This is what the investigation found out (from the Asterisk article):
LAX was equipped with ground radar that helped identify the locations of airplanes on the airport surface. However, it was custom built and finding spare parts was hard, so it was frequently out of service. The ground radar display at Wascher’s station was not working on the day of the accident.
It was difficult for Wascher to see Intersection 45, where the SkyWest plane was located, because lights on a newly constructed terminal blocked her view.
After clearing the USAir plane to land, Wascher failed to recognize her mistake because she became distracted searching for information about another plane. This information was supposed to have been passed to her by another controller but was not. The information transmission hierarchy at the facility was such that the task of resolving missing data fell to Wascher rather than intermediate controllers whose areas of responsibility were less safety-critical.
Although it’s inherently risky to instruct a plane to hold on the runway at night or in low visibility, it was legal to do so, and this was done all the time.
Although there was an alarm system to warn of impending midair collisions, it could not warn controllers about traffic conflicts on the ground.
Pilot procedure at SkyWest was to turn on most of the airplane’s lights only after receiving takeoff clearance. Since SkyWest flight 5569 was never cleared for takeoff, most of its lights were off, rendering it almost impossible for the USAir pilots to see.
Thank you for the details! I change my mind about the locus of responsibility, and don’t think Wascher seems as directly culpable as before. I don’t update my heuristic, I still think there should be legal consequences for decisions that cause human deaths,
My new guess is that something more like “the airport” should be held accountable and fined some substantial amount of money for the deaths, to go to the victim’s families.
Having looked into it a little more I see they were sued substantially for these, so it sounds like that broadly happened.
This is what the investigation found out (from the Asterisk article):
LAX was equipped with ground radar that helped identify the locations of airplanes on the airport surface. However, it was custom built and finding spare parts was hard, so it was frequently out of service. The ground radar display at Wascher’s station was not working on the day of the accident.
It was difficult for Wascher to see Intersection 45, where the SkyWest plane was located, because lights on a newly constructed terminal blocked her view.
After clearing the USAir plane to land, Wascher failed to recognize her mistake because she became distracted searching for information about another plane. This information was supposed to have been passed to her by another controller but was not. The information transmission hierarchy at the facility was such that the task of resolving missing data fell to Wascher rather than intermediate controllers whose areas of responsibility were less safety-critical.
Although it’s inherently risky to instruct a plane to hold on the runway at night or in low visibility, it was legal to do so, and this was done all the time.
Although there was an alarm system to warn of impending midair collisions, it could not warn controllers about traffic conflicts on the ground.
Pilot procedure at SkyWest was to turn on most of the airplane’s lights only after receiving takeoff clearance. Since SkyWest flight 5569 was never cleared for takeoff, most of its lights were off, rendering it almost impossible for the USAir pilots to see.
Does that make you update your heuristic?
Thank you for the details! I change my mind about the locus of responsibility, and don’t think Wascher seems as directly culpable as before. I don’t update my heuristic, I still think there should be legal consequences for decisions that cause human deaths,
My new guess is that something more like “the airport” should be held accountable and fined some substantial amount of money for the deaths, to go to the victim’s families.
Having looked into it a little more I see they were sued substantially for these, so it sounds like that broadly happened.