Aircraft Accident/Incident Report

San Francisco, California
Saturday, March 27, 2010 11:12 PDT

NTSB Narrative Summary Released at Completion of Accident

An operational error occurred when a Boeing 777 and a Cessna 182 transiting the Class B surface area passed within approximately 480 feet laterally and 300 feet vertically of each other. Both airplanes were under control of air traffic control at the time of the incident. Postincident investigation determined that the local controller issued a takeoff clearance to the Boeing 777 without resolving a potential conflict with the Cessna, which was southbound just west of the airport. The controller attempted to establish approved separation between the two airplanes after the Boeing departed, but was unable to do so. The pilot of the Cessna took evasive action to pass behind the Boeing. Review of tower procedures revealed deficiencies that permitted aircraft to cross the runway 28L/R departure corridor while the runways were active, facilitating conflicts of this nature.

NTSB Probable Cause Narrative

The local controller's issuance of a takeoff clearance to the Boeing 777 without ensuring that approved separation would exist with the Cessna 182. Contributing to the incident were tower procedures that permitted transitioning aircraft to cross the runway 28 departure corridor at low altitude while runways 28L/R were in use.

Event Information

Type of Event Incident
Event Date 3/27/2010
Event Day of the Week Saturday
Time of Event 1112
Event Time Zone Pacific Daylight Time
Event City San Francisco
Event State CALIFORNIA
Event Country --
Zipcode of the event site --
Event Date Year 2010
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude --
Event Location Longitude --
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source --
Time of the weather observation
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID --
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation --
Lighting Conditions --
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling --
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) --
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator --
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) --
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None 268
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 29189
NTSB Notification Source United Airlines
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Dec 15 2011 1:18PM
User who most recently changed record hopj
Basic weather conditions --
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft #2

Aircraft Registration Number -- --
NTSB Number OPS10IA020A OPS10IA020B
Missing Aircraft Indicator -- --
Federal Aviation Reg. Part -- --
Type of Flight Plan filed IFR VFR
Flight plan Was Activated? Yes --
Damage None None
Aircraft Fire None None
Aircraft Explosion None --
Aircraft Manufacturer's Full Name BOEING CESSNA
Aircraft Model 777-222 182R
Aircraft Series Identifier -- --
Aircraft Serial Number 30549 18268457
Certified Max Gross Weight -- --
Aircraft Category Airplane Airplane
Aircraft Registration Class -- --
Aircraft is a homebuilt? No No
Flight Crew Seats -- --
Cabin Crew Seats -- --
Passenger Seats -- --
Total number of seats on the aircraft 400 4
Number of Engines 2 1
Fixed gear or retractable gear Fixed Fixed
Aircraft, Type of Last Inspection -- --
Date of Last Inspection -- --
Airframe hours since last inspection -- --
Airframe Hours -- --
ELT Installed Unknown Unknown
ELT Activated Unknown Unknown
ELT Aided Location of Event Site Unknown Unknown
ELT Type -- --
Aircraft Owner Name -- --
Aircraft Owner Street Address 1200 E ALGONQUIN RD 2443 FILLMORE ST # 339
Aircraft Owner City ELK GROVE VILLAGE SAN FRANCISCO
Aircraft Owner State IL CA
Aircraft Owner Country USA USA
Aircraft Owner Zipcode 60007 94115-1814
Operator is an individual? No No
Operator Name -- --
Operator Same as Owner? No No
Operator Is Doing Business As -- --
Operator Address Same as Owner? No No
Operator Street Address -- --
Operator City -- --
Operator State -- --
Operator Country USA USA
Operator Zip code -- --
Operator Code UALA --
Owner has at least one certificate Yes - certificate holder None
Other Operator of large aircraft? No No
Certified for Part 133 or 137 Operation -- --
Operator Certificate Number UALA011A --
Indicates whether an air carrier operation was scheduled or not Scheduled --
Indicates Domestic or International Flight International --
Operator carrying Pax/Cargo/Mail Passenger Only --
Type of Flying (Per_Bus / Primary) -- Personal
Second Pilot on Board -- No
Departure Point Same as Event Yes No
Departure Airport Code -- --
Departure City San Francisco Unknown
Departure State CA --
Departure Country USA USA
Departure Time 1112 --
Departure Time Zone PDT --
Destination Same as Local Flt -- --
Destination Airport Code ZBAA kpao
Destination City Beijing Palo Alto
Destination State -- CA
Destination Country CH USA
Specific Phase of Flight -- --
Report sent to ICAO? -- --
Evacuation occurred -- --
Date of most recent change to record Aug 20 2010 12:17PM Nov 21 2011 10:41AM
User who most recently changed record misp broda
Since inspection or accident -- --
Event Location Runway Number and Location -- --
Runway Length -- --
Runway Width -- --
Sight Seeing flight No No
Air Medical Flight No No
Medical Flight -- --