OPS10IA015

NTSB incident investigation · Cessna 208B · Phoenix, AZ · March 20, 2010

Incident · No injuriesIncident investigationFinal report
Date
March 19, 2010, 18:28 local (Mar 20, 2010, 01:28 UTC)
Place
Phoenix, AZ
Phase of flight
Landing
Aircraft
N992FECessna 208BN742SWBoeing 737-7H4
Defining events
Landing-flare/touchdown: Near midair/TCAS alert/loss of separationTaxi-into takeoff position: Airport occurrence
Weather
Visual (VMC) · Day
Status
Completed · report May 19, 2011
Report
Approved by Office Director
NTSB office
Operational Factors Division
Case key
75525

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 NTSB’s determination of the probable cause, and any contributing factors.

The Cessna 208 pilot’s failure to identify the correct landing runway.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

While holding in position after being issued a takeoff clearance, the Boeing 737 captain noticed the Cessna 208 overflying his position and landing in front of him on runway 25R. The Cessna pilot was given clearance to land on runway 25L but instead landed on runway 25R, missing the 737 by about 50 feet. The pilot of the Cessna 208 noted having difficulty seeing the runway due to the setting sun beyond the departure end of runway 25R. Furthermore, he did not state whether or not he was able to make visual contact on final approach with the Boeing 737 that was holding in position in front of him on the runway.

Factual narrative

The factual narrative472 words

On Friday, March 19, 2010, at approximately 6:28 p.m. mountain standard time, a runway incursion occurred at the Phoenix Sky Harbor International Airport (PHX) involving Empire Airways (CFS) flight 7775, a Cessna 208, and Southwest Airlines (SWA) flight 1063, a Boeing 737-700. The CFS7775 aircraft was cleared to land on runway 25L but landed on runway 25R, overflying the SWA1063 flight which was holding in position on the approach end of runway 25R. CFS7775 was being conducted as a Title 14 CFR Part 135 scheduled cargo flight and SWA1063 was being conducted as a Title 14 CFR Part 121 air carrier flight. CFS7775 was cleared to land on runway 25L, but landed on runway 25R at the same time SWA1063 had been issued a takeoff clearance. PHX air traffic control reported that the pilot of CFS7775 tracked inbound to runway 25L as cleared, but on short final CFS7775 turned right and landed on runway 25R. The approach ends of runways 25R and 25L are staggered, with the threshold of 25R located approximately 2,480 feet east of the runway 25L threshold. The pilot of SWA1063 reported seeing CFS7775 overflying his position and landing on runway 25R, and he stated at the time that he would “wait for departure”. The airport surface detection equipment (ASDE-X) ground radar system did not issue an alert. Weather conditions were clear daylight, with the sun low on the western horizon. Initial reports from the pilot of SWA1063 indicated that the closest proximity between the two aircraft was 50 feet. The pilot of the CFS7775 reported having difficulty seeing the runway on final approach “because of the setting sun being right down the runway”. Subsequently, he set both navigation radios to the Instrument Landing System (ILS) frequency and engaged the autopilot to the fly the approach course while “looking for the runway” but noticed a discrepancy between the course deviation needles on the two horizontal situation indicators. Realizing he could not “rely on the two needles for verification of the runway” he looked up and saw that he was “just to the left of centerline”. He aligned himself for runway 25R and proceeded to land. In his written statement, he did not mention seeing the Southwest Boeing 737 holding for takeoff on runway 25R. The captain of SWA1063 reported seeing CFS7775 overflying him after being given clearance to takeoff on runway 25R from Phoenix tower, missing the aircraft by about “50 feet” and coming from a “7-8 o’clock position.” The captain did not proceed to take off because “this airplane [CFS7775] was now on the runway ahead of us and slowing.” According to the captain, the tower told CFS7775 after landing: “Empire 7775, you landed on [runway] 25R; you were cleared to land on [runway] 25L.” After CFS7775 cleared the runway, SWA1063 was reissued a takeoff clearance and departed.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft · 2

Registration
N992FE
Reported as
Cessna 208B
Category
Airplane
Serial number
208B0128
Engine
P&W PT6A SERIES, 500 horsepower, turbo prop
Damage
No damage
Flight
Part 135
Departed
FLG · Flagstaff, AZ
Destination
PHX · Phoenix, AZ
Flight plan
IFR
Airport
PHX · Phoenix Sky Harbor, runway 25R, asphalt

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
N742SW
Reported as
Boeing 737-7H4
Category
Airplane
Serial number
29278
Engines
CFM Intl. CFM56 SERIES, 2,200 horsepower, turbo fanCFM Intl. CFM56 SERIES, 2,200 horsepower, turbo fan
Damage
No damage
Flight
Part 121
Operator
Southwest Airlines
Registered owner
Southwest Airlines Co
Airport
PHX · Phoenix Sky Harbor, runway 25R, asphalt

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.

Weather

Conditions
Visual (VMC) · Day

Docket · 2

The files NTSB released with the investigation on March 7, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 172 KB in all.