The National Transportation Safety Board has released its final report on a runway incursion incident at San Diego International Airport (KSAN) in August 2023, citing “poor judgment” and oversight lapses by air traffic control as the cause.
According to the report, Southwest Airlines Flight 2493, a Boeing 737-700, was holding in position for departure on Runway 27 when a Cessna Citation was cleared to land on the same runway. The airport’s ground radar system, Airport Surface Detection Equipment Model-X (ASDE-X), triggered both visual and aural alerts warning of the conflict.
Controllers responded, but not before the required separation was lost.
Unrelated Tasks
Investigators determined that the tower controller’s prioritization of unrelated tasks diverted attention from monitoring the arriving and departing aircraft. The controller later told investigators they had exercised poor judgment in managing duties.
At the same time, the operations supervisor was occupied with troubleshooting a jammed flight strip printer instead of switching to a backup device and maintaining oversight of the operation.
The NTSB concluded the probable cause was the local controller’s poor judgment in duty prioritization, which led to the runway incursion and loss of separation. A contributing factor was the supervisor’s decision to focus on the faulty printer rather than supervising active operations.
No injuries or aircraft damage occurred in the incident, but the aircraft came within 100 feet of each other.
