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Missed Turn at YYZ


blues deville
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AC mainline goes around after Sky Regional busts one of YYZ's more serious runway incursion hot spots. 

https://www.aeroinside.com/item/8074/sky-regional-e175-at-toronto-on-jul-28th-2016-runway-incursion?utm_source=newsletter&utm_campaign=20160816

Edited by blues deville
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Typically we only hear negative occurrences from the media.  I'm sure there are plenty of positive examples of the operation, none that we will ever hear about.  I'm not defending them, but this sort of thing does happen - even to the best of us.

 

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If there are taxiway intersections which have repeated incursions, highlighting the hot spots on a Jepp 10-9 chart is not a foolproof solution. New airport signage or surface painted markings need to be developed before the result is more serious than a go-around.

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3 hours ago, hollywud said:

Typically we only hear negative occurrences from the media.  I'm sure there are plenty of positive examples of the operation, none that we will ever hear about.  I'm not defending them, but this sort of thing does happen - even to the best of us.

 

Absolutely true, hollywud. Thankfully, my first and last one was at Logan ~1995. I caught myself just crossing the hold-short line on 15R. A few years earlier, we lined up on what we thought was the intersection of 06L @ CYUL during a blizzard. In fact, we lined up on 10, with a clearance to takeoff. The error was caught and the takeoff not attempted. Tower was advised and nobody lost an eye.

A HEADING CHECK PRIOR TO THROTTLE UP SHOULD BE A MENTAL CHECK BY EVERY PILOT ON EVERY TAKEOFF!!!!!

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3 hours ago, Moon The Loon said:

Absolutely true, hollywud. Thankfully, my first and last one was at Logan ~1995. I caught myself just crossing the hold-short line on 15R. A few years earlier, we lined up on what we thought was the intersection of 06L @ CYUL during a blizzard. In fact, we lined up on 10, with a clearance to takeoff. The error was caught and the takeoff not attempted. Tower was advised and nobody lost an eye.

A HEADING CHECK PRIOR TO THROTTLE UP SHOULD BE A MENTAL CHECK BY EVERY PILOT ON EVERY TAKEOFF!!!!!

I believe map/runway/heading check is now part of all Boeing SOP's. 

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Not to defend their lack of attention to detail, but taxiing outbound for departure of YYZ 23 is normally A and H.

It's possible that the non-standard taxi routing may have played a role in my mind. "A" ends at "H".  "B" crosses it, and also crosses 05-23.

 

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3 hours ago, Moon The Loon said:

Absolutely true, hollywud. Thankfully, my first and last one was at Logan ~1995. I caught myself just crossing the hold-short line on 15R. A few years earlier, we lined up on what we thought was the intersection of 06L @ CYUL during a blizzard. In fact, we lined up on 10, with a clearance to takeoff. The error was caught and the takeoff not attempted. Tower was advised and nobody lost an eye.

A HEADING CHECK PRIOR TO THROTTLE UP SHOULD BE A MENTAL CHECK BY EVERY PILOT ON EVERY TAKEOFF!!!!!

Runway 10 at YYZ? You sure your surname isn't Wright, or Bleriot? ;)

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51 minutes ago, Canoehead said:

Not to defend their lack of attention to detail, but taxiing outbound for departure of YYZ 23 is normally A and H.

It's possible that the non-standard taxi routing may have played a role in my mind. "A" ends at "H".  "B" crosses it, and also crosses 05-23.

 

It's very possible Canoehead. I think "B" is normally a southbound taxi route when landing 05/23. The odd time I've had to use 15L due to performance, we've taxiied north on "A" to "H" and made the left turn to"B" to cross 05/23. That zig-zag helps reduce the potential error.

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OANS or EFB map displays are a great tool for airport ground navigation. There is still the man/machine connection which results in today's human error incidents. 

OANS: http://www.airbus.com/newsevents/news-events-single/detail/on-board-airport-navigation-system-oans-debuts-on-a320-and-a330-families-of-aircraft/

EFB: http://www.boeing.com/commercial/aeromagazine/aero_23/EFB.pdf

 

Edited by blues deville
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Yet another one at one of Toronto's south end hot spots. Is the problem fatigued commuter/connector pilots or YYZ itself?

https://www.aeroinside.com/item/8125/expressjet-crj9-at-toronto-on-aug-16th-2016-runway-incursion?utm_source=newsletter&utm_campaign=20160823

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4 hours ago, blues deville said:

Yet another one at one of Toronto's south end hot spots. Is the problem fatigued commuter/connector pilots or YYZ itself?

https://www.aeroinside.com/item/8125/expressjet-crj9-at-toronto-on-aug-16th-2016-runway-incursion?utm_source=newsletter&utm_campaign=20160823

That configuration has stop bars protecting 24R/06L.  The article does not indicate if they were active or not.  Pretty much all you can do has been done short of a MAJOR re-design of that south complex such as end-around taxiways (not likely to happen).  Perhaps more emphasis on surface operations during recurrent training might be one partial solution.

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2 hours ago, Robert Perkins said:

That configuration has stop bars protecting 24R/06L.  The article does not indicate if they were active or not.  Pretty much all you can do has been done short of a MAJOR re-design of that south complex such as end-around taxiways (not likely to happen).  Perhaps more emphasis on surface operations during recurrent training might be one partial solution.

Emphasis during recurrent would certainly be a good thing but I've always thought landing on 06R/24L at YYZ and then crossing the parallel was just accident waiting to happen. During night time ops its pretty hard to miss those stop bars. Not sure, as you say, if they were functioning or not.

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The only way to ensure hold short is to have bollards come up and bar the way. If you are unfamiliar with the airport and the lighting scheme and not paying 100% attention you will cause an incursion sooner or later.

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16 hours ago, mo32a said:

The only way to ensure hold short is to have bollards come up and bar the way. If you are unfamiliar with the airport and the lighting scheme and not paying 100% attention you will cause an incursion sooner or later.

Maybe YYZ needs to install something like that ASAP.

https://www.aeroinside.com/item/8130/canada-a333-at-toronto-on-aug-17th-2016-runway-incursion?utm_source=newsletter&utm_campaign=20160824

Edited by blues deville
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IMO, this is part human factor, part systemic (overloaded freq, equipment, traffic flow).  No one goes to work in this business, in any seat,  with the intent of being a slacker.  No point in casting blame if best efforts are continuing to yield unsafe outcomes. 

Have a look at YYZ's ground layout, traffic flow and ATC interface.   Consider the timing of a lot of critical communications when compared with the timing of onboard calls.

In my opinion, ground operations such as YYZ, but certainly not only there,  include a constant process where one step opens holes in the Reason layers, requiring the successful execution of a later step to prevent an incursion.    There are plenty of cases now where the crew was cleared to do something, then the cancellation of that clearance was blocked.  The crew went with the instruction they heard last.

That' of course, is not the only cause, it's a web.  There are still too many events where the callsign is clipped off the front of the ATC transmission.  I was taxiing just a short while ago when there were two aircraft in motion with the last three digits of the flight number the same.  Clipped transmission, wrong aircraft took the instruction.  Nothing happened in that case because the other crew spoke up and asked, 'was that for us?'. 

ATC is not doing this on purpose and really is in a tough spot.  The individual transmitting can't tell if their transmission is clipped or blocked and the flight crew may  be dealing with all sorts of noise, cabin secure call, company frequency (should not be active but often is), auto callouts caused by pre takeoff checklists such as config tests (aircraft dependent) or 'approaching runway' (again aircraft dependent)

A number of US airports are installing runway safety aids in recognition of just how tough a nut this is to crack.  To the poster's points above, unless we deal with the overall event environment and change the infrastructure itself, you can swap any airline's name into these incident reports.  It's not if, it's when.

All just my opinion

Vs

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