# NTSB OPS23FA010: Boeing 737-7BD, N7734H, San Diego, CA, August 11, 2023 - Type: NTSB incident investigation - Classification: Incident · Class 4 · Field · Final report - Date: August 11, 2023, 19:06 UTC - Place: San Diego, CA · Approach end of RWY 27 - Coordinates: 32.730189, -117.17562 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.7302&lon=-117.1756&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining events: [Taxi-into takeoff position: Air traffic event](https://openairdocs.org/ntsb-events/100); [Approach-IFR final approach: Air traffic event](https://openairdocs.org/ntsb-events/100) - 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 - NTSB case key (mKey): 192847 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS23FA010 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192847/pdf - Page: https://openairdocs.org/ntsb/OPS23FA010 ## Probable cause (aircraft 1) 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 NTSB's coded findings; those marked are part of the probable cause. - [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · ATC (probable cause), aircraft 1 - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1 - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · ATC personnel (probable cause), aircraft 1 - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2 - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · ATC personnel (probable cause), aircraft 2 - [Oversight: oversight of operation](https://openairdocs.org/ntsb-findings/04032015): Organizational issues › Support/oversight/monitoring · ATC (probable cause), aircraft 2 ## Analysis (aircraft 1) 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 best describes what happened. - [Taxi-into takeoff position: Air traffic event](https://openairdocs.org/ntsb-events/100) (defining event), aircraft 1 - [Approach-IFR final approach: Air traffic event](https://openairdocs.org/ntsb-events/100) (defining event), aircraft 2 ## Aircraft 1 - Registration: [N7734H](https://openairdocs.org/aircraft/N7734H), registered now, S/N 33923, built 2006 (OpenAirDocs) - Reported make and model: BOEING 737-7BD - Registry model: [Boeing 737-7BD](https://openairdocs.org/model/boeing-737-7bd) (registry code 1384511) (OpenAirDocs) - Registry engine: [CFM International CFM56-7B22 series](https://openairdocs.org/engine/cfm-international-cfm56-7b22-series) (registry code 13043, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 33923 - Year built: 2006 - Engines: CFM INTL CFM56-7B22 22700 lbs thrust turbo fan; CFM INTL CFM56-7B22 22700 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 ## Aircraft 2 - Registration: N564HV (not matched to a registry record) - Reported make and model: TEXTRON AVIATION INC 560XL - Category: Airplane - Serial number: 560-6211 - Year built: 2016 - Engines: P&W CANADA PW545C 4119 lbs thrust turbo fan; P&W CANADA PW545C 4119 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) 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. - [NTSB DCA24LA290](https://openairdocs.org/ntsb/DCA24LA290), Aug 19, 2024: Boeing 737 (N7734H), Highland Meadows, NM, no damage. Probable cause: An encounter with convectively induced turbulence during descent. 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.