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Accidents · NTSB OPS23FA010 · Final report

Boeing 737-7BD and Textron Aviation INC 560XL incident near San Diego, California, August 11, 2023

On August 11, 2023 at about 7:06 pm local time, 2 aircraft, Boeing 737-7BD (N7734H) and Textron Aviation INC 560XL (N564HV), were involved in the same incident near San Diego, California (San Diego Intl airport). The NTSB record does not give the injuries. The weather was visual conditions (good weather).

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The NTSB's probable cause their words, unchanged

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.
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.

Source: NTSB aviation accident database, copy made October 4, 2026. Docket and reports at the NTSB.

What the record shows

Date
August 11, 2023 · about 7:06 pm local time
Place
San Diego, California · San Diego Intl · map
Type
Incident
Injuries
The NTSB record does not give the injuries.
Weather
visual conditions (good weather)
Aircraft 1
Boeing 737-7BD, built 2006 · all 737-7BDs on the register
Registration
N7734H · registry record · serial 33923
Damage
Not recorded
Flight
Flight · scheduled airline rules (Part 121)
Aircraft 2
Textron Aviation INC 560XL, built 2016
Registration
N564HV · registry record · serial 560-6211
Damage
Not recorded
Flight
Executive or corporate flight · general aviation rules (Part 91)

The NTSB's narrative for the Boeing 737-7BD final · quoted from the NTSB record

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.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The NTSB's narrative for the Textron Aviation INC 560XL final · quoted from the NTSB record

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.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record for the Boeing 737-7BD from the NTSB's investigation tables, in plain English

What happened, in order

  1. Air traffic event during taxi (into takeoff position) defining event

The NTSB's findings

  • Organizational issues › Support/oversight/monitoring › Oversight › Oversight of operation › ATC
  • Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › ATC personnel
  • Personnel issues › Task performance › Use of equip/info › Use of equip/system › ATC personnel

The aircraft

  • Last inspection: inspection type not recorded
  • Seats: 149
  • Landing gear: retractable
  • Engine 1: Cfm Intl CFM56-7B22 (turbofan); 0 hours total
  • Engine 2: Cfm Intl CFM56-7B22 (turbofan); 0 hours total
  • Operator: Southwest Airlines CO

The flight

  • Destination: KSJC San Jose CA
  • Flight plan: IFR
  • Runway 09/2, 9,401 ft by 200 ft
  • A second pilot was aboard

Weather at the time

  • Light: daylight
  • Wind: from 300° at 7 knots
  • Visibility: 10 statute miles
  • Sky: broken clouds at 1,400 ft
  • Temperature: 72°F (22°C), dew point 64°F (18°C)
  • Altimeter: 29.95 inHg
  • Observation at 6:51 pm from KSAN

Weather report (METAR): KSAN 120151Z 30007KT 10SM BKN014 BKN200 22/18 A2995 RMK AO2 SLP141 T02170178

The factual record for the Textron Aviation INC 560XL from the NTSB's investigation tables, in plain English

What happened, in order

  1. Air traffic event during approach (IFR final approach)

The NTSB's findings

  • Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › ATC personnel
  • Personnel issues › Task performance › Use of equip/info › Use of equip/system › ATC personnel
  • Organizational issues › Support/oversight/monitoring › Oversight › Oversight of operation › ATC

The aircraft

  • Last inspection: inspection type not recorded
  • Seats: 13
  • Landing gear: retractable
  • Engine 1: P&W Canada PW545C (turbofan); 0 hours total
  • Engine 2: P&W Canada PW545C (turbofan); 0 hours total

The flight

  • Departed from: KDSM Des Moines IA at 3:38 pm
  • Flight plan: IFR
  • A second pilot was aboard

Documents from the investigation the NTSB's docket: the evidence folder behind the report

The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.

Other NTSB records under N7734H the same tail number, which may have belonged to a different aircraft at the time

2024-08-19DCA24LA290 · accident near Highland Meadows, NM · serious injuries
2002-11-13FTW03LA045 · accident near Carrizo Springs, TX · substantial damage · minor injuries

About this page

Everything above comes from the NTSB's public accident database: the narrative, probable cause and findings are the NTSB's own words, and the coded tables behind its report (pilot, aircraft, flight, weather, injuries, sequence of events) are written out in plain English. Pilots' ages, home towns and medical details are left out on purpose. The documents and photographs are the NTSB's docket, the folder of records gathered during the investigation, shown as the NTSB released them (the NTSB redacts some personal details first) and listed under the NTSB's own titles. This site's own text never names pilots, passengers or anyone else involved. A preliminary report describes what is known soon after the event and can change; the final report, with the probable cause, usually follows one to two years later and this page is refreshed when it does. Case number OPS23FA010.