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TSB Canada: Toronto runway incursions due to uncommon taxiway layout between parallel runways
31 January 2019

The Transportation Safety Board of Canada (TSB) published its report of the investigation into 27 runway incursions that occurred between two closely spaced parallel runways at Toronto/Lester B. Pearson International Airport, Canada, between June 2012 and November 2017.

The investigation found that all the incursions happened on the inner runway (24R), after the flight crews involved had landed on the outer runway (24L) 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.

The TSB made 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.

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