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August 11, 2023 · Boeing 737-7BD · N7734H

San Diego, CA

Overview

Report Status
Probable Cause
Event Type
Incident
Date
August 11, 2023
Location
San Diego, CA
Aircraft
Boeing 737-7BD (2006)
Tail Number
N7734H
Operator
Southwest Airlines
NTSB Number
OPS23FA010

Southwest Airlines flight 2493 (SWA2493) and a Textron Aviation, Inc. 560XL (N564HV) were involved in a runway incursion with overflight that resulted in a loss of separation at San Diego International Airport (SAN). SAN was equipped with the Airport Surface Detection Equipment Model-X (ASDE-X) surface radar system. The system was operational and functioned as designed. It produced both aural and visual alerts that indicated that there was an aircraft [N564HV] landing with another aircraft [SWA2493] still in position on the same runway. The local control (LC) controller immediately reacted to the ASDE-X alerts, and issued instructions to resolve the conflict, but not before standard separation had been lost. The SAN Airport Traffic Control Tower (SAN ATCT) facility was equipped with two flight strip printers, one functioned as a primary device, and the second as a backup in case the first unit failed. In post incident interviews, the SAN ATCT personnel stated that they received no training on the use or troubleshooting of these printers. Prior to the incident, the primary printer jammed. During the post-incident interview with the operations supervisor (OS), they stated that they chose to troubleshoot the primary printer rather than switching to the backup, and that this drew their attention away from the operation at the time of the incident. FAA Order JO 7110.65BB, Air Traffic Control, 2-10-3, Tower Team Position Responsibilities, states in part: Tower Team Concept and Intent: There are no absolute divisions of responsibilities regarding position operations. The tasks to be completed remain the same whether one, two, or three people are working positions within a facility/sector. The team, as a whole, has responsibility for the safe and efficient operation of that facility/sector. The LC controller noticed a flight strip at their workstation that indicated an initial altitude for an uninvolved departing aircraft that was not in accordance with facility directives and contacted Southern California Terminal Radar Approach Control (SCT TRACON) to coordinate an appropriate altitude. This diverted their attention from N564HV and SWA2493 momentarily. During the post-incident interview conducted with the LC controller, they stated that they had used poor judgment in prioritizing their duties. This duty prioritization was not consistent with guidance contained in FAA Order JO 7110.65BB, Air Traffic Control, 2-1-1, ATC Service.

NTSB Probable Cause

The local control controller’s poor judgment in duty prioritization which distracted them from monitoring arriving and departing traffic and resulted in a runway incursion and loss of same runway separation. Contributing was the operations supervisor’s decision to troubleshoot a faulty flight strip printer instead of maintaining direct supervision of the operation.

Full Narrative

Southwest Airlines flight 2493 (SWA2493) and a Textron Aviation, Inc. 560XL (N564HV) were involved in a runway incursion with overflight that resulted in a loss of separation at San Diego International Airport (SAN). SAN was equipped with the Airport Surface Detection Equipment Model-X (ASDE-X) surface radar system. The system was operational and functioned as designed. It produced both aural and visual alerts that indicated that there was an aircraft [N564HV] landing with another aircraft [SWA2493] still in position on the same runway. The local control (LC) controller immediately reacted to the ASDE-X alerts, and issued instructions to resolve the conflict, but not before standard separation had been lost. The SAN Airport Traffic Control Tower (SAN ATCT) facility was equipped with two flight strip printers, one functioned as a primary device, and the second as a backup in case the first unit failed. In post incident interviews, the SAN ATCT personnel stated that they received no training on the use or troubleshooting of these printers. Prior to the incident, the primary printer jammed. During the post-incident interview with the operations supervisor (OS), they stated that they chose to troubleshoot the primary printer rather than switching to the backup, and that this drew their attention away from the operation at the time of the incident. FAA Order JO 7110.65BB, Air Traffic Control, 2-10-3, Tower Team Position Responsibilities, states in part: Tower Team Concept and Intent: There are no absolute divisions of responsibilities regarding position operations. The tasks to be completed remain the same whether one, two, or three people are working positions within a facility/sector. The team, as a whole, has responsibility for the safe and efficient operation of that facility/sector. The LC controller noticed a flight strip at their workstation that indicated an initial altitude for an uninvolved departing aircraft that was not in accordance with facility directives and contacted Southern California Terminal Radar Approach Control (SCT TRACON) to coordinate an appropriate altitude. This diverted their attention from N564HV and SWA2493 momentarily. During the post-incident interview conducted with the LC controller, they stated that they had used poor judgment in prioritizing their duties. This duty prioritization was not consistent with guidance contained in FAA Order JO 7110.65BB, Air Traffic Control, 2-1-1, ATC Service.

Flight

Event TypeIncident
Event Time12:06 PDT
Nearest AirportSan Diego Intl (0nm ESE)
Runway09/2
Runway Length9401 ft
Runway Width200 ft
Flight Plan FiledIFR
Flight Plan ActivatedYes
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBoeing 737-7BD
Tail NumberN7734H
Aircraft CategoryAir
OperatorSouthwest Airlines
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsCfm Intl · CFM56-7B22 · Turbofan · 22700 | Cfm Intl · CFM56-7B22 · Turbofan · 22700 | P&W Canada · PW545C · Turbofan · 4119
Seats149

People & Injuries

Fatal0
Serious0
Minor0
Uninjured0
Total0

Conditions

ConditionsVMC
LightDaylight
Wind300° @ 7 kt
Visibility10 sm
CeilingBroken clouds 1400 ft
Temperature / Dew Point64 F
Altimeter29.95 inHg
Observation Time18:51
Weather SourceWFAC

Appendix: Source Data