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Cases › DCA23FA149 · Part 121 airline · Class 1

BOEING 737-79PSOUTHWEST AIRLINES CO

Austin, TX, USA · 2023-02-04·N7827A

0
fatal
0
serious
No injury
highest injury
—
damage

What happened

NTSB summary, verbatim

On February 4, 2023, about 0640 central standard time, Southwest Airlines (SWA) flight 708, a Boeing 737-700, N7827A, and Federal Express Corporation (FedEx) flight 1432, a Boeing 767-300, N297FE, were involved in a runway incursion at Austin Bergstrom International Airport (AUS), Austin, Texas. The flight crew of the FedEx airplane, which was arriving on runway 18L, executed a missed approach as the SWA airplane was departing from the same runway. The 128 occupants aboard the SWA airplane and the 3 occupants aboard the FedEx airplane were not injured, and neither airplane sustained damage. SWA flight 708 was a regularly scheduled international passenger flight operating under Title 14 Code of Federal Regulations (CFR) Part 121 from AUS to Cancún International Airport (CUN), Cancún, Mexico. FedEx flight 1432 was a domestic cargo flight operating under Part 121 from Memphis International Airport (MEM), Memphis, Tennessee, to AUS. Night instrument meteorological conditions prevailed at the time of the incident.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
N7827A (55053046610)
Liam Thompson · CC BY-SA 4.0 · Wikimedia Commons

Probable cause

the Board's determination
the local controller’s incorrect assumption that the Southwest Airlines (SWA) airplane would depart from the runway before the Federal Express airplane arrived on the same runway, which resulted in a loss of separation between both airplanes. Contributing to the controller’s incorrect assumption were his expectation bias regarding the SWA airplane’s departure, his lack of situational awareness regarding the SWA airplane’s position when the flight crew requested takeoff clearance, and the air traffic control tower’s lack of training (before the incident) on low visibility operations. Contributing to the incident was the SWA flight crewmembers’ failure to account for the traffic that was on short final approach and to notify the controller that they would need additional time on the runway before the takeoff roll. Also contributing to the incident was the Federal Aviation Administration’s failure to require surface detection equipment at Austin-Bergstrom International Airport and direct alerting for flight crews.

Occurrence sequence

2 stepsNTSB coding · CICTT taxonomy
  1. 1 · Takeoff
    Runway incursion veh/AC/person
    defining event
  2. 1 · Approach-IFR missed approach
    Near midair/TCAS alert/loss of separation
    defining event

Findings

12 causal · 1 contributing
  • CAUSE
    Personnel issues › Action/decision › Info processing/decision › Expectation/assumption — ATC personnel
  • CAUSE
    Personnel issues › Action/decision › Info processing/decision › Expectation/assumption — ATC personnel
  • CAUSE
    Personnel issues › Psychological › Attention/monitoring › Task monitoring/vigilance — ATC personnel
  • CAUSE
    Personnel issues › Psychological › Attention/monitoring › Monitoring other aircraft — ATC personnel
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Training › Recurrent training — ATC
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Training › Recurrent training — ATC
  • CAUSE
    Personnel issues › Psychological › Attention/monitoring › Monitoring environment — Pilot of other aircraft
  • CAUSE
    Personnel issues › Task performance › Communication (personnel) › Lack of communication — Pilot of other aircraft
  • CAUSE
    Personnel issues › Task performance › Communication (personnel) › Lack of communication — Flight crew
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Enforcement › Equipment requirements — FAA/Regulator
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Enforcement › Equipment requirements — FAA/Regulator
  • CAUSE
    Personnel issues › Psychological › Attention/monitoring › Monitoring environment — Flight crew
  • FACTOR
    Aircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Design

Safety recommendations

7 issuedwhat changed because of this accident
  • A-24-010Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: For airports that are certificated under Title 14 Code of Federal Regulations Part 139 and are currently not equipped with airport surface detection equipment, model X (ASDE-X) or airport surface surveillance capability, implement surface detection equipment that • tracks the movement of arriving and departing aircraft, • determines the proximity between those aircraft, and • provides air traffic controllers with visual and aural cues of surface movements to aid in their decision making processes.

  • A-24-011Open - Unacceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require air traffic controllers to • advise pilots, through direct communication and automatic terminal information system broadcasts, when visual contact with aircraft operating on taxiways and runways cannot be established or maintained and • instruct pilots to provide accurate position reports to aid the controller in determining an aircraft’s location in such conditions.

  • A-24-012Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Brief all air traffic controllers about the circumstances of this incident, emphasizing the effect that certain conditions might have on a pilot’s ability to begin a takeoff in a timely manner, including • low-visibility weather conditions, such as fog; • ambient conditions, such as temperature; and • surface conditions, such as ice, snow, and other precipitation, as noted in Order 7110.65, Air Traffic Control, paragraph 5-8-4, Departure and Arrival.

  • A-24-013Open - Acceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Amend the Aeronautical Information Manual so that it instructs pilots to inform controllers, before entering an active runway with the intent to depart, when they need time on the runway for any reason before beginning the takeoff roll.

  • A-24-014Open - Unacceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require all airports with a Surface Movement Guidance and Control System plan to ensure that their plans and the associated letters of agreement correspond with each other and the stakeholder duties and responsibilities described in Advisory Circular 120-57, Surface Movement Guidance and Control System.

  • A-24-015Open - Unacceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Direct training administrators at airports with a Surface Movement Guidance and Control System plan to require initial and annual refresher training for all stakeholders, including air traffic controllers and airport operations personnel, on the information in the airport’s plan.

  • A-24-016Open - Unacceptable ResponseCLASS IIletter ↗

    TO THE FEDERAL AVIATION ADMINISTRATION: Require training administrators at all operating air traffic control towers to conduct annual refresher training on low-visibility operations.

Sequence of events

3 timed eventsfrom the FDR factual report · claude-sonnet-5
  1. 06:30 CSTIncidentp.3
    Incident occurred involving Airplane 1 (FedEx Boeing 767-300) and Airplane 2 (Southwest Boeing 737-700) at Austin, Texas
  2. 06:39:00 to 06:42:00 CSTIncidentp.6
    Time window designated as "Incident" period for FDR data plots and tables
  3. Unspecified (dashed line reference time)Go-aroundp.6
    Initiation of the go-around by Airplane 1 (FedEx), shown as a dashed line reference on each figure

NTSB analysis

from the final report

On February 4, 2023, about 0640 central standard time, Southwest Airlines (SWA) flight 708, a Boeing 737-700, N7827A, and Federal Express Corporation (FedEx) flight 1432, a Boeing 767-300, N297FE, were involved in a runway incursion at Austin Bergstrom International Airport (AUS), Austin, Texas. The flight crew of the FedEx airplane, which was arriving on runway 18L, executed a missed approach as the SWA airplane was departing from the same runway. The 128 occupants aboard the SWA airplane and the 3 occupants aboard the FedEx airplane were not injured, and neither airplane sustained damage. SWA flight 708 was a regularly scheduled international passenger flight operating under Title 14 Code of Federal Regulations (CFR) Part 121 from AUS to Cancún International Airport (CUN), Cancún, Mexico. FedEx flight 1432 was a domestic cargo flight operating under Part 121 from Memphis International Airport (MEM), Memphis, Tennessee, to AUS. Night instrument meteorological conditions prevailed at the time of the incident.