“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.