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Misinterpretation of ATC communication factor in August 2019 runway incursion at Toronto
15 January 2021

Misinterpretation of ATC communication factor in August 2019 runway incursion at Toronto

The Transportation Safety Board of Canada (TSB) released its investigation report into the August 2019 runway incursion between two aircraft at the Toronto/Lester B. Pearson International Airport, Canada.

On 9 August 2019 at 12:40 local time, an Air Canada Boeing 777-300 landed on runway 33L. Three minutes later, an Air Georgian CRJ-200 was instructed to line up on parallel runway 33R. In accordance with air traffic control (ATC) instructions, the Boeing 777 was crossing runway 33R. Simultaneously, the flight crew of the CRJ-200 began its take-off roll on the same runway without a take-off clearance from ATC. When the CRJ-200 flight crew saw the Boeing 777 over the crest of the runway, they rejected the takeoff and exited via a taxiway.

The investigation found that while completing the pre-departure checks, the flight crew of the CRJ-

200 was informed of a change in departure instructions. The first officer received and read back the line-up instruction with the departure amendment, but misinterpreted that ATC communication as a clearance for takeoff.

It was determined that the number of pre-departure tasks the flight crew was required to complete within a short amount of time increased their workload, and that the workload was further increased by the additional tasks brought by the change in instructions. Thus, it was found that the increased workload, the expectation to receive a take-off clearance without delay, and the misinterpretation of the line-up instructions led the CRJ-200 flight crew to initiate take-off roll without a take-off clearance. Also, because of the grade profile of runway 33R, the fuselage of the Boeing 777 would not have been visible to the CRJ-200 flight crew at the start of the take-off roll, therefore they had no visual indication that it was unsafe to begin the takeoff.

Following the occurrence, NAV CANADA issued a directive reminding air traffic controllers to cancel the take-off clearance or issue an instruction to abort takeoff when runway incursion monitoring and conflict alert system stage 2 alerts are activated by a departing aircraft.

Air Georgian Limited conducted an internal safety investigation as per the company’s safety management system. It amended its standard operating procedures to mandate an ATC query if one of the two crew members was unaware of the content of an ATC clearance or instruction.

Sriwijaya Air Boeing 737-500 crashed after takeoff from Jakarta

ASN Accident Statistics Highlight Need for More Work on Runway Excursions, Conflict Zones

The international airline industry in 2020 suffered eight fatal accidents resulting in 314 fatalities, both of which are below the industry’s five-year average, according to statistics released today by the Aviation Safety Network (ASN). Included in the 2020 totals are two events in which airliners were inadvertently shot down, killing 182 passengers and crew.

Eight fatal accidents are the fewest on record for a full year. The safest year in aviation history was 2017 with 10 fatal accidents and 44 lives lost.

The global COVID-19 pandemic had a severe impact on the aviation industry in 2020, causing a significant drop in the number of flights operated. Industry studies suggest that worldwide air traffic in 2020 was about half of that in 2019. Just over 19 million flights were operated last year, which is about the same number as were flown in 1999, when ASN registered 43 fatal accidents resulting in 689 fatalities.

Major improvements have been made in aviation safety over the past 20 years, but significant challenges remain, and two of those were underscored in 2020: approach and landing accidents and commercial flights over conflict zones.

Runway excursion accidents in Turkey and India resulted in 23 fatalities.

“These two runway excursion accidents highlight the fact that much still needs to be done to prevent overruns and to make sure runway environments follow International Civil Aviation Organization (ICAO) recommendations,” said ASN CEO Harro Ranter.

“International aviation provides critical economic and social connectivity, but the global nature of aviation can put it at risk when flights overfly conflict zones,” said Foundation President and CEO Dr. Hassan Shahidi. “All countries must adhere to established ICAO guidance on aircraft flying through conflict zones. It is the responsibility of the state to provide timely risk information to airlines during military conflict and to close its airspace if necessary.”

The ASN statistics are based on all worldwide fatal commercial aircraft accidents (passenger and cargo flights) involving civil aircraft of which the basic model has been certified for carrying 14 or more passengers.

The Aviation Safety Network is an independent organisation located in the Netherlands. Founded in 1996, its goal is to provide everyone with a professional interest in aviation with up-to-date, complete and reliable authoritative information on airliner accidents and safety issues. ASN is an exclusive service of Flight Safety Foundation. The figures have been compiled using the airliner accident database of the Aviation Safety Network, the internet leader in aviation safety information. The Aviation Safety Network uses information from authoritative and official sources.

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Harro Ranter
the Aviation Safety Network
e-mail: hr@aviation-safety.net
twitter: @AviationSafety

FAA extends conflict zone Notam on Pakistan airspace by a year

The U.S. Federal Aviation Administration extended the Conflict Zone Notam on Pakistani airspace by a year, to 1 January 2022.
Although there were no extremist/militant attacks against civil aviation in the territory and airspace of Pakistan in 2020, the FAA states, civil aviation remains an attractive target for extremist/militant groups due to the impact and visibility of such attacks.

Learjet 31 suffers runway excursion after landing at Diamantina Airport, Brazil

Avianca A319 struck pyrotechnic balloon on landing at Bogotá Airport, Colombia

Volga-Dnepr resumes An-124 flights after accident

Volga-Dnepr Airlines has announced that it is taking steps to resume operations with their fleet of Antonov An-124 cargo aircraft.

Flights were suspended as of November 25, 2020 following an accident on November 13, when one of Volga-Dnepr’s An-124 cargo planes suffered an uncontained engine fan disk failure of the no.3 D-18T engine.

After accomplishing the relevant service directives the aircraft will resume service. The first aircraft to be ready, was RA-82077. It took off from Leipzig, Germany on December 26, bound for Shanghai, China.

Loss of separation during parallel approach Schiphol Airport

Static system not connected after maintenance: loss of airspeed on B777-F

Transport Canada validates the design changes to the Boeing 737 MAX aircraft

Transport Canada has completed their independent review of the design changes to the Boeing 737 MAX aircraft recently certified by the Federal Aviation Administration (FAA).

The return to service of these aircraft in Canada is complex, with additional aircraft changes, maintenance and training.

In January 2021, the department expects to issue a Canadian Airworthiness Directive which will stipulate the Canadian design changes that must be incorporated in Canadian aircraft. At the same time, the department will also mandate the training requirements for air crew through an Interim Order.

Thus, prior to a return to service of the aircraft in Canadian airspace, Transport Canada will require:

  • modifications to the aircraft as specified in the Canadian Airworthiness Directive;
  • incorporation of the revised pilot training syllabus into the Transport Canada-approved training program for each Canadian airline; and
  • airlines to conduct maintenance on the aircraft to ensure it will operate safely, given the aircraft have been in storage for some time.

Specifically, the Canadian design changes for the Boeing 737 MAX will include an enhanced flight deck procedure that provides the option for a pilot-in-command to disable a loud and intrusive warning system (commonly called the “stick shaker”) when the system has been erroneously activated by a failure in the angle of attack sensor system. This feature will help to reduce pilot workload given what has been learned from the two tragic accidents, and has been fully evaluated by Transport Canada’s flight test pilots. There will also be differences in training including training on the enhanced flight deck procedure.

The commercial flight restrictions for the operation of the Boeing 737 MAX aircraft in Canadian airspace remain in effect and will not be lifted until Transport Canada is fully satisfied that all its safety concerns have been addressed, that required modifications have been incorporated, that enhanced flight crew procedures are in place, and that all training has been conducted in Canada.