OPS10IA090

NTSB incident investigation · Boeing 737-7H4 · Burbank, CA · April 19, 2010

Incident · No injuriesIncident investigationFinal report
Date
April 19, 2010, 10:58 local (17:58 UTC)
Place
Burbank, CA
Injuries
124 uninjured
Phase of flight
Landing
Aircraft
N473WNBoeing 737-7H4N4415RCessna 172M
Defining events
Landing-landing roll: Air traffic eventTakeoff: Air traffic event
Weather
Visual (VMC) · Day
Status
Completed · report December 27, 2011
Report
Approved by Office Director
NTSB office
Operational Factors Division
Parties
Federal Aviation Administration, National Air Traffic Controller Association
Case key
75802

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 improper separation procedures by air traffic control.

Findings · 4

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

Analysis

A Boeing 737 (B737) was landing on runway 8 and a Cessna 172 (C172) was operating in the local touch-and-go traffic pattern when the C172, in the departure phase of a touch and go on runway 15, flew through the intersection of runway 8 in front of the B737, which was on landing rollout. According to the local controller and the controller-in-charge, they did not see the situation develop between the C172 and B737 because another aircraft, which had just departed, distracted them, and their attention was focused on the radar display, not out the tower window.

Factual narrative

The factual narrative508 words

On Monday, April 19, 2010 at approximately 1058 pacific daylight time, Southwest Air Lines (SWA) flight 649, a Boeing 737-700 and N4415R, a Cessna 172 were involved in a near collision on the surface at the Bob Hope Airport (BUR), Burbank, California. The B737 was landing on runway 8, and the C172 was in the departure phase of a touch and go on runway 15, when it passed airborne through the intersection in front of the B737 flight. The incident occurred during daytime visual meteorological conditions (VMC). The B737 was on a regularly scheduled passenger flight from Metropolitan Oakland International Airport (OAK), Oakland, California enroute to BUR and was operating under the provisions of 14 Code of Federal Air Regulation Part 121. The Southwest flight had 119 passengers and a crew of five onboard. No injuries were reported. The C172 was practicing take-offs and landings at BUR, and was operating under the provisions of 14 Code of Federal Regulations Part 91. The C172 had one person onboard. No injuries were reported. At approximately 1046, N4415R reported in to BUR air traffic control tower (ATCT) requesting touch and go approaches in the traffic pattern. The C172 completed one touch and go to runway 8 and was then instructed by ATC to enter a left downwind for runway 15 for his second approach. Approximately two minutes later, the B737 reported in to BUR ATCT on approximately an 8-mile final for an instrument landing system (ILS) approach to runway 8. The local controller (LC) issued the B737 a landing clearance to runway 8, and then subsequently issued the C172 a touch and go clearance to runway 15. Immediately following those clearances, the LC became moderately busy providing traffic advisories to other aircraft in the airspace; however, the B737 and C172 were not provided traffic advisories on each other. Approximately two minutes later, the C172 was airborne in the departure phase of a touch and go on runway 15 and passed through the intersection of runway 15/8 in front of the B737 landing on runway 8. According to the LC and the controller in charge (CIC), they did not see the situation develop between the C172 and B737, because another aircraft that had just departed distracted them, and their attention was focused on the radar display, not out the tower window. The LC and CIC first became aware of the situation when the clearance delivery/flight data controller (CD/FD) looked out of the window and saw said “hey!” when he saw the C172 airborne and climbing over the intersection, and the landing B737 flight rolling through the same intersection, perpendicular to each other. The B737 continued to his gate, and C172 completed two more approaches at BUR before departing toward Van Nuys. Burbank airport had several video cameras located on the airfield that were used by airport operations. One of those cameras captured the incident. The replay of the video indicated that approximately 10 seconds had lapsed from the time C172 passed overthe runway intersection before B737 had rolled through that same intersection.

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
N473WN
Reported as
Boeing 737-7H4
Category
Airplane
Serial number
33832
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
Departed
KOAK · Oakland, CA
Destination
KBUR · Burbank, CA
Flight plan
Unknown
Airport
KBUR · Bob Hope Airport, runway 08, 5,802 × 150 ft, 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
N4415R
Reported as
Cessna 172M
Category
Airplane
Serial number
17263163
Engine
Lycoming 0-320 SERIES, 180 horsepower
Damage
No damage
Flight
Personal · Part 91
Operator
Rhodes John D
Registered owner
Rhodes John D
Departed
KBUR · Burbank, CA
Destination
KVNY · Van Nuys, CA
Flight plan
Unknown
Airport
KBUR · Bob Hope Airport, runway 15, 6,885 × 150 ft, 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
Wind
130° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 48 °F
Observed at
KBUR

Docket · 3

The files NTSB released with the investigation on November 9, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 332 KB in all.