Overview
• Operator 1: Mesa Airlines (American Eagle)
• Aircraft 1: Bombardier CRJ-900
• Registration: N954LR
• Flight Number: AA-5826
• Route: Phoenix, AZ (PHX) to Burbank, CA (BUR)
• Occupants: 41 people
• Incident Type: Go-around due to potential conflict on runway
• Operator 2: SkyWest Airlines (United Express)
• Aircraft 2: Embraer ERJ-175
• Registration: N619UX
• Flight Number: UA-5326
• Route: Burbank, CA (BUR) to San Francisco, CA (SFO)
• Occupants: 73 people
• Incident Type: Departing aircraft in close proximity to landing aircraft
• Date: 22 February 2023
• Location: Burbank Bob Hope Airport (BUR), California, USA
• Casualties: None
• Nature of Incident: Loss of separation between landing and departing aircraft on the same runway
Incident Summary
A SkyWest Embraer ERJ-175, operating as flight UA-5326 from Burbank to San Francisco, was cleared to line up and wait (LUAW) on Runway 33, then held in position for approximately two minutes.
Meanwhile, a Mesa Airlines Bombardier CRJ-900, operating as flight AA-5826 from Phoenix to Burbank, was on final approach to the same runway (Runway 33). The tower informed the crew that another aircraft was holding in position but did not issue an immediate landing clearance.
During this period, the controller was managing a private aircraft on approach to Runway 33, which had to be instructed to go around due to close proximity with the CRJ-900.
Approximately two minutes after the ERJ-175 was instructed to line up and wait, the controller cleared it for takeoff and, in the same transmission, cleared the CRJ-900 to land.
Concerned about maintaining safe separation, the CRJ-900 crew initiated a go-around, reporting that they had received a Traffic Collision Avoidance System (TCAS) Resolution Advisory (RA). The controller, seemingly caught off guard by the go-around, issued confusing heading instructions, initially directing the CRJ-900 to turn right, then left.
The ERJ-175 continued climbing and also received a TCAS RA instructing them to descend briefly before resuming normal climb.
The CRJ-900 later joined a downwind and landed safely about 12 minutes after the go-around.
The National Transportation Safety Board (NTSB) investigated the incident, ultimately concluding that ATC mismanagement and distractions caused the unsafe proximity between both aircraft.
On February 27, 2025, the NTSB released its final report, citing:
1. The local controller was distracted by managing a separate go-around of a Cirrus SR-22 on another runway, leading to errors in traffic sequencing.
2. The controller failed to reassess the separation distance between the departing ERJ-175 and the approaching CRJ-900.
3. The lack of surface detection equipment at Burbank Airport contributed to the inability to monitor aircraft movements effectively.
Sequence of Events
Pre-incident Conditions:
• Mesa Airlines CRJ-900 (AA-5826) was on approach to Runway 33 at Burbank.
• SkyWest Embraer ERJ-175 (UA-5326) was instructed to line up and wait on Runway 33 for departure.
• The controller was handling multiple aircraft, including a Cirrus SR-22 on approach to Runway 26, which was instructed to go around.
Takeoff & Landing Conflict:
• After about two minutes of holding in position, the ERJ-175 was cleared for takeoff.
• In the same transmission, the controller cleared the CRJ-900 to land.
• The CRJ-900 crew, unsure about maintaining safe separation, queried ATC to confirm their landing clearance, which was affirmed.
• At 600 feet AGL, the CRJ-900 crew spotted the departing ERJ-175 below them and initiated a go-around.
TCAS Alert & Confusion:
• The CRJ-900 received a TCAS RA, instructing the crew to alter their climb to avoid a conflict.
• The controller, seemingly surprised by the go-around, issued conflicting instructions:
• First, the CRJ-900 was told to turn right.
• Then, ATC changed the instruction to a left turn.
• The ERJ-175 also received a TCAS RA, instructing them to descend briefly before resuming climb.
• The two aircraft reached a minimum separation distance of 0.29 miles (1,680 feet laterally) at the same altitude before diverging.
Final Outcome:
• The ERJ-175 continued to San Francisco without further issues.
• The CRJ-900 was vectored back for another approach and landed safely approximately 12 minutes later.
Investigation & Findings
Final NTSB Report (February 27, 2025):
The probable cause of the incident was:
• The local controller’s workflow was disrupted by handling a separate go-around on another runway, leading to a misjudgment in aircraft separation.
Contributing factors included:
1. The controller’s failure to reassess the distance between the departing SkyWest ERJ-175 and the approaching Mesa CRJ-900.
2. Lack of surface detection equipment at Burbank Airport, which could have alerted ATC to the conflict sooner.
Analysis & Safety Recommendations
For Air Traffic Control (ATC):
• Improve monitoring of aircraft sequencing to prevent simultaneous takeoff and landing clearances on the same runway.
• Increase controller training on prioritizing workload and handling multiple simultaneous conflicts.
• Install advanced surface detection equipment at Burbank Airport to track aircraft movements more accurately and prevent similar incidents.
• ATC should avoid issuing simultaneous takeoff and landing clearances when separation distance is near the minimum required.
For Airlines & Pilots:
• Encourage proactive go-around decisions when separation concerns arise, even if ATC has issued a landing clearance.
• Pilots should remain vigilant and query ATC whenever a landing clearance seems unsafe.
• Improve crew training on handling TCAS RA responses in busy airspace and during go-arounds.
For Airport Operators & FAA:
• Accelerate implementation of Airport Surface Detection Equipment (ASDE-X) at Burbank and similar high-traffic airports to prevent runway conflicts.
• Review operational procedures at smaller airports with intersecting runways to reduce ATC workload and miscommunication risks.
Weather Conditions at the Time (METAR Reports for BUR – Burbank Airport)
• Wind: Variable at 5-10 knots
• Visibility: 10 statute miles
• Sky Conditions: Clear
• Temperature: 18°C
• Altimeter: 30.02 inHg
Conclusion
This incident highlights the risks of ATC workload distractions, misjudged separation distances, and the critical need for surface detection equipment at airports with high traffic volume.
While no injuries or damage occurred, the proximity of the two aircraft posed a significant safety risk, as both received TCAS RAs to avoid a midair collision.
The controller’s focus on a separate go-around led to an incorrect assumption that sufficient separation existed, resulting in simultaneous takeoff and landing clearances. The lack of ground surveillance equipment at Burbank Airport further exacerbated the issue.
To prevent future incidents, controllers must prioritize sequencing, pilots must remain proactive in safety decision-making, and airports must invest in enhanced tracking technology to improve situational awareness.
Disclaimer
“This report is based on available information as of 28 February 2025. While every effort has been made to ensure accuracy, the completeness of the details cannot be guaranteed. If you are the rightful owner of any referenced materials and wish them removed, please email takedown@cockpitking.com.”
