Runway Incursions

[Kip Powick]

OTTAWA—The radar screen Toronto’s Pearson airport told the heart-stopping tale of a looming disaster.

A radar scope in the control tower showed two targets — one of them an Air Canada Embraer jet about to land — on a collision course.

The controller, perched high above the runways and taxiways, could see the landing lights of the approaching jet. But the identity of the other target was hidden in the late-evening darkness.

Unfolding in the darkness at Canada’s busiest airport was a runway incursion, one of the biggest threats to aviation safety today. A Star analysis of Transport Canada data counted 5,677 incursions by aircraft, vehicles and pedestrians since 1999, averaging almost 400 a year.

The controller issued urgent orders to the Air Canada crew to abort their landing to avoid the mystery target — instructions that were ignored.( Is this "Press" playing with the facts or ????)

On the radar screen, the two targets merged — a nightmare scenario for any air traffic controller.

The Air Canada aircraft touched down safely, its crew oblivious to their near-brush — their flight had passed less than 50 feet over a van that had driven into their path.

The March 11 incident was “very close,” an investigator said later.

Just over a week later, pilots of a Boeing 727 cargo jet at Hamilton airport are told to abort their take-off roll. The jet slows to a stop halfway down the runway — ahead are two snowplows.

And in April, a controller at Pearson twice orders the crew of a commuter jet to stop on a taxiway. Yet they continue and intrude on an adjacent runway just as a Sunwing Boeing 737 jet is taking off.

While aviation has been getting safer, runway incursions — when aircraft or vehicles blunder on to an active runway or even taxiway by mistake — remain a weak spot.

The Transportation Safety Board of Canada has warned about “potentially catastrophic outcomes” of incursions.

“There is ongoing risk that aircraft may collide with vehicles or other aircraft on the ground at Canadian airports,” the safety board warned in one report into a close call at the Calgary airport in 2010.

The worst aviation accident ever was a runway incursion at the airport in the Canary Islands, when a departing Boeing 747 collided with another jumbo jet on the runway, killing 583 people.

“It’s a concern worldwide,” said Mark Clitsome, director of air investigations for the safety board, the independent agency that probes transportation occurrences.

“We’ve been watching those numbers for last few years and they’re not going down. So we’re concerned,” he told the Star in an interview.

The safety board has put runway incursions on its watchlist of transportation problems that pose the greatest risk to travellers.

There are many reasons for an incursion. In the case of the Air Canada near-miss, the van had been left in gear when parked at a nearby gate and had rolled across the runway without its driver.

More often, inattention and confusion are to blame. Pilots can lose their way in the maze of taxiways or in a moment’s inattention neglect to hear a controller’s instructions. Radio communications can get mixed up. Airport signs identifying runways and taxiways can be confusing. Vehicle drivers get lost.

“A lot of these airports have multiple taxiways and multiple turn-offs from runways. At night, in poor weather or if (pilots) get busy, they could wind up turning onto the wrong taxiway . . . or crossing a live runway,” Clitsome said.

But technology plays a part, too. The safety board has flagged problems with the radar system that monitors surface movements at Toronto airport and warns controllers of potential conflicts.

The system was “at its limits” and outdated software means the radar “provided insufficient warning time to avert a potential collision,” the board warned after a 2007 investigation into an incursion.

Yet six years later, the recommended upgrades have yet to happen, the Star has learned.

Statistics prepared by a working group to curb incursions counted 1,078 incidents between Jan. 1, 2010 and Dec. 31, 2012. Of those, 126 were blamed on air traffic control, 651 were because of pilot errors and 301 were blamed on pedestrians or vehicles.

“This is an industry that involves a lot of humans and therefore we always have to be conscious of the human error element,” said Rob Thurgur, assistant vice-president, operational support for Nav Canada, the agency that operates the country’s air traffic control system.

“That’s . . . why we have the procedures and the vigilance that is trying to mitigate the human error out of the aviation system,” he said in an interview.

Thurgur also stressed that incursion statistics need to be viewed in context, noting that in most incidents there’s no risk of a collision.

Indeed, of the 1,078 incursions in the last two years, only four were classed as “extreme risk.” Another 16 were deemed “high risk,” 437 had “some risk” and the rest — 621 — had little or no risk, according to numbers compiled by the working group.

The safety board concedes that the chance of an incursion leading to a crash remains “relatively rare.” But it still warns that the “consequences can be catastrophic” because of the chance for a high-speed collision.

The Air Line Pilots Association International has warned that the “risk of a runway incursion event that could kill hundreds of people in a single accident is real and growing larger” because of increasing air traffic.

Nav Canada is heading a working group that includes airline pilots, airport operators, the safety board and Transport Canada to look at curbing incursions.

“We work collaboratively together to come up with the best phraseology, the best signage, the best documentation and the best technology and the best operation and procedures so we can minimize the risk,” Thurgur said.

He said technical troubles have delayed the upgrade of the ground radar system at Pearson urged by the safety board. Originally scheduled for last September, it could be early fall before the new system is ready.

“Because of the complexity of these systems, they don’t just go in overnight,” he said.

“We frankly ran into some software complications and we’ve had to make some changes. We’re still working towards making that upgrade,” Thurgur said.

By late summer, Nav Canada is also planning to add an extra layer of surveillance at Pearson, using aircraft radio transponders to track their position on the airport. The system is already up and running in Montreal and Calg

[boestar]

The instructions I am sure were not "ignored" probably lost in the fray of a critical phase of flight and heavy workload and simply missed.

[Kip Powick]

The instructions I am sure were not "ignored" probably lost in the fray of a critical phase of flight and heavy workload and simply missed.

I have my doubts that they were even "issued" or "missed" and lean toward a made-up story.

I find it hard to believe that the pilots would not see the vehicle, even at night, and if an ATC TX was made to a specific flight number to "GO-AROUND", I don't think it would be ignored, even if the pilots did not know the reason for the call..

...........................but it wouldn't be the first time I have been wrong in May 2013.. !!!!

[Don Hudson]

boestar;

Re, "The instructions I am sure were not "ignored" probably lost in the fray of a critical phase of flight and heavy workload and simply missed."

Yes, I completely agree - it makes no sense whatsoever for an aircrew, especially a Canadian crew, to hear an ATC command to go-around and choose not acknowledge it deciding instead to continue the landing.

A reputation for journalistic accuracy and worthwhile media reporting has to be earned. With very little credibility in journalistic investigation and reporting on aviation matters here and in the U.S. (with notable exceptions such as Andy Pasztor's work in the WSJ and the Canwest-Vancouver Sun's Larry Pynn), one cannot rely upon the daily news stream in order to understand an aviation event but must instead go to a number of sources to balance the "news" for oneself.

The term used by the reporter is "ignored", and I think Kip's comment is correct, although I don't think the press was "playing with the facts" - to give the benefit of the doubt on aviation reporting, I don't think most reporters assigned to cover aviation know enough about aviation to be able to do "play with the facts". Instead, a common-use word, ("ignored"), has been used in a specific way which, in the context of the story, has serious implications in aviation. The choice of the word is merely careless reporting, which is not unexpected.

edit: Hi Kip - contrary to being hard to believe, I think it is completely plausible, given past accidents, that an air crew on approach could not see a vehicle on the runway at night.

The runway collision at Los Angeles is an example, where a USAir B737 on approach collided with a Skywest Metroliner in position. From the Wiki, "The first officer, who was flying the USAir 1493 during the accident leg, reported that he did not see SkyWest 5569 until he lowered the nose of his aircraft onto the runway after landing. He also said that he applied the brakes, but did not have enough time for evasive action. Statements made by passengers who survived the crash were consistent with this testimony.^[6]"

[Seeker]

Kip, the first one has already been dissected here:

http://theairlinewebsite.com/topic/398052-close-one/

[Johnny]

Kip;

The amount of superfluous calls between 2000' AGL and landing is out of control. Dictated by junior office managers, that have never been (real) Pilots.

[Kip Powick]

Kip, the first one has already been dissected here:

http://theairlinewebsite.com/topic/398052-close-one/

Ok..Thanks for the link..of which only the audio worked !!!

I agree with comments where most feel the controller did not use the correct/complete call sign as well as it was a very hurried TX.......The lack of call sign could be a reason the crew disregarded the call.

Thanks to all for the comments.

PS...back when the earth was flat and I was going through Harvard training (RCAF), we had a guy bail-out, (student flying solo), because the tower controller prefaced the aircraft number with the wrong Training Squadron Call Sign...

[Specs]

"We’ve been watching those numbers for last few years and they’re not going down. So we’re concerned,”

That was the line that grabbed my attention.

[J.O.]

Those recordings do not tell the whole story because they are clipped. That site uses recordings that are picked up by a scanner. I have it on reliable authority that the controller used the full call sign every time he called that flight.

[Seeker]

Those recordings do not tell the whole story because they are clipped. That site uses recordings that are picked up by a scanner. I have it on reliable authority that the controller used the full call sign every time he called that flight.

That's certainly possible and if you heard it from someone who heard the actual tower recording I believe it too but, as I said in the previous thread - even if the controller used the correct phraseology he made two brief, low-key, relatively monotone, transmissions very late in the approach of the aircraft when he was aware of the developing situation several minutes earlier. The pilots should have heard them and should have done a go-around but if he had told them when they were first handed over from the arrival guy about the issue and told to be ready for a possible go-around and/or said in a louder and more commanding tone;

"AIR CANADA 178 GO-AROUND!" rather than, "air canada 178 go-around" maybe the guys would have actually heard it and responded.

[J.O.]

I wasn't passing blame on anyone, just refuting comments (again - as I did before on the other thread) that the guy in the tower didn't use proper phraseology.

[Guest]

Lack of coordination contributed to a 2016 runway incursion at Calgary International Airport, Alberta Français

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NEWS PROVIDED BY

Transportation Safety Board of Canada

12:00 ET

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EDMONTON, Feb. 5, 2018 /CNW/ - In its investigation report (A16W0170) released today, the Transportation Safety Board of Canada found that the common practice of clearing aircraft and vehicle movements across an infrequently used runway without prior coordination contributed to a runway incursion at the Calgary International Airport, Alberta, in December 2016. The risk of collisions on runways is on the TSB's Watchlist of issues that must be addressed to make Canada's transportation system even safer.

 

In the late afternoon of 2 December 2016, the Calgary airport switched operations from using parallel north/south runways to the infrequently used Runway 29 due to strong westerly winds. Consequently, Air Canada flight 221 was cleared for takeoff on Runway 29 by the tower controller. However, during the takeoff roll, the flight crew saw a Sunwest Aviation cargo aircraft crossing Runway 29 on Taxiway A. Because the Sunwest aircraft was more than halfway across Runway 29 at that time, the Air Canada crew elected to continue with the takeoff, which was completed without further incident.

The investigation determined that the runway incursion occurred after the ground controller cleared the Sunwest aircraft to cross Runway 29 while the Air Canada flight was departing. The ground controller, who was simultaneously overseeing the movement of two other aircraft, inadvertently applied the usual practice of clearing aircraft to cross Runway 29 without coordinating with the tower controller. Since the construction of parallel runways in 2014, Runway 29 was mostly used at night – when ground and tower control responsibilities are combined and coordination is not required – and during strong westerly winds during the day. As a result, there was little opportunity to maintain proficiency in Runway 29 operations during the day, and no training to practice those operations, including the need to coordinate before crossing Runway 29. Additionally, the runway jurisdiction system on the controllers' displays, a tool to remind them of which controller is responsible for which runways, did not provide a sufficiently compelling cue to ensure coordination with tower control before clearing an aircraft to cross Runway 29.

There have been four other runway incursions involving Runway 29 at the Calgary airport since parallel runway operations began in 2014. Issues of declining proficiency with Runway 29 operations were identified through NAV CANADA's safety management system (SMS). Although some corrective measures were taken, further safety action that had been identified was not pursued. If proposed safety actions are not tracked to completion, there is an increased likelihood that identified safety risks will not be effectively mitigated. Safety management and oversight is an issue on the TSB Watchlist.

Following this occurrence, NAV CANADA took a number of steps to improve procedures for Runway 29 operations at the Calgary airport. It has created a new "monitor" control position to provide more effective surveillance when using Runway 29. It has also improved the display systems used by controllers as memory aids when coordination is required.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.

The TSB is online at www.tsb.gc.ca. Keep up to date through RSS, Twitter (@TSBCanada), YouTube, Flickr and our blog.

SOURCE Transportation Safety Board of Canada