OPS23FA010

NTSB incident investigation · Boeing 737-7BD · San Diego, CA · August 11, 2023

IncidentClass 4 · FieldFinal report
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.

Aircraft · 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.