- Date
- August 11, 2023, 19:06 UTC
- Place
- San Diego, CA · Approach end of RWY 27
- Phase of flight
- Taxi
- Aircraft
- N7734HBoeing 737-7BDN564HVTextron 560XL
- Defining events
- Taxi-into takeoff position: Air traffic eventApproach-IFR final approach: Air traffic event
- Weather
- Visual (VMC) · Day
- Status
- Completed · report September 29, 2025
- Report
- Approved by Office Director
- Investigation class
- Class 4 - Basic report with no Prelim publish
- NTSB office
- Operational Factors Division
- Parties
- NATCA, FAA
- Case key
- 192847
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 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.
Findings · 6
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.
Analysis
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.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.
N7734H · Boeing 737-7BD
Air traffic eventDefining eventN564HV · Textron 560XL
Air traffic eventDefining eventAircraft · 2
- Registration
- N7734H
- Reported as
- Boeing 737-7BD
- Category
- Airplane
- Serial number
- 33923
- Built
- 2006
- Engines
- CFM Intl CFM56-7B22, 22,700 lbs thrust, turbo fanCFM Intl CFM56-7B22, 22,700 lbs thrust, turbo fan
- Damage
- No damage
- Flight
- Part 121
- Operator
- Southwest Airlines Co
- Registered owner
- Southwest Airlines Co
- Airworthiness certificate
- Unknown
- Destination
- KSJC · San Jose, CA
- Flight plan
- IFR
- Airport
- SAN · San Diego Intl, runway 09/27, 9,401 × 200 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
- N564HV
- Reported as
- Textron 560XL
- Category
- Airplane
- Serial number
- 560-6211
- Built
- 2016
- Engines
- P&W Canada PW545C, 4,119 lbs thrust, turbo fanP&W Canada PW545C, 4,119 lbs thrust, turbo fan
- Damage
- No damage
- Flight
- Executive/Corporate · Part 91
- Registered owner
- Hy-Vee Inc
- Airworthiness certificate
- Unknown
- Departed
- KDSM · Des Moines, IA
- Destination
- Same as departure
- Flight plan
- IFR
- Equipment
- Unknown
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 300° at 7 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- 1,400 ft broken
- Temperature
- 72 °F, dew point 64 °F
- Altimeter
- 29.95 inHg
- Icing
- Unknown
- Turbulence
- Unknown
- Observed at
- KSAN
- METAR
- KSAN 120151Z 30007KT 10SM BKN014 BKN200 22/18 A2995 RMK AO2 SLP141 T02170178
Other investigations on N7734H · 1
Matched to the same aircraft by N-number and date.