Serious accident at YYZ narrowly averted

[dagger]

http://www.thestar.c...at-pearson?bn=1

Pilot maneuver averted disaster at Pearson

Lesley Ciarula TaylorStaff Reporter

The Transportation Safety Board of Canada and American Airlines are investigating a near-collision on a Pearson International Airport runway that forced an Air Canada pilot into emergency manoeuvres to avoid disaster.

Air traffic controllers ordered an American Eagle commuter plane to “stop, stop, stop” as it meandered onto a runway where the Air Canada Airbus was taking off on Nov. 18.

“I can confirm we are working with the Transportation Safety Board in Canada and an internal investigation,” American Airlines spokeswoman Mary Frances Fagin told the Star on Friday.

She declined to elaborate.

The 50-seat American Eagle Embraer EMB-145 commuter plane had just landed on a flight from Chicago at 11:27 p.m. on runway 24L, the Transport Canada Civil Aviation Daily Occurrence Report said.

Air traffic controllers told the pilots to move off to runway at the Delta 4 exit and stay off runway 24L, the report said.

“The flight crew read back the instruction correctly,” report author John Donaldson said.

A 120-seat Air Canada Airbus 319 headed for Halifax was moving down runway 24R. An air traffic controller saw the American Eagle “passing the hold line and stop bars” and ordered, “Stop. Stop. Stop.”

The commuter plane kept going and stopped partially on the runway, the report said. The flight crew contacted the tower with the words, “Say again.”

The Air Canada pilot “rotated around taxiway Delta 2 and overflew” the commuter plane in its way.

American Airlines owns the regional American Eagle carrier.

Transport Canada, Air Canada and the Greater Toronto Airports Authority were not immediately available for comment.

U.S. safety experts familiar with the incident told the Wall Street Journal that the incidents appears to be one of the most serious near-collisions reported recently in North America.

A U.S. Government Accountability Office report last month noted that the United States has not experienced a fatal commercial airline crash since 2009.

Air Canada’s last crash was in 1997, in Fredericton, N.B., and last crash involving death was in 1983. American Eagle had two fatal crashes in 1994, one in 1992 and one in 1988.

[AAS]

"Air traffic controllers told the pilots to move off to runway at the Delta 4 exit and stay off runway 24L, the report said."

Thats not exactly what CADORS says.

"NAV CANADA staff at Toronto Tower reported that EGF4125 had landed on runway 24L and was instructed to exit at taxiway DELTA4 and hold short of runway 24R."

And that makes more sense.

[Ex 9A Guy]

Link here to the report on avherald.com usually a pretty reliable source.

YYZ Runway Incursion

How to find the audio on LiveATC.net

To find the ATC recording from this incident, goto the archive that Derek specified (YYZ TWR, Nov 18, 2300-2330).

Jump to 19:08 in the timeline. You will hear TWR clear AC614 for T/O. AC614 acknowledges T/O clearance. TWR instructs EF4125 to exit RW 24L at D4 and Hold Short 24R.

TWR radios "STOP, STOP, STOP" at 19:55. TWR instructs EF4125 to phone TWR at 20:40.

[J.O.]

Very fortunate that this wasn't worse.

[dagger]

Interesting comments with that AvHerald story

[Kip Powick]

Just be thankful that more than 95% of the individuals making comments after the published story in the BIG YZ newspapers, are not involved in the aviation industry...sheeeesh

[Don Hudson]

These are the same issues with the LAX double-parallels. IIRC, there are even notes on the charts to maintain extra vigilance when landing on and clearing from the outboard parallels. The airport video should show how far the Eagle was into the runway after the crew said to the tower, "Say again...?"

The AC A319 rotated just before D2 according to the AVHerald story; I wonder how close to Vr the AC flight was when he rotated for the liftoff?

The "Caution:" on the Airport Chart kinda says it all...

Don

[Dork]

These are the same issues with the LAX double-parallels. IIRC, there are even notes on the charts to maintain extra vigilance when landing on and clearing from the outboard parallels. The airport video should show how far the Eagle was into the runway after the crew said to the tower, "Say again...?"

The AC A319 rotated just before D2 according to the AVHerald story; I wonder how close to Vr the AC flight was when he rotated for the liftoff?

The "Caution:" on the Airport Chart kinda says it all...

Don

Hey Dag...

You get what you pay for. Good luck...this is the tip of the iceberg.

More to come...Watch the LCCs fold and the pension thieves try to push them....Think of lawn darts...

Dork

[Kip Powick]

Hey Dag...

You get what you pay for. Good luck...this is the tip of the iceberg.

More to come...Watch the LCCs fold and the pension thieves try to push them....Think of lawn darts...

Dork

????????????????????????????????????

[CAT3DUAL]

It's going to be interesting to find out what sort of duty day the American Eagle crew had on the go.

[Don Hudson]

It's going to be interesting to find out what sort of duty day the American Eagle crew had on the go.

Well, that's completely true I think. There is a great deal more to a serious mistake like this than can be said at the moment.

The Colgan accident highlighted a number of issues which have been in the background particularly with regional carriers in the US. The higher standards for licensing and training as well as experience may be part of this near-accident.

Dork, I think I understand what you're trying to say and probably don't disagree with you regarding some of these factors.

That said, this isn't the tip of the iceberg until we know what happened. It will be interesting to see what the report has to say about crew training, experience and recency as well as duty day. Maybe there's a medical issue, maybe they lost situational awareness, maybe they had an interruption from the cabin, maybe someone's got a divorce or a bankruptcy going on, etc, etc. We just don't know. And we don't know how close the A319 was to rotation speed or whether the aircraft was pulled up at or even below V1, (Vr usually is equal to V1 on this airplane). Perhaps the captain knew that the tailored WAT speeds are intended to lift maximum weight off each runway (overspeed technique) and s/he already had lots of speed (well above VMCA but below Vr for the runway but also still safe for the weight).

All this and more has to be considered and taken further or dismissed. The incident history of these parallels will also be examined but I don't seem to recall them being as notorious as Los Angeles, especially the 24's.

Don

[Kip Powick]

Don/Dork..

AMR owns American Eagle, has since the mid to late '90s.

As I recall it is a regional airline, not a LCC and I believe it has over 270 aircraft and flys to over to over 150 destinations.(my memory is probably failing me with some of the numbers so bear with me)

No matter what we find through the investigation, this is, IMO, not "the tip of the iceberg."

This is a simple case of lost situational awareness and it could have happened to anyone for, at this time, reasons unknown.

Had this incident been between two major airlines with WB aircraft no one would be insinuating that the error was because "you get what you pay for".

They screwed up, plain and simple and hopefully the 'investigation' ascertains why.

The problem with any "incident that happens on "our" turf " is all the arm-chair quarterbacking that springs out of the woodwork almost immediately.

Don, I believe you are one of the most ardent supporters of "let's see what comes out of the investigation FIRST".....bravo.

PS.....the real tradgedy is the most recent fatal(6 deaths) accident, (father, 3 of his kids, copilot, mechanic) in Arizona and unfortunately that aircraft , I believe, had no CVR or FDR.

[Seeker]

The following link has nothing to do with the incident at YYZ but it gives me a cold feeling every time I listen to it/watch it:

[J.O.]

That is an excellent training video and should be mandatory viewing for every IFR pilot and controller in the business. I really feel for the controller who was working "blind" and who acted based on what she believed to be the real traffic situation. An unresolved ambiguity is easy to overlook when one is task saturated. Thankfully the USAir crew were listening carefully and chose rightly to set the brakes until the issue was resolved. I am not attempting to throw a dig in here, but imagine if this had been a bilingual tower and the UAL crew had been speaking a different language ...

[deicer]

It may be naive thinking, but wouldn't it be safer and more efficient to depart 24L and arrive 24R?

The way I look at it is that it would make for only one crossing point, at the threshold, rather than the potential of multiple crossing points with the different arriving aircraft and having to hold for an aircraft that may already be rolling.

Inbound aircraft would clear to the infield without interfering with takeoffs, and departing aircraft would be held until absolutely certain the way was clear across the arrival runway.

If a large aircraft requires the additional runway length, then it would seem to be easier to slot the occasional departure between arrivals on 24R and keep allowing the rest to stage across to 24L.

The reverse would work as well for the 6's.

Any thoughts?

[J.O.]

That's a reasonable question. I'm no expert on the subject but I suspect that every possible permutation was considered before the current traffic management plan was put in place. The problem I see with reversing it is the fact that an aircraft waiting on the ground for takeoff is a higher priority than an aircraft waiting on the ground after landing. Given that airlines are trying to minimize the amount of pre-departure taxi fuel, I understand the motivation. When a landing aircraft and a departing aircraft are sharing the same runway, the lander has priority. A departing aircraft that is crossing the landing runway faces the same priority, because they are sharing the same runway while he's crossing. The other consideration is that crossing an active runway is not a very speedy exercise, especially with a fully loaded widebody that's come to a full stop at the hold line. When the dual operation is in use, arrivals tries their best to apply minimum separation on the landing runway. If the crossing aircraft is a bit slow getting clear and you have to send a lander around, you've just added an additional arrival into the mix at a time when you're already at close to full capacity under the dual operation.

[Moon The Loon]

The following link has nothing to do with the incident at YYZ but it gives me a cold feeling every time I listen to it/watch it:

Sent more than shivers up my spine. What on earth was the controller thinking? There was a definite lack of "listening" going on. Good on the second FedEx to take a deep breath and wait.

[Kip Powick]

Sent more than shivers up my spine. What on earth was the controller thinking? There was a definite lack of "listening" going on. Good on the second FedEx to take a deep breath and wait.

:Grin-Nod: Actually...there was no second FedEx aircraft waiting for TO..It was a US Air :Grin-Nod:

[Moon The Loon]

:Grin-Nod: Actually...there was no second FedEx aircraft waiting for TO..It was a US Air :Grin-Nod:

picky, picky, picky... :b:

[Kip Powick]

Yeh, I was just funnin' you !!

************************************************************

For all of you still enjoying the "pointy end"......................

Remember when you are out there...listen...listen...listen...

Fly Safe

[Don Hudson]

Don/Dork..

AMR owns American Eagle, has since the mid to late '90s.

As I recall it is a regional airline, not a LCC and I believe it has over 270 aircraft and flys to over to over 150 destinations.(my memory is probably failing me with some of the numbers so bear with me)

No matter what we find through the investigation, this is, IMO, not "the tip of the iceberg."

This is a simple case of lost situational awareness and it could have happened to anyone for, at this time, reasons unknown.

Had this incident been between two major airlines with WB aircraft no one would be insinuating that the error was because "you get what you pay for".

They screwed up, plain and simple and hopefully the 'investigation' ascertains why.

The problem with any "incident that happens on "our" turf " is all the arm-chair quarterbacking that springs out of the woodwork almost immediately.

Don, I believe you are one of the most ardent supporters of "let's see what comes out of the investigation FIRST".....bravo.

PS.....the real tradgedy is the most recent fatal(6 deaths) accident, (father, 3 of his kids, copilot, mechanic) in Arizona and unfortunately that aircraft , I believe, had no CVR or FDR.

Kip;

You wrote, "Don, I believe you are one of the most ardent supporters of 'let's see what comes out of the investigation FIRST.' "

Yes, I am, which is why I wrote, "That said, this isn't the tip of the iceberg until we know what happened.", and;

"It will be interesting to see what the report has to say about crew training, experience and recency as well as duty day. Maybe there's a medical issue, maybe they lost situational awareness, maybe they had an interruption from the cabin, maybe someone's got a divorce or a bankruptcy going on, etc, etc. We just don't know. And we don't know how close the A319 was to rotation speed or whether the aircraft was pulled up at or even below V1, (Vr usually is equal to V1 on this airplane). Perhaps the captain knew that the tailored WAT speeds are intended to lift maximum weight off each runway (overspeed technique) and s/he already had lots of speed (well above VMCA but below Vr for the runway but also still safe for the weight).

All this and more has to be considered and taken further or dismissed."

I note that you have already come to two conclusions:

1. "No matter what we find through the investigation, this is, IMO, not 'the tip of the iceberg.' ", and,

2. "This is a simple case of lost situational awareness and it could have happened to anyone for, at this time, reasons unknown."

I am aware of who owns American Eagle and know that it isn't an LCC - it is a regional which is the reason for my initial remarks. I am referencing a dialogue that occurred here after the Colgan accident, a dialogue which remains open regarding US regional carriers, in my view. Some of the issues, (training, duty days, hiring, experience, cockpit discipline issues, adherence to SOPs, CRM) have been spoken to but the questions on these areas of interest remain if only to be ultimately dismissed, perhaps with some changes. Whether any of these have a bearing on this incident remains to be determined.

I responded to Dork the way I did because I think he pointed to one of the many aspects which require investigation, that of duty day and fatigue and quite reasonably so as this is classic fatigue behaviour. But we won't know until we examine their records, so let's ask the question and find out. No conclusion is drawn here. Asking the question does not imply any particular conclusion.

Further, I recognized Dork's perhaps-blunt characterization, "you get what you pay for" because it is a fact, especially where aviation is concerned. Some here have dismissed past observations, mainly from flight crews and flight safety people, regarding this very principle and told pilots to "get used to what the market will bear". We know very well how our profession has been cheapened but some don't seem to recognize the other side of "market forces" and that there is an equally valid reality which is still unfolding. That reality is a very large subject which is currently in sharper focus, as it ought to be. Loss-of-control accidents, particularly stalling one's aircraft, have increased over the past five years. These accidents have significant human factors aspects and the reasons need to be understood. I know precisely where Dork's remark is coming from and wrote an essay about it which I posted here a while back.

I then disagreed with Dork that, at this point, we can say that this is a "get what you pay for" event. We don't know what kind of incident this is yet.

That conclusion, and any 'conclusion' for that matter, cannot be drawn until a thorough examination of the many aspects of the incident takes place. I listed some but obviously not all which must be examined in my response.

Yes, the accident in Arizona was terribly tragic.

We were in Chandler Wednesday evening preparing for Thanksgiving dinner Thursday when the tragic accident to which you refer occurred. it was dusk, (beautiful sunset), the evening was clear but high clouds were coming in from the northwest, (the next day was overcast and raining later in the day, yesterday was clear and 75F). The accident happened at around 1815 to 1830. The aircraft was on an southeast-bound track from Falcon Field to Safford, about 125nm away. The direct line from Falcon to Safford is west of the Superstitions and the Flat Iron peak area where the accident occurred. A cam of the Superstitions shows the accident aircraft moving from left to right, disappearing for a moment, then a flash and fire.

We don't know yet who was flying (it may not be possible to determine), but at least one on board, the owner of the business that owned (just bought; it hadn't flown in a while) the aircraft would have known the area well and likely Mr. Hardy who was a pilot and who had his three children on board.

Lots of questions here too, the first being about the altitude and track they were on. Which runway did they depart on...the 4's or 22's, (likely the 4's), what track/course was planned, what minimum altitude was planned, did the PIC lose SA in late twilight, what radio aids/nav facilities were available and working, what altimeter settings were given and set, would the dark hills be perceptible in the coming darkness. did they have a GPS? etc, etc.

Really, really sad accident.

Don

[dragon]

It's going to be interesting to find out what sort of duty day the American Eagle crew had on the go.

Most interesting, given Little Rock.

Of course Little Rock, involved a very experienced check pilot, a very inexperienced FO, Little Rock unfolded in poor conditions, following a plethora of cumulative duty and rest period issues.

Little Rock was mainlaine American Airlines.

Regardless of the eventual findings here, fatigue has directly contributed to many unnecessary deaths in Canada and around the world, and will unfortunately, contribute to many more.

Fatigue is NOT being addressed in Canada.