ASN Wikibase Occurrence # 345555
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Date: | Thursday 10 June 2021 |
Time: | 17:45 LT |
Type: | Boeing 737-8H4 (WL) |
Owner/operator: | Southwest Airlines |
Registration: | N8674B |
MSN: | 36941/5706 |
Year of manufacture: | 2015 |
Total airframe hrs: | 19003 hours |
Fatalities: | Fatalities: 0 / Occupants: 177 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | San Diego International Airport, CA (SAN/KSAN) -
United States of America
|
Phase: | Landing |
Nature: | Passenger - Scheduled |
Departure airport: | Phoenix-Sky Harbor International Airport, AZ (PHX/KPHX) |
Destination airport: | San Diego International Airport, CA (SAN/KSAN) |
Investigating agency: | NTSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:Southwest flight WN1648, a Boeing 737-8H4 (N8674B) and Alaska Airlines flight AS3371 (operated by SkyWest), an Embraer ERJ-175LR (N197SY), were involved in a runway incursion incident at the San Diego international Airport.
The SkyWest flight was positioned on Runway 27 for takeoff at the same time the Southwest flight was cleared to land on the same runway.
The SkyWest flight was instructed to Line Up and Wait (LUAW) on Runway 27.
According to FAA recordings, the Southwest flight was instructed to go around on an approximate 0.84-mile final (about 1.2 miles from the runway 27 displaced threshold); however, the transmission was blocked and the instruction was not heard by the crew. The air traffic control tower controller instructed the SkyWest flight to exit the runway at taxiway C2 about 11 seconds prior to instructing the Southwest flight to go around and to not overfly the SkyWest airplane. The Southwest flight maneuvered around the SkyWest flight exiting the runway and subsequently landed on Runway 27. The closest proximity was 0.18 miles laterally and 200 feet vertically.
A review of the FAA audio recordings indicated that the tower controller informed the Southwest flight that there would be traffic holding in position for takeoff on the runway following a preceding arrival aircraft. The controller then issued instructions to other uninvolved aircraft, including a helicopter that was transitioning the airspace. Just after the controller issued instructions for the SkyWest flight to exit the runway, and when the Southwest flight was on an approximate 1.2-mile final, the ASDE-X provided a mandatory go-around alert, and the controller issued go-around instructions to Southwest. The Southwest flight subsequently maneuvered and offset to the left of Runway 27, and then back to the right, and the aircraft aligned with and landed on Runway 27. The SkyWest crew did not hear the air traffic controller's transmission to the Southwest flight to go around. The SkyWest crew reported they did hear the Southwest flightcrew's query about the airplane on the runway.
According to the FAA, the tower controller was communicating with a helicopter transitioning the airspace after they had instructed SkyWest to LUAW. This additional communication likely distracted the controller from monitoring the position of the SkyWest and Southwest airplanes.
Although the FAA reported that tower communication was working normally at the time of the event, they were requested to conduct testing on the strength of the radio signal from the tower cab at various distances away from the airport. However, there was no indication that the FAA was able to conduct such testing and therefore it could not be conclusively determined if the control tower's frequency strength was adequate to overpower an airborne aircraft's transmission for other aircraft operating on the airport. Therefore, it is likely that the air traffic controller and the Southwest flightcrew's simultaneous transmissions canceled each other with no indication to the controller, the arriving aircraft, nor any other aircraft on the frequency.
Probable Cause: The blocked go-around radio instruction from the air traffic control tower to the arrival aircraft which resulted in the arrival aircraft continuing the landing approach. This led to a loss of separation between the landing aircraft and the aircraft awaiting departure on the runway. Contributing to the loss of separation was the controller's distraction communicating with a helicopter transitioning the airspace.
Accident investigation:
|
| |
Investigating agency: | NTSB |
Report number: | OPS21LA003 |
Status: | Investigation completed |
Duration: | 2 years and 2 months |
Download report: | Final report |
|
Sources:
NTSB OPS21LA003
Location
Revision history:
Date/time | Contributor | Updates |
14-Sep-2023 19:30 |
ASN Update Bot |
Added |
14-Sep-2023 19:39 |
harro |
Updated |
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