# NTSB OPS10IA090: Boeing 737-7H4, N473WN, Burbank, CA, April 19, 2010 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: April 19, 2010, 10:58 local (17:58 UTC) - Place: Burbank, CA - Coordinates: 34.170082, -118.339027 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.1701&lon=-118.3390&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining events: [Landing-landing roll: Air traffic event](https://openairdocs.org/ntsb-events/100); [Takeoff: Air traffic event](https://openairdocs.org/ntsb-events/100) - Highest injury: No injuries - Injuries: 124 uninjured - 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 - NTSB case key (mKey): 75802 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS10IA090 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75802/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75802 - Page: https://openairdocs.org/ntsb/OPS10IA090 ## Probable cause (aircraft 1) The improper separation procedures by air traffic control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: expectation/assumption](https://openairdocs.org/ntsb-findings/02041525): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1 - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1 - [Info processing/decision: expectation/assumption](https://openairdocs.org/ntsb-findings/02041525): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2 - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2 ## Analysis (aircraft 1) 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 (aircraft 1) 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 best describes what happened. - [Landing-landing roll: Air traffic event](https://openairdocs.org/ntsb-events/100) (defining event), aircraft 1 - [Takeoff: Air traffic event](https://openairdocs.org/ntsb-events/100) (defining event), aircraft 2 ## Aircraft 1 - Registration: [N473WN](https://openairdocs.org/aircraft/N473WN), registered now, S/N 33832, built 2004 (OpenAirDocs) - Reported make and model: BOEING 737-7H4 - Registry model: [Boeing 737-7H4](https://openairdocs.org/model/boeing-737-7h4) (registry code 1384404) (OpenAirDocs) - Registry engine: [CFM International CFM56 series](https://openairdocs.org/engine/cfm-international-cfm56-series) (registry code 13802, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 33832 - Engines: CFM INTL. CFM56 SERIES 2200 horsepower turbo fan; CFM INTL. CFM56 SERIES 2200 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 ## Aircraft 2 - Registration: [N4415R](https://openairdocs.org/aircraft/N4415R), registered now, S/N 17263163, built 1974 (OpenAirDocs) - Reported make and model: CESSNA 172M - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17263163 - Engines: 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 ## 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 files) The files NTSB released with the investigation on November 9, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75802. 332 KB in all. - ATC 3 - Controller Statements (item 1, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357539&FileExtension=.PDF&FileName=ATC%203%20-%20Controller%20Statements-Redacted.PDF - ATC 3 - Daily Record of Facility Operation (item 2, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357543&FileExtension=.PDF&FileName=ATC%203%20-%20Daily%20Record%20of%20Facility%20Operation-Redacted.PDF - ATC 3 - Statement of Party Representatives (item 3, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357545&FileExtension=.PDF&FileName=ATC%203%20-%20Statement%20of%20Party%20Representatives-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.