 43°F (6°C)
- Altimeter: 30.00 inHg
- Observation at 1:51 am from LAX, 1 miles away
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Crew | 2 | 2 | 2 | |
| Passengers | 20 | 11 | 15 | 37 |
The factual record for the Fairchild SA-227-AC from the NTSB's investigation tables, in plain English
Pilot
- Certificate: airline transport pilot
- Ratings: multi-engine land; instrument: airplane
- Flight time: 8,808 hours in all; 2,107 in this make and model
- Medical certificate: Class 1 (valid medical--no waivers/lim.)
- Seat: left
The aircraft
- Last inspection: inspection type not recorded, January 2, 2000
- Maximum gross weight: 14,500 lb
- Seats: 19
- Landing gear: retractable
- Engine: Garrett TPE-331 (turboprop); 0 hours total
- Fire on the ground
- Operator: Skywest Airlines, INC.
The flight
- Destination: PMD Palmdale CA
- Flight plan: IFR
- Runway 24L, 10,285 ft by 150 ft
- A second pilot was aboard
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Crew | 2 | |||
| Passengers | 10 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.