NTSB Probable Cause

(1) FAILURE OF THE FEDERAL AVIATION ADMINISTRATION TO PROVIDE AIR TRAFFIC CONTROL PROCEDURES THAT ADEQUATELY TAKE INTO CONSIDERATION HUMAN PERFORMANCE FACTORS SUCH AS THOSE WHICH RESULTED IN THE FAILURE OF THE NORTH LOCAL CONTROLLER TO DETECT THE DEVELOPING CONFLICT BETWEEN N44UE AND EA 111, AND (2) THE FAILURE OF THE NORTH LOCAL CONTROLLER TO ENSURE THE SEPARATION OF ARRIVING AIRCRAFT WHICH WERE USING THE SAME RUNWAY. CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF THE NORTH LOCAL CONTROLLER TO FOLLOW THE PRESCRIBED PROCEDURE OF ISSUING APPROPRIATE TRAFFIC INFORMATION TO EA 111, AND FAILURE OF THE NORTH FINAL CONTROLLER AND THE RADAR MONITOR CONTROLLER TO ISSUE TIMELY SPEED REDUCTIONS TO MAINTAIN ADEQUATE SEPARATION BETWEEN AIRCRAFT ON FINAL APPROACH.