Runway incursion at YYZ (driverless van)
Yes, an interesting factual report. The first go-around instruction was masked by a louder EGPWS standard callout and the second one had the callsign clipped off it, leading the crew to disregard it as they couldn’t see any reason to go-around.
As hoofie says, lots of cheesy holes lining up. The good news is that it was such an unusual alignment of circumstances, it is unlikely to occur very frequently. Where’s the red Very Pistol when you need it?
As hoofie says, lots of cheesy holes lining up. The good news is that it was such an unusual alignment of circumstances, it is unlikely to occur very frequently. Where’s the red Very Pistol when you need it?
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Just a couple of things that I noticed from this side of the pond..
'The tower controller requested an inspection and an unoccupied Sunwing Airlines van was found with the engine running, engaged in gear'....
Which seems to imply that the vehicle had automatic transmission, and an ineffective handbrake. Surely these type of vehicles should not be left unattended with the engine running... EVER...
Also the non-standard ATC Instruction to 'Pull Up' does not seem to be too wise for an aircraft already in a high nose attitude, nearing the flair and stall.
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'The tower controller requested an inspection and an unoccupied Sunwing Airlines van was found with the engine running, engaged in gear'....
Which seems to imply that the vehicle had automatic transmission, and an ineffective handbrake. Surely these type of vehicles should not be left unattended with the engine running... EVER...
Also the non-standard ATC Instruction to 'Pull Up' does not seem to be too wise for an aircraft already in a high nose attitude, nearing the flair and stall.
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"Pull up and go-around" is still the correct phraseology on this side of the pond and until it is officially changed, that's what will be used. Its only been about 5 years or so since we finally got rid of "Taxi to position and hold".
The influence of the big ATC system to our south is very strong and changes happen at a glacial pace. But at least we can say "Cleared ILS approach".
The influence of the big ATC system to our south is very strong and changes happen at a glacial pace. But at least we can say "Cleared ILS approach".
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Interesting report. What is not clear to me is the position of the van at the critical moment....when the aircrew should have seen it. As nobody in the tower or on the ground had a good look at it, due to the dim light on the top of the van and the outdated ground intrustion alert system, it seems to me the van may have rolled across the runway and into the grass by the taxiway by the time the aircraft would have entered the flare.
The aircrew says they didn't see any obstruction on the runway. Alas, the CVR was overwritten...perhaps this hole in the cheese should be nailed shut without delay.
How can emergency ATC transmissions be enhanced so not to be overlooked?
The only time I was given an emergency order - TURN LEFT NOW!!!!! from the glider I was towing, the tone of voice left no doubt. We would have had a midair had he not got my immediate attention, as the other aircraft was not visible from the highwing tug.
The aircrew says they didn't see any obstruction on the runway. Alas, the CVR was overwritten...perhaps this hole in the cheese should be nailed shut without delay.
How can emergency ATC transmissions be enhanced so not to be overlooked?
The only time I was given an emergency order - TURN LEFT NOW!!!!! from the glider I was towing, the tone of voice left no doubt. We would have had a midair had he not got my immediate attention, as the other aircraft was not visible from the highwing tug.
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I've never seen 9 slices of Swiss Cheese have their holes lined up before, but this is what we see in this case.
Lots of lessons learned here, but it was way too close. Had the aircraft landed on the piano keys or threshold, we could well have been conducting an autopsy on a major accident.
Lots of lessons learned here, but it was way too close. Had the aircraft landed on the piano keys or threshold, we could well have been conducting an autopsy on a major accident.
That is supposed to be what is done. Every airside vehicle operator at YYZ is licensed and they are trained to shut off the engine whenever they are leaving the vehicle.
Which seems to imply that the vehicle had automatic transmission, and an ineffective handbrake. Surely these type of vehicles should not be left unattended with the engine running... EVER...
You've probably never lived through a Canadian winter
It is quite common on winter mornings, to see cars running, with the doors locked, while the owner waits inside until it warms up. You can even buy remote starters, that allow you to start the car from inside your house!
As far as this incident is concerned, it is clear that after the driver moved the van forward a few feet, he forgot to put it in Park in his haste to get out and take over the shutting of the aircraft door.
The "handbrake" on this van, like most North American vehicles, is a foot-pedal, to the left of the brake pedal, with a ratchet to hold it on. It is referred to as the Emergency Brake, and is hardly ever used in normal driving. Most drivers, including me, rely on the Park setting of the transmission, unless on a steep hill.
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Certainly as interesting read.
I am a little puzzled though about the cockpit audio report on page 5.
This seems to have precise timing of each spoken phrase, either crew, radio or EGPWS, which implies from a CVR; yet page 7 relates how there was an hour delay after arriving at Ottawa before the DVDRs power was disconnected as requested by the TSB. Google tells me that the flight time from Toronto to Ottawa is one hour, so with a 2-hour recording capability, does this add up?
Cheers!
I am a little puzzled though about the cockpit audio report on page 5.
This seems to have precise timing of each spoken phrase, either crew, radio or EGPWS, which implies from a CVR; yet page 7 relates how there was an hour delay after arriving at Ottawa before the DVDRs power was disconnected as requested by the TSB. Google tells me that the flight time from Toronto to Ottawa is one hour, so with a 2-hour recording capability, does this add up?
Cheers!
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All this discussion about the van, whether it was in park, the engine running etc is all very interesting but for me the important bit was that despite being ordered to go around twice the plane didn't!
Yes there were various factors why the crew didn't but this aspect seems to have been ignored!
The automatic announcements drowned out the first one, the crew didn't see anything (sorry that don't wash, when it's dark and you're concentrating on touchdown point, chances of seeing anything else is small) the crew discussed the second call and decided it wasn't for them - what about "if in doubt ask"
Where are the recommendations regarding all of this?
Next time you send someone round will you really expect them to pull up now?
Yes there were various factors why the crew didn't but this aspect seems to have been ignored!
The automatic announcements drowned out the first one, the crew didn't see anything (sorry that don't wash, when it's dark and you're concentrating on touchdown point, chances of seeing anything else is small) the crew discussed the second call and decided it wasn't for them - what about "if in doubt ask"
Where are the recommendations regarding all of this?
Next time you send someone round will you really expect them to pull up now?
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Certainly as interesting read.
I am a little puzzled though about the cockpit audio report on page 5.
This seems to have precise timing of each spoken phrase, either crew, radio or EGPWS, which implies from a CVR; yet page 7 relates how there was an hour delay after arriving at Ottawa before the DVDRs power was disconnected as requested by the TSB. Google tells me that the flight time from Toronto to Ottawa is one hour, so with a 2-hour recording capability, does this add up?
I am a little puzzled though about the cockpit audio report on page 5.
This seems to have precise timing of each spoken phrase, either crew, radio or EGPWS, which implies from a CVR; yet page 7 relates how there was an hour delay after arriving at Ottawa before the DVDRs power was disconnected as requested by the TSB. Google tells me that the flight time from Toronto to Ottawa is one hour, so with a 2-hour recording capability, does this add up?
1 hour turnaround (or more)
1 hour flight to Ottawa
Ground crew enter and
for an hour 3 hours from incident - even disconnection immediately may have lost the information.
Yet another reason for shelling out another 50c for a larger SD card.
Rotate on this!
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3 hours from incident - even disconnection immediately may have lost the information.
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Interesting report. It's unlikely most of the events would be repeated, an empty vehicle left in drive, aimed at a runway, with a dim beacon, passing directly under a landing plane.
However a crew about to land, missing an important audible instruction, due to noise in the cabin, or being 'fixated' on the visual side of the landing is more likely to be repeated.
How about the ATC positions being fitted with big red mushroom emergency stop style buttons, which immediately activate a big red X on both sides of the runway, and transmit on all frequencies, the carefully pronounced "short pause ALL AIRCRAFT ON APPROACH, PULL UP AND GO AROUND" pre recorded message.
That saves the controller having to identify the aircraft, it gives the crew a visual stimulus, and requires technology I have available in my shed.
(Stephen Fry or Joanna Lumley would be ideal for the announcement.)
However a crew about to land, missing an important audible instruction, due to noise in the cabin, or being 'fixated' on the visual side of the landing is more likely to be repeated.
How about the ATC positions being fitted with big red mushroom emergency stop style buttons, which immediately activate a big red X on both sides of the runway, and transmit on all frequencies, the carefully pronounced "short pause ALL AIRCRAFT ON APPROACH, PULL UP AND GO AROUND" pre recorded message.
That saves the controller having to identify the aircraft, it gives the crew a visual stimulus, and requires technology I have available in my shed.
(Stephen Fry or Joanna Lumley would be ideal for the announcement.)
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The aircraft is equipped with 2 digital voice–data recorders (DVDRs), which are capable of recording 2 hours of cockpit audio. At the TSB’s request, the crew of C-FLWH’s subsequent flight from Toronto to Ottawa was instructed by Air Canada Operations to disconnect power to the DVDRs upon arrival in Ottawa. The flight crew was met by company maintenance staff at the gate who informed the flight crew that they would do it. The maintenance crew did not disconnect the power to the DVDRs until an hour later, and the relevant cockpit voice data was overwritten. The TSB’s review of the company maintenance control manual determined that the guidance on how to perform this procedure was unclear.
In this case it would have been extremely useful to be able to hear what the go-around calls sounded like from the aircraft viewpoint rather than the transmitting station's viewpoint. Also the discussion in the cockpit - the "was that for us" would have been useful.
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The point that I was trying to make; with some uncertainty because I don't know how long the a/c was on the ground at Toronto nor the flight time to Ottawa, was where did the appearingly accurate time-stamps come from for the table on page 5 of the report and indeed the audio, where at the bottom of page 4 it says:
"Once below 500 feet above ground level (agl) on the approach, the following audio occurred in the cockpit" [my emphasis]
The listed sources of message suggest that a CVR (with time stamping) was in fact running, which is contrary to the statement on page 7 that the cockpit voice data was overwritten (due to 2 hour duration of the DVDR memory.
"Once below 500 feet above ground level (agl) on the approach, the following audio occurred in the cockpit" [my emphasis]
The listed sources of message suggest that a CVR (with time stamping) was in fact running, which is contrary to the statement on page 7 that the cockpit voice data was overwritten (due to 2 hour duration of the DVDR memory.
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The automatic announcements drowned out the first one, the crew didn't see anything (sorry that don't wash, when it's dark and you're concentrating on touchdown point, chances of seeing anything else is small) the crew discussed the second call and decided it wasn't for them - what about "if in doubt ask"
Where are the recommendations regarding all of this?
Next time you send someone round will you really expect them to pull up now?
Where are the recommendations regarding all of this?
Next time you send someone round will you really expect them to pull up now?
Between all the EGPWS calls (Rad Alts, Minima), SOP calls, Airbus "Retard" let alone intercom chatter, some of these get missed. I am only subconsciously listening for an ATC call, since "Cleared to Land" is the last call I expect. A strongly worded call like used in the UK, presumably introduced as a result of experience, stands the best chance (repeated, emphasised) of getting through and not getting drowned out.
As hoofie says, lots of cheesy holes lining up. The good news is that it was such an unusual alignment of circumstances, it is unlikely to occur very frequently. Where’s the red Very Pistol when you need it?
... which also involved an ATC call just before landing that failed to produce its intended result, and pilots 'blocking' cues to 'Go Around' while focussed on the landing.
In any case the above report is a good read and has a happy ending.
