It was just 
                                      after 6:00pm on the evening of February 
                                      2nd, 1991 and USAir flight 1493 was 
                                      preparing to land at Los Angeles 
                                      International. Six crew members and 83 
                                      passengers were aboard the 737 during its 
                                      three hour flight from Columbus, Ohio. On 
                                      the ground, Skywest's flight 5569 was 
                                      preparing for takeoff. The Metroliner 
                                      carrying 10 passengers and two crew was 
                                      bound for Palmdale, one of the many rush 
                                      hour commuter flights out of the LA area.
                                      
                                      USAir 1493 cleared for 
                                      the ILS 24L approach as Skywest 5569 was 
                                      taxing away from the gate towards runway 
                                      24L. Due to traffic, Skywest 5569 was 
                                      cleared to taxi to 24L and enter at the 
                                      intersection of taxiway 45, some 2,200ft 
                                      from the runway threshold. As the Skywest 
                                      Metro awaited it takeoff clearance, USAir 
                                      1493 touched down near the threshold of 
                                      runway 24L and shortly thereafter slammed 
                                      into 5569. Both aircraft skidded down the 
                                      runway, the Metro crushed beneath the 
                                      737's fuselage. The wreckage came to rest 
                                      on the far side of the taxiway against an 
                                      empty building. All 12 in the Skywest 
                                      aircraft were killed as were 21 people in 
                                      the USAir 737, including the captain.
                                      
                                      ......Clearly both aircraft believed they 
                                      had sole use of the runway at the time of 
                                      the crash. In order to determine the the 
                                      origin of the confusion, a careful 
                                      analysis of radio transcripts and ATC 
                                      procedures at Los Angeles International 
                                      was begun. After receiving clearance from 
                                      Clearance Delivery, the flight strips go 
                                      directly to the local controller LC), 
                                      bypassing the ground controller (GC). 
                                      While this lessened the GC's workload by 
                                      not having to mark the flight strips, it 
                                      actually increased the LC's workload by 
                                      denying them information regarding the 
                                      aircraft's position on the field. Aircraft 
                                      were allowed to request intersection 
                                      departures directly from the GCs. Because 
                                      Skywest 5569 was taxing from the south 
                                      side of the airport, it had been in 
                                      contact with both GC1 and GC2 on its way 
                                      to runway 24L and had been cleared to hold 
                                      short at taxiway 45 before contacting LC2.
                                      
                                      
                                      It's initial call to LC2, it reported "at 
                                      [taxiway] 45 we'd like to go from here if 
                                      we can." After the accident, LC2 reported 
                                      that she had not heard the "at [taxiway] 
                                      45" part of the transmission. Because the 
                                      flight strips bypassed the GCs, there was 
                                      no indication for LC2 as to the aircraft's 
                                      position. LC2 then cleared 5569 to taxi up 
                                      to and hold short of runway 24L which was 
                                      acknowledged. During this time, another 
                                      flight, Wings West 5006, had just landed 
                                      and was attempting to clear the runway. 
                                      The crew had inadvertently changed 
                                      frequencies and was out of contact with 
                                      LC2. Skywest 5569 was cleared into 
                                      position and hold on runway 24L. 
                                      Communications with 
                                      Wings West 5006 was re-established just 
                                      after this instruction and several seconds 
                                      were spent with unnecessary transmissions 
                                      regarding the loss of communication. 
                                      Southwest 725 was also preparing for 
                                      takeoff at the time and LC2 also cleared 
                                      it to taxi up to and hold short of runway 
                                      24L. Just after this, USAir 1493 called 
                                      for the left side. LC2 confirmed that 
                                      Southwest 725 was holding short and then 
                                      cleared 1493 to land. Shortly thereafter, 
                                      Wings West 5072 called ready for 
                                      departure. There was no flight strip in 
                                      front of LC2 for 5072, so she and several 
                                      others began a search for it. It was found 
                                      still at the Clearance Delivery station, 
                                      believed to still be waiting for initial 
                                      contact. Just after the strip was found, 
                                      LC2 saw 1493 touchdown and cleared 725 to 
                                      taxi into position and hold. Just seconds 
                                      after this transmission, 1493 collided 
                                      with 5569 still sitting in position and 
                                      hold at intersection 45 on 24L.
                                      
                                      ......The First Officer of 1493 reported 
                                      that the touchdown was normal. As the nose 
                                      was being lowered, he reported that the 
                                      landing lights began to reflect on 5569's 
                                      propellers and its rear position light 
                                      became visible. Maximum braking was 
                                      applied, but there was insufficient space 
                                      and time to avoid the collision. He did 
                                      not report hearing that another aircraft 
                                      had been placed in position and hold even 
                                      though 1493 had come on to LC2's frequency 
                                      prior to the instructions. LC2 was clearly 
                                      distracted by several events in the few 
                                      short minutes prior to the accident. 
                                      Allowing 5569 to make an intersection 
                                      departure was acceptable and she cleared 
                                      the flight into position and hold prior to 
                                      giving 1493 landing clearance. 
                                      
                                      Initial confusion with 5006 caused her to 
                                      lose awareness of 5569's position. The 
                                      further confusion regarding the flight 
                                      strip of 5072 caused her again to avert 
                                      her attention from the situation on the 
                                      active runways. She later said she had 
                                      believed 5072 taxiing in front of the 
                                      tower to runway 24L was actually 5569 and 
                                      formed a mental picture that all was 
                                      correct. The NTSB cited many factors as 
                                      contributing to the cause of the accident. 
                                      Primary was ATC procedures at LAX. The FAA 
                                      later required LAX to revise its flight 
                                      strip handling to relieve the LCs from 
                                      carrying the full responsibility of flight 
                                      strip marking and handling and allowing 
                                      better awareness during high workloads. 
                                      LC2 was also cited for becoming distracted 
                                      and allowing a breakdown in awareness 
                                      during the incident period. 
                                      The NTSB also cited 
                                      lighting placement on the Metro, showing 
                                      that its light blended with and were not 
                                      conspicuous against the runway environment 
                                      background during low light periods. 
                                      Although both flight crews were operating 
                                      within their ATC clearances, they were 
                                      both still responsible for "see and avoid" 
                                      operations since conditions were VFR.
                                      
                                      ......On a personal note, I was acquainted 
                                      with one of the individuals on board 
                                      Skywest 5569. This and the fact that I am 
                                      from the LA area and have been in and out 
                                      of the airport many times brought this 
                                      accident to the forefront of my attention. 
                                      I have been given "position and hold" 
                                      clearances on several occasions with 
                                      another aircraft on approach. I used to 
                                      accept them and sit with my back to the 
                                      other aircraft, hoping that I would be 
                                      cleared for takeoff before the other 
                                      aircraft made it to the runway. 
                                      After researching this 
                                      accident further, I no longer accept them 
                                      unless I hear a clearly understood 
                                      transmission from both the tower and the 
                                      other aircraft. Due to the high volume of 
                                      training at my local airport, the tower 
                                      will always advise traffic on final of any 
                                      attempts to release another aircraft prior 
                                      to its arrival. It will also advise the 
                                      traffic on the ground of the approaching 
                                      aircraft's position in relation to 
                                      touchdown. Remember, as PIC, you are 
                                      responsible for your aircraft's safety and 
                                      you do not have to accept an instruction 
                                      you do not feel comfortable with. Be 
                                      pro-active in both your flight and ground 
                                      operations and don't assume that everyone 
                                      else knows of your position.