Mesa CRJ9 and Skywest E175 at Burbank on Feb 22nd 2023, loss of separation on runway
Last Update: February 28, 2025 / 00:47:30 GMT/Zulu time
Incident Facts
Date of incident
Feb 22, 2023
Classification
Incident
Flight number
UA-5326
Departure
Burbank, United States
Destination
San Francisco, United States
Aircraft Registration
N619UX
Aircraft Type
Canadair CL-600 Regional Jet CRJ-705
ICAO Type Designator
CRJ9
A Mesa Airlines Canadair CRJ-900 on behalf of American Airlines, registration N954LR performing flight AA-5826 from Phoenix,AZ to Burbank,CA (USA) with 41 people on board, was on final approach to runway 33 when tower advised a departure was in position and would take off before them and instructed the aircraft to continue. A private aircraft on approach also to runway 33 got too close to the CRJ-900 and was instructed to go around.
About two minutes after the E175 had been cleared to line up runway 33, tower cleared the aircraft for takeoff and in the same sentence cleared the CRJ-900 to land.
The CRJ-900 however initiated a go around and was instructed to turn left, the crew reported receiving a TCAS RA, the E175 was instructed to continue their climb and was later instructed to turn left after the aircraft were clear of conflict. The E175 continued to destination, the CRJ-900 joined a downwind and landed on runway 33 about 12 minutes after the go around.
The NTSB reported: "NTSB investigating Feb. 22 runway incursion at Bob Hope Burbank Airport that occurred when a Skywest Embraer 175 was departing Runway 33 as a Mesa Airlines CRJ9 executed a pilot-initiated go-around as it was inbound for landing on the same runway. No damage or injuries reported."
On Jun 21st 2024 the NTSB released their preliminary report summarizing the sequence of events:
On February 22, 2023, about 1855 Pacific standard time (PST), Mesa Airlines (dba American Eagle) flight 5826, N954LR, a Bombardier CRJ900 and SkyWest Airlines (dba United Express) flight 5326, N619UX, an Embraer ERJ 170-200, were involved in a loss of minimum separation event at the Bob Hope Airport (BUR), Burbank, CA. The closest proximity was 0.29 miles at the same altitude. There were no injuries reported to the 73 passengers and crew onboard the SkyWest airplane or to the 41 passengers and crew members onboard the Mesa airplane.
The NTSB summarized the testimonies:
Mesa Airlines flight 5826
The flight crew of flight 5826 reported that they were cleared for the visual approach to runway 33 and instructed to contact the BUR airport traffic control tower (ATCT). After checking in with ATCT they were instructed to “continue for runway 33, traffic holding in position”. After multiple queries to ATCT to obtain a landing clearance with no response, and while on about a 2-mile final approach they were cleared to land followed immediately by a takeoff clearance for flight 5326. Concerned about maintaining adequate separation the flight crew asked ATCT to confirm their landing clearance to which the controller replied affirmative. At about 600 feet above ground level (AGL) and with flight 5326 in sight and beginning their takeoff roll flight 5826 flight crew elected to conduct a go-around. They notified ATCT of the missed approach and were instructed “roger, climb to 4,000 and turn right heading 270. No, left, left turn heading 270”. While in the turn they observed flight 5326 climbing underneath their aircraft and received a traffic advisory (TA) from the onboard traffic and collision advisory system (TCAS). Shortly thereafter, the ATCT instructed them to “turn right heading 240. Wait, left, left turn heading 240”. Having received a resolution advisory (RA) from the TCAS they notified the tower that they were complying with the RA to which she replied “Roger, contact LA approach”. The flight was vectored for another visual approach to runway 33 and landed without further incident.
SkyWest Airlines flight 5326
The flight crew of the flight 5326 reported that they were instructed by air traffic control to back taxi on runway 33 and line up and wait. After what appeared to be a couple minute delay they were cleared for takeoff and subsequently heard the ATCT confirm a landing clearance for another aircraft. Following departure, they turned left to a heading of 270° as required per the departure procedure. While rolling out of the turn they received a TCAS RA alert “descend, descend”. They responded to the RA and resumed normal operations following the TCAS “Clear of conflict” notification.
Burbank Air Traffic Control
The local controller stated that she was distracted by a SR-22 which was instructed to conduct a go-around on runway 26. However, she believed that flight 5326 had been cleared for takeoff when flight 5826 was on about a 2-mile final, and that standard runway separation would have existed had flight 5826 continued to a full stop landing rather than initiating a missed approach. She said the pilot initiated missed approach was unexpected and another controller helped her deconflict the traffic by telling her to “turn them”.
According to FAA Order 7110.65Z, the controller was required to apply a 2-mile separation between a departing aircraft on its takeoff roll and an arriving aircraft on final approach. Radar data indicated that flight 5826 was about 1.5 miles from the runway threshold when flight 5326 was cleared for takeoff and about .80 mile from the runway threshold when they initiated the missed approach.
On Feb 27th 2025 the NTSB released their final report concluding the probable cause of the incident was:
The interruption of the local controller’s workflow due to the necessitated management of a go-around of a third airplane that was approaching a different runway.
Contributing to the incident was:
1) the controller’s decision to continue the landing of ASH5826, likely without a re-assessment of its distance from the departing SKW5326, after the interruption, and
2) the lack of surface detection equipment at the Bob Hope Airport to aid the controller with traffic management.
The NTSB analysed:
This incident occurred after the local controller (LC) cleared SkyWest Airlines (dba United Express) flight 5326 (SKW5326) for takeoff from runway 33 at Bob Hope Airport (BUR) and instructed Mesa Airlines (dba American Eagle) flight 5826 (ASH5826) to continue its approach to land on the same runway. At the time of takeoff clearance, ASH5826 was 1.6 miles from the threshold of the same runway. Shortly after SKW5326 began its takeoff roll, the flight crew of ASH5826 determined the separation was insufficient and initiated a go-around. At this time, SKW5326 was at a groundspeed of 27 kts and accelerating across the runway threshold, and ASH5826 was 4,200 ft from the threshold at an altitude of 300 ft above ground level (agl).
The LC instructed ASH5826 to climb and maintain 4,000 ft, and fly the runway heading, which put their airplane on a converging course with SKW5326, who was on the assigned standard instrument departure (SID) heading of 270. Twenty-seven seconds later, the LC instructed ASH5826 to turn right, heading 270 then changed it to turn left, heading 270 which put the two airplanes on parallel headings. Forty-seven seconds later, the crew of ASH5826 reported they were responding to a TCAS RA [traffic alert and collision avoidance system resolution advisory], and the LC instructed them to turn right 30 degrees, then changed the instruction to a left 30degree turn. The airplanes’ closest point of separation was 1,680 ft during the left turn. After that, the separation began to increase and both airplanes were handed off to Southern California Terminal Radar Approach Control.
Federal Aviation Administration (FAA) Order 7110.65Z, Air Traffic Control, Chapter 2, section 1, paragraph 2-1-6, Safety Alert, requires controllers to “issue a safety alert to an aircraft if they are Page 1 of 20aware the aircraft is in a position/altitude that, in your judgment, places it in unsafe proximity to terrain, obstructions, or other aircraft.” However, for this event, the local controller did not issue a traffic advisory or safety alert, as required, to either of the flight crews immediately after ASH5826 reported going around, or during the following minutes when both airplanes were in an unsafe proximity to each other.
Prior to the incursion, at 18:53:06, the LC instructed SKW5326, which was on the ground departing Burbank, to turn right onto runway 33 and to Line Up and Wait (LUAW). The aircraft performance study found that at this time, ASH5826, was 7.9 NM (9 statute miles) from the threshold, at 2,800 ft above ground level (agl), and approaching runway 33 at BUR. According to FAA Order 7110.65Z, Air Traffic Control, Chapter 3, section 9, paragraph 3-9-4, the intent of LUAW” is to position aircraft for an imminent departure.”
About 19 seconds later, ASH5826 checked in with BUR tower, and the local controller advised the crew that traffic (SKW5326) was holding in position on runway 33, and they were instructed to continue their approach. SKW5326 entered runway 33 and by 1854:30 the airplane was aligned with the runway heading and stopped behind the runway threshold waiting for a takeoff clearance.
Around this time, the LC instructed an uninvolved visual flight rules (VFR) Cirrus airplane to perform a go-around on runway 26. During a postincident interview, the LC stated the go-around was issued because the airplane was too high for the approach. However, the LC did not inform the Cirrus pilot of the reason for the go-around, but the pilot complied immediately with ATC instructions. The LC then instructed the Cirrus pilot to turn base for runway 33 and follow a regional jet (ASH5826) on a 2-mile final. Several transmissions were conducted between the Cirrus pilot and the LC because there was confusion on which cross wind traffic pattern leg the pilot should fly.
The LC’s communications with the Cirrus may have been a distraction that delayed the takeoff clearance for SKW5326, which would have reduced separation between the two airplanes. Further, the focus on the Cirrus may have prevented the LC from performing an adequate scan of the runway and airport environment to determine the positions of SKW5326 and ASH5826 before issuing a takeoff and landing clearance, respectively.
FAA Order 7110.65Z, paragraph 3-10-3, Same Runway Separation, instructed a controller to “separate an arriving aircraft from another aircraft using the same runway by ensuring that the arriving aircraft does not cross the landing threshold until…the other aircraft has departed and crossed the runway end.”
At the time of the incident, the BUR airport traffic control tower did not have surface detection equipment which would have allowed air traffic controllers to track the movement of aircraft and vehicles on airport surfaces and on final approach. This type of system would provide controllers with visual and aural warnings when a potential conflict existed. Had BUR tower been equipped with this technology, it would have alerted the controller to the reduced separation between the two airplanes prior to the SKW5326 takeoff clearance. It likely would have also detected the potential conflict during the initial portion of the ASH5826 go-around. These warnings would have likely allowed the controller to prevent these conflicts altogether or reduced their severity.
Aircraft Registration Data
Incident Facts
Date of incident
Feb 22, 2023
Classification
Incident
Flight number
UA-5326
Departure
Burbank, United States
Destination
San Francisco, United States
Aircraft Registration
N619UX
Aircraft Type
Canadair CL-600 Regional Jet CRJ-705
ICAO Type Designator
CRJ9
This article is published under license from Avherald.com. © of text by Avherald.com.
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