DCA23FA149

NTSB incident investigation · Boeing 737-79P · Austin, TX · February 4, 2023

Incident · No injuriesClass 1 · FieldFinal report
Date
February 4, 2023, 06:40 local (12:40 UTC)
Place
Austin, TX
Injuries
131 uninjured
Phase of flight
Takeoff
Aircraft
N7827ABoeing 737-79PN297FEBoeing 767-32LF
Defining events
Takeoff: Runway incursion veh/AC/personApproach-IFR missed approach: Near midair/TCAS alert/loss of separation
Weather
Instrument (IMC) · Night
Status
Completed
Report
Board-adopted at Board Meeting · Board meeting June 6, 2024
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
NATCA, Federal Express, Alpa, FAA, Boeing Air Safety Investigation, SWAPA, Honeywell, Southwest - Flight Safety
Safety recommendations
Yes
Case key
106680

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

the local controller’s incorrect assumption that the Southwest Airlines (SWA) airplane would depart from the runway before the Federal Express airplane arrived on the same runway, which resulted in a loss of separation between both airplanes. Contributing to the controller’s incorrect assumption were his expectation bias regarding the SWA airplane’s departure, his lack of situational awareness regarding the SWA airplane’s position when the flight crew requested takeoff clearance, and the air traffic control tower’s lack of training (before the incident) on low visibility operations. Contributing to the incident was the SWA flight crewmembers’ failure to account for the traffic that was on short final approach and to notify the controller that they would need additional time on the runway before the takeoff roll. Also contributing to the incident was the Federal Aviation Administration’s failure to require surface detection equipment at Austin-Bergstrom International Airport and direct alerting for flight crews.

Findings · 13

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

N7827A · Boeing 737-79P

Info processing/decision: expectation/assumptionPersonnel issues › Action/decision · ATC personnelBoeing 737-79P: 1 caseAll aircraft: 51 casesProbable cause
Attention/monitoring: task monitoring/vigilancePersonnel issues › Psychological · ATC personnelBoeing 737-79P: 1 caseAll aircraft: 330 casesProbable cause
Training: recurrent trainingOrganizational issues › Support/oversight/monitoring · ATCBoeing 737-79P: 1 caseAll aircraft: 6 casesProbable cause
Communication (personnel): lack of communicationPersonnel issues › Task performance · Flight crewBoeing 737-79P: 1 caseAll aircraft: 84 casesProbable cause
Enforcement: equipment requirementsOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBoeing 737-79P: 1 caseAll aircraft: 1 caseProbable cause
Attention/monitoring: monitoring environmentPersonnel issues › Psychological · Flight crewBoeing 737-79P: 1 caseAll aircraft: 809 casesProbable cause

N297FE · Boeing 767-32LF

Info processing/decision: expectation/assumptionPersonnel issues › Action/decision · ATC personnelBoeing 767-32LF: 1 caseAll aircraft: 51 casesProbable cause
Attention/monitoring: monitoring other aircraftPersonnel issues › Psychological · ATC personnelBoeing 767-32LF: 1 caseAll aircraft: 231 casesProbable cause
Training: recurrent trainingOrganizational issues › Support/oversight/monitoring · ATCBoeing 767-32LF: 1 caseAll aircraft: 6 casesProbable cause
Attention/monitoring: monitoring environmentPersonnel issues › Psychological · Pilot of other aircraftBoeing 767-32LF: 1 caseAll aircraft: 809 casesProbable cause
Communication (personnel): lack of communicationPersonnel issues › Task performance · Pilot of other aircraftBoeing 767-32LF: 1 caseAll aircraft: 84 casesProbable cause
Enforcement: equipment requirementsOrganizational issues › Support/oversight/monitoring · FAA/RegulatorBoeing 767-32LF: 1 caseAll aircraft: 1 caseProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

N297FE · Boeing 767-32LF

Analysis

On February 4, 2023, about 0640 central standard time, Southwest Airlines (SWA) flight 708, a Boeing 737-700, N7827A, and Federal Express Corporation (FedEx) flight 1432, a Boeing 767-300, N297FE, were involved in a runway incursion at Austin Bergstrom International Airport (AUS), Austin, Texas. The flight crew of the FedEx airplane, which was arriving on runway 18L, executed a missed approach as the SWA airplane was departing from the same runway. The 128 occupants aboard the SWA airplane and the 3 occupants aboard the FedEx airplane were not injured, and neither airplane sustained damage. SWA flight 708 was a regularly scheduled international passenger flight operating under Title 14 Code of Federal Regulations (CFR) Part 121 from AUS to Cancún International Airport (CUN), Cancún, Mexico. FedEx flight 1432 was a domestic cargo flight operating under Part 121 from Memphis International Airport (MEM), Memphis, Tennessee, to AUS. Night instrument meteorological conditions prevailed at the time of the incident.

Aircraft · 2

Registration
N7827A
Reported as
Boeing 737-79P
Category
Airplane
Serial number
28255
Built
2003
Airframe hours
56,774
Engines
CFM Intl CFM56-7B24, 24,200 lbs thrust, turbo fanCFM Intl CFM56-7B24, 24,200 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Southwest Airlines Co
Registered owner
Southwest Airlines Co
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 29, 2023
Destination
MMEX · Cancun, OF
Flight plan
IFR
Airport
AUS · Austin-Bergstrom International Airport, runway 18L, 9,000 × 150 ft, concrete
Equipment
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Registration
N297FE
Reported as
Boeing 767-32LF
Category
Airplane
Serial number
41068
Built
2012
Engines
GE CF6-80C2B6F, 60,030 lbs thrust, turbo fanGE CF6-80C2B6F, 60,030 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Federal Express Corp
Registered owner
Federal Express Corp
Airworthiness certificate
Unknown
Departed
KMEM · Memphis, TN
Destination
Same as departure
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 4

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N7827A
Age
54
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
August 7, 2022
Seat
Left
Restraint
5-point
Flight hours
20,600 total · 6,000 in this make and model · 17,200 as pilot in command · 140 in the last 90 days · 60 in the last 30 days · 6 in the last 24 hours
Role
Co-pilot, aircraft N7827A
Age
49
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
January 21, 2023
Seat
Right
Restraint
5-point
Flight hours
8,907 total · 4,893 in this make and model · 2,515 as pilot in command · 230 in the last 90 days · 79 in the last 30 days · 5 in the last 24 hours
Role
Pilot, aircraft N297FE
Age
56
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Multi-engine land
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
5-point
Flight hours
23,500 total · 16,000 in this make and model
Role
Pilot, aircraft N297FE
Age
49
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land
Medical
Class 1, With waivers/limitations
Seat
Right
Restraint
5-point
Flight hours
8,000 total · 465 in this make and model

Weather

Conditions
Instrument (IMC) · Night
Wind
Calm
Temperature
30 °F, dew point 30 °F
Altimeter
30.43 inHg
Observed at
AUS

Docket · 42

The files NTSB released with the investigation on November 29, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.2 GB in all.

Meteorology factual reportItem 1 · PDF · 21 pages · 2.0 MBMeteorology attachment 1 - austin weather dataItem 2 · PDF · 25 pages · 232 KBMeteorology attachment 2 - FAA order JO7900.5E surface observationsItem 3 · PDF · 178 pages · 3.4 MBAircraft systems factual reportItem 4 · PDF · 6 pages · 102 KBFlight data recorder - specialist's factual reportItem 5 · PDF · 23 pages · 13 photos · 5.0 MBFlight data recorder - attachment 1 (csv data - fedex)Item 6 · ZIP · 5.9 MBFlight data recorder - attachment 2 (csv data - southwest)Item 7 · ZIP · 70 KBOperational factors factual reportItem 8 · PDF · 51 pages · 1.7 MBOperational factors attachment 1 fedex pilots interview and transcriptsItem 9 · PDF · 80 pages · 202 KBOperational factors attachment 2 swa pilots interview and transcriptItem 10 · PDF · 77 pages · 288 KBOperational factors attachment 3 fedex crew trainingItem 11 · PDF · 11 pages · 535 KBOperational factors attachment 4 swa crew trainingItem 12 · PDF · 19 pages · 2.0 MBOperational factors attachment 5 fedex simulator evaluationItem 13 · PDF · 20 pages · 1.0 MBOperational factors attachment 6 swa simulator evaluationItem 14 · PDF · 29 pages · 2.6 MBOperational factors attachment 7 swa engine run-up procedure with engine anti-ice on [excerpt]Item 15 · PDF · 2 pages · 44 KBOperational factors attachment 8 swa aircraft deicing procedures [excerpt]Item 16 · PDF · 4 pages · 152 KBHuman performance factual report swa (flight crew 72 hour history)Item 17 · PDF · 4 pages · 161 KBHuman performance (flight crew fedex 72-hour factual report)Item 18 · PDF · 4 pages · 161 KBHuman performance aus local controller (lc) factualItem 19 · PDF · 6 pages · 249 KBATC - group chair's factual report - finalItem 20 · PDF · 18 pages · 1.3 MBATC - attachment 1 - ATC audio transcriptItem 21 · PDF · 7 pages · 77 KBATC - attachment 2 - aus ATC audio recordingsItem 22 · ZIP · 42.9 MBATC - attachment 3 - aerobahn playbackItem 23 · WMV · 5.2 MBATC - attachment 4 - aus ATCT facility logs and recordsItem 24 · PDF · 16 pages · 9.1 MBATC - attachment 5 - interview summariesItem 25 · PDF · 293 pages · 61.3 MBATC - attachment 6 - aus ATCT training records - lce controllerItem 26 · PDF · 1,897 pages · 1.4 GBATC - attachment 7 - aus ATCT facility ordersItem 27 · PDF · 240 pages · 86.1 MBATC - attachment 8 - facility training documentationItem 28 · PDF · 436 pages · 346 MBATC - attachment 9 - aus loa/smgcs plan letter of agreementItem 29 · PDF · 22 pages · 9.3 MBATC - addendum 1 - group chair's factual reportItem 30 · PDF · 481 pages · 191 MBATC - addendum 2 - group chair's factual reportItem 31 · PDF · 28 pages · 11.9 MBAircraft performance studyItem 32 · PDF · 30 pages · 6.7 MBAircraft performance addendumItem 33 · PDF · 12 pages · 2.5 MBAircraft performance erratumItem 34 · PDF · 2 pages · 112 KBADS-B data N7827AItem 35 · CSV · 48 KBADS-B data N297FEItem 36 · CSV · 103 KBADS-B data prior airplanesItem 37 · XLSX · 4.6 MBMedical factual reportItem 38 · PDF · 7 pages · 158 KBMedical factual report addendumItem 39 · PDF · 2 pages · 107 KBParty submission - air line pilots association, international (alpa)Item 40 · PDF · 9 pages · 247 KBParty submission - southwest airlines pilots association (swapa)Item 41 · PDF · 10 pages · 283 KBAustin animation descriptionItem 42 · PDF · 6 pages · 75 KB