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Dangerous runway incidents at Pearson airport probed in new TSB report

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Dangerous runway incidents at Pearson airport probed in new TSB report

The Transportation Safety Board is set to release a new report on its investigation into a series of runway incidents at Canada's busiest airport.

Transportation Safety Board will release details of its investigation starting at 10 a.m. ET

CBC News · Posted: Jan 31, 2019 8:55 AM ET | Last Updated: a minute ago
 
The TSB releases a report on its investigation into a series of dangerous runway incursions at the country's busiest airport. 0:00

 

The Transportation Safety Board is set to release a new report on its investigation into a series of runway incidents at Canada's busiest airport.

The independent safety watchdog's findings on runway incursions at Toronto's Pearson International Airport will be released at a news conference starting at 10 a.m. ET.

A runway incursion is when an aircraft or ground vehicle "mistakenly occupies an active runway," according to the TSB.

Since 2010, the TSB has completed probes into 10 separate incursions at Pearson. They include several incidents that involved two planes colliding at low speeds. 

Between 2013 and 2017, Nav Canada — the organization that oversees Canada's civil aviation navigation system — reported an average of 445 runway incursions at airports each year. While the "vast majority" of those instances posed little or no risk to passengers, crew and airport staff, 21 of them were classified as "high severity," the TSB says.

"These could have led to a collision with aircraft, damage, injuries and loss of life," it says on its website. 

Over that same period, there has been an 18 per cent increase in the overall rate of runway incursions per 100,000 arrivals and departures across Canada. 

While industry stakeholders have taken actions to address the problem of incursions, the TSB says more can be done.

"Additional technological improvements could be made, for example, runway status lights, a form of direct-to-pilot warning. These exist in at least 23 international locations, though none has yet been installed in Canada," the agency says.

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With the 24's there is no taxiway in between (too close together) and I am guessing that is where most of the incidents occur. Even something as basic as red flashing taxiway lights would help.

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Pearson runway 'incursions' pose serious crash risk: safety board

by The Canadian Press

Posted Jan 31, 2019 6:43 am EST

Last Updated Jan 31, 2019 at 10:50 am EST

 
tsbreport-jan31.jpg
The Transportation Safety Board of Canada speaking at a news conference on Jan. 31, 2019, about improving runway safety at Pearson International Airport. CITYNEWS/Adrian Ghobrial
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Air safety authorities say the runway setup at Toronto’s Pearson International Airport poses a serious risk of crashes.

The Transportation Safety Board (TSB) said there were 27 runway incursions between June 2012 and November 2017.

Incursions occur when an aircraft finds itself on the wrong runway.

The board said the incursions all involved aircraft that landed on an outer runway but ended up on an adjacent inner runway.

The incidents occurred despite instructions from air traffic control to stop before entering the second runway.

The report cites design problems with the airfield and busy flight crews missing various cues.

“All 27 incursions examined involved flight crews who understood they needed to stop, and that they were approaching an active runway,” Kathy Fox, chairperson of the board said in a statement.

“Despite all the visual cues, including lights, signage and paint markings, professional crews were not stopping in time as required, thereby risking a collision with another aircraft on the other runway.”

Below are the recommendations made by the TSB:

  • Air traffic controllers need to issue more emphatic and clearer safety instructions to flight crews
  • Change procedures so crews do post-landing checks only after clearing all active runways
  • Change the unique layout of runways and taxiways at Pearson

 

“Safety is our top priority, and we will continue to make improvements that enable continued safe operations for the surrounding communities and the nearly 50 million people who use Toronto Pearson on an annual basis,” the Greater Toronto Airports Authority said in a statement.

“Since 2013, the GTAA has continued to address incidents at Toronto Pearson by working with the air carriers, particularly those regional U.S. carriers that experience a higher number of the incidents. In addition to specific enhancements to our runways and taxiways, new lighting systems, and mandatory LED backlit signage, we have also provided up-to-date safety information and educational outreach to these carriers about our operations.”

Watch the full Transportation Safety Board’s press conference below.

https://toronto.citynews.ca/2019/01/31/tsb-runway-incursions-pearson/

http://www.bst-tsb.gc.ca/eng/medias-media/communiques/aviation/2019/a17o0038-20190131.asp

TSB makes four recommendations to improve runway safety at Canada’s busiest airport

Richmond Hill, Ontario, 31 January 2019 – Today, the Transportation Safety Board of Canada (TSB) is making four recommendations, following its safety issue investigation (A17O0038) into 27 runway incursions that occurred between two closely spaced parallel runways at Toronto/Lester B. Pearson International Airport, Ontario, between June 2012 and November 2017.

“Pearson International airport traffic is tightly controlled and monitored, and all 27 incursions examined involved flight crews who understood they needed to stop, and that they were approaching an active runway,” said Kathy Fox, Chair of the TSB. “Despite all the visual cues, including lights, signage and paint markings, professional crews were not stopping in time as required, thereby risking a collision with another aircraft on the other runway.”

The investigation found that all the incursions happened on the inner runway, after the flight crews involved had landed on the outer runway and were taxiing on a rapid-exit taxiway between the two runways. Several characteristics of the rapid exits in this area, known locally as the “south complex,” are different from almost every other major airport in North America. The exits lead directly to the “inner” parallel runway, the hold lines are located immediately following a 65-degree curve and, most notably, they are farther away from the protected runway than is commonly seen elsewhere. These uncommon features mean that the hold lines are not where crews are expecting to see them.

It was also determined that, although flight crews were aware of the increased risk for runway incursions in the area because they are designated as “hot spots” on the airport charts, that guidance did not bring crews' attention to specific strategies to mitigate the risk of incursion. Instead, crews followed their standard operating procedures and initiated their post-landing actions immediately after exiting the runway, taking their attention away from other more critical tasks—such as identifying the hold line. The timing of those tasks distracted the crew at a point when limited time was available to recognize the visual cues requiring them to stop, and contributed to their overlooking those cues.

Today, the TSB is making four recommendations to make these runways safer. The first one is that NAV CANADA amend its phraseology guidance so that safety-critical transmissions are more compelling to flight crews in order for crews to take the safest course of action. The next two recommendations are for Transport Canada and the United States Federal Aviation Administration (FAA) to work with operators to amend standard operating procedures so that crews only commence post-landing checks after a landing aircraft has cleared all active runways. Finally, the Board recommends that the Greater Toronto Airports Authority make physical changes to the taxiway layout at Pearson International's south complex to address the risk of incursions between the parallel runways.

“Fixing these complex issues won't be easy, which means all those involved must work together,” said Fox. “Because clearly, more needs to be done—so that all flight crews see the cues and react as required.”

More details about the Board's recommendations can be found in the backgrounder.


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.

For more information, contact:
Transportation Safety Board of Canada
Media Relations
Telephone: 819-994-8053

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Landing on the outer parallel and holding short of the inner while monitoring tower frequency is standard ops for all of the large scale US airports.

Not sure they are seeing the same problems as CYYZ.

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Is Heathrow busier than CYYZ ???

Heathrow uses a similar runway pattern much differently.  One runway for landing another for departures.

KLAX is similar as well, if you split the north and south complex, and view them as separate airports.

Separation is not the same issue in these types of utilizations.

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13 minutes ago, rudder said:

How about ATL? Busiest airport on the planet. Same setup x2.

Very good example.

It illustrates the point I was trying to make, that "new" ideas are not required here in an attempt to re-invent the wheel.

On top of that if we would like to discuss the ancient and pathetic airspace structure around CYYZ, that may be worth looking at.

CYYZ has added imo, ridiculous night time RNAV approaches that are not very efficient in that they don't even tie in to the conventional RNAV Stars (arrival routes).

This has the effect of hanging the aircraft high, when finally once receives a clearance for one of these approaches.

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Note the mention of US Regionals.

Greater Toronto Airports Authority statement regarding the Transportation Safety Board of Canada’s January 31 report on runway incursions at Toronto Pearson

Provided by Greater Toronto Airports Authority

January 31, 2019

logo_topnav_toronto_pearson.gif

The GTAA is reviewing the recommendations of the Transportation Safety Board. We welcome the findings and we have fully participated in the review. Safety is our top priority, and we will continue to make improvements that enable continued safe operations for the surrounding communities and the nearly 50 million people who use Toronto Pearson on an annual basis. Since 2013, the GTAA has continued to address incidents at Toronto Pearson by working with the air carriers, particularly those regional U.S. carriers that experience a higher number of the incidents. In addition to specific enhancements to our runways and taxiways, new lighting systems, and mandatory LED backlit signage, we have also provided up-to-date safety information and educational outreach to these carriers about our operations. We remain vigilant with regard to industry trends and developments in technology that can help us meet our commitment to safety.

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Slow news week. 

Toronto/YYZ is no different from many other major airports around the world. For example, Chicago/ORD is one of several legacy fields which have evolved into multiple runways, complex taxiways and terminals. 

Perhaps the TSB should be looking at experience levels or fatigue issues of pilots in 2019.

Also, the added phrase “Cleared to land 06R, expect to hold short of 06L” would give pilots a “heads up”. No different from a “Cleared to YYZ via the Duvos One Arrival. Expect to hold at Boxum”. 

Edited by blues deville

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CYYZ is an airport where if you dare to change comm frequency without being instructed to do so you will be ignored then lectured.

Perhaps ATC MANOPS for Pearson should be examined.

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The big difference when comparing YYZ to ORD or ATL is that the parallel runways at the those US airports have an taxiway running between the two. YYZ does not and that was one of the most concerning aspects with the TSB.

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2 hours ago, Trader said:

The big difference when comparing YYZ to ORD or ATL is that the parallel runways at the those US airports have an taxiway running between the two. YYZ does not and that was one of the most concerning aspects with the TSB.

SFO does not. 28L/28R

Not sure if SFO is having this problem also. And in SFO foreign carrier ESL issues are prevalent.

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3 hours ago, Trader said:

The big difference when comparing YYZ to ORD or ATL is that the parallel runways at the those US airports have an taxiway running between the two. YYZ does not and that was one of the most concerning aspects with the TSB.

This TSB group needs to travel. 

Many don’t such as LAX 24L/R. Usually land on the right side and cross over to the terminal. No taxiway between them.

 

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21 hours ago, rudder said:

CYYZ is an airport where if you dare to change comm frequency without being instructed to do so you will be ignored then lectured.

Perhaps ATC MANOPS for Pearson should be examined.

Why would you?

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22 hours ago, rudder said:

CYYZ is an airport where if you dare to change comm frequency without being instructed to do so you will be ignored then lectured.

Perhaps ATC MANOPS for Pearson should be examined.

If you change comm frequency without being instructed to do so, how the heck would they be able to contact you ??? 

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23 hours ago, Malcolm said:

If you change comm frequency without being instructed to do so, how the heck would they be able to contact you ??? 

Ahhh, the perfect "non-pilot" question!  You win a gold star - ⭐

 

The answer to that question would take many paragraphs, rejoinders, caveats, warnings and several "special cases" but suffice to say there are some situations where a frequency change is obvious.

Edited by seeker

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On 2/1/2019 at 1:17 PM, rudder said:

CYYZ is an airport where if you dare to change comm frequency without being instructed to do so you will be ignored then lectured.

Perhaps ATC MANOPS for Pearson should be examined.

I fully agree ATC has a responsibility in rectifying this problem but I don’t think YYZ is unique in handling pilots who change frequencies without authorization. If a busy controller loses contact with you while you’re moving around an airport surface you’d better have either a good reason or a good apology ready to share.

That AC flight into SFO missing several calls to G/A from the tower could have gotten an earful but instead just a sarcastic response. I think the flightcrew heard that loud and clear. 

 

Edited by blues deville

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54 minutes ago, seeker said:

Ahhh, the perfect "non-pilot" question!  You win a gold star - ⭐

 

The answer to that question would take many paragraphs, rejoinders, caveats, warnings and several "special cases" but suffice to say there are some situations where a frequency change is obvious.

Only some?  Then the change without notice is dumb....  A Non Pilot Answer.

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1 hour ago, Malcolm said:

A Non Pilot Answer.

Exactly.

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1 hour ago, Malcolm said:

Only some?  Then the change without notice is dumb....  A Non Pilot Answer.

Well..... I'll just throw out a couple of  times where the change of frequency is obvious and is done without notice.....ON THE GROUND......If one is on the ground at an airport and monitoring your last assigned frequency and oddly you stop hearing any TX...it may be that your radio has failed on that frequency. Time to go to another  airport frequency. Bear in mind, one would not move the aircraft  beyond the previously cleared point ..... especially if it meant crossing an active runway. 

IN THE AIR.....When flying and you enter another countries FIR and have not been advised to change frequency  by your last ATC controller and you can not contact them, (your last controller) on any of "their" frequencies it would be advisable to attempt contact on  frequencies that are applicable for the FIR you just entered.

Certainly there are other reasons where changing frequency without notice may be warranted but those reasons would be super exemptions and probably only utilized to prevent a disaster.

Every pilots main concern is the safety of their aircraft and its contents but there are times when common sense prevails and radio frequencies are changed without being  advised to do so.

  • Thanks 1

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Many airports around the world have their own specific procedures for automatic frequency changes which pilots know to follow. LAX for example has their “50 yard line” separating the north and south side ground control and departing LAX taxiing to 25L/R you pass by a sign advising you to “monitor” tower. All of these procedures save numerous repeated calls to aircraft maneuvering on the ground.

Perhaps YYZ needs to look at these methods to relieve controllers who could focus on other duties. When you’re taxiing towards a runway within a few feet of the departure end, I don’t know why you need a voice call to tell you to switch to tower. 

Edited by blues deville
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4 hours ago, blues deville said:

Perhaps YYZ needs to look at these methods to relieve controllers who could focus on other duties. When you’re taxiing towards a runway within a few feet of the departure end, I don’t know why you need a voice call to tell you to switch to tower. 

1

Bingo, there is even signage in YYZ approaching the holding bays to monitor Tower frequency and yet every time there is a transmission from Ground telling departing aircraft to switch to Tower frequency.

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1 minute ago, Ex 9A Guy said:

Bingo, there is even signage in YYZ approaching the holding bays to monitor Tower frequency and yet every time there is a transmission from Ground telling departing aircraft to switch to Tower frequency.

Well, not every crew is as alert as the AC and WS crews.  I don't have a problem being told to change freqs, the problem I have with YYZ ground movements is when they issue a hold point and then don't give a freq change (because they get busy or forget) and then if you change to the next freq (after a few thousand times I know what the apron freq will be or what the north ground freq is) the next guy doesn't know who you are even though you say "this is so-and-so on Bravo approaching AlphaKilo".  The other option is to stop and wait for 1.2 seconds for them to give the next freq (which I already know) and then power-up to get rolling again.

How is it that in LGA and ORD, two airports I am intimately familiar with, you can and indeed are expected to exit the runway and change to the appropriate ground freq without a formal handoff while YYZ can't seem to handle someone switching from ground to apron at the specified entry point?

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