FlightFollowerATC's terrible mistake Creates Collision Risk for Two Jets
The Runway Conflict Was Only the Beginning
On February 22, 2023, American Eagle flight 5826, a Bombardier CRJ900, was arriving at Hollywood Burbank Airport while United Express flight 5326, an Embraer E175, was preparing to depart runway 33.
Accident Facts
- Accident
- DCA23LA185
- Date
- 22 February 2023
- Location
- Hollywood Burbank Airport, California
- Aircraft
- Bombardier CRJ900 (American Eagle 5826) / Embraer E175 (United Express 5326)
- Outcome
- Loss of separation;
The local controller had cleared the SkyWest aircraft to line up and wait. Mesa 5826 continued its approach. The departing aircraft was then cleared for takeoff while the arrival was still on final.
The Mesa crew recognized that the separation was no longer safe and initiated a go-around. That maneuver prevented a runway collision. But the controller then issued headings that brought the two aircraft into a second conflict in the air.
The First Barrier Was the Runway
The NTSB found that the controller's workflow was interrupted by another aircraft's go-around on a different runway. That interruption contributed to the failure to maintain the required runway separation.
The Mesa crew then became the first effective barrier. Rather than continuing onto a runway already occupied by a departing aircraft, the crew initiated a go-around.
That prevented the obvious outcome—a runway collision—but the go-around itself created a new traffic geometry that had to be managed immediately.
The Go-Around Became a Second Conflict
After the missed approach began, the controller instructed Mesa 5826 to climb to 4,000 feet and fly runway heading. The aircraft then received a series of heading instructions, including immediate reversals.
The NTSB's performance and ATC studies show how the two aircraft converged. At the closest point, the aircraft were about 1,680 feet apart horizontally and at the same altitude.
Technology Could Have Provided an Earlier Warning
The NTSB also identified the lack of surface-detection equipment at Burbank as a contributing factor. Such equipment could have detected the developing runway conflict and provided an additional warning to the controller.
The Board did not treat technology as a substitute for controller performance. Instead, it identified the missing equipment as a safety gap that allowed a developing conflict to remain dependent on human recognition.
The event therefore shows two different safety layers failing or becoming strained: controller workflow and airport surveillance.
The NTSB Found Two Separate Safety Problems
The final report separates the runway conflict from the airborne conflict. The first was created when SkyWest was cleared for takeoff while Mesa was still approaching. Mesa's go-around prevented the runway collision.
The second developed after the go-around because the controller's instructions placed the aircraft on converging paths. The Board's analysis shows that the controller's interrupted workflow affected both stages.
The aircraft crews and TCAS ultimately broke the chain, but the system had already crossed two separate separation barriers.
The NTSB concluded that the probable cause 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.”
Conclusion
Burbank's February 2023 event was remarkable because the same traffic pair encountered two separate collision hazards within seconds. The first was a runway conflict; the second was an airborne convergence after the go-around.