Procedural deficiencies led to December 2013 runway incursion at the Ottawa/MacDonald-Cartier International Airport
Gatineau, Quebec, 16 July 2015 – The Transportation Safety Board of Canada (TSB) released today its investigation report (A13H0003) into the December 2013 runway incursion at the Ottawa/MacDonald-Cartier International Airport, in Ontario. There were no injuries and no damage to aircraft or airport property.
On 1 December 2013, a Piaggio P-180 turboprop aircraft with 2 pilots aboard was authorized to taxi across Runway 14 on its way to Runway 07 at the Ottawa/MacDonald-Cartier International Airport. At the same time, a Jazz de Havilland DHC-8 with 3 crew and 15 passengers aboard was also taxiing to Runway 14 for takeoff. After being cleared for takeoff, the DHC-8 was on its takeoff roll when the P-180 crossed Runway 14, approximately 4400 feet in front of it. Neither aircraft was aware of the runway incursion and continued their flights without further incident.
The investigation determined that the NAV CANADA ground controller issued instructions to the P-180 to taxi unrestricted from the apron to Runway 07, across Runway 14, despite the frequent use of Runway 14 for departing aircraft. Additionally, after issuing taxi instructions to the P-180, the ground controller did not transfer the information to the airport controller. While operating procedures require that this be done, they do not indicate exactly when the transfer must be performed. As such, the airport controller’s display did not indicate that the P-180 was taxiing for Runway 07 when take-off clearance was issued to the DHC-8. The investigation also found that the Tower was staffed below unit guidelines at that time.
Following the occurrence, the Ottawa Tower issued a directive instructing controllers to indicate that a vehicle or aircraft was cleared to cross a runway by activating a runway crossing indicator (RCI) on the flight data entry. The RCI can only be deactivated once the aircraft or vehicle has left the protected area on the other side of the runway. NAV CANADA also made changes to its procedures when operating short-staffed.
The risk of collisions on runways has been identified as one of the risks to Canada’s transportation system and is included on the TSB's 2014 Watchlist. The Board is calling for improved procedures and enhanced collision warning systems to be implemented at Canada's airports.
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
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