ASN Wikibase Occurrence # 301915
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Date: | Saturday 15 October 2022 |
Time: | 04:13 UTC |
Type: | Boeing 737 MAX 8 |
Owner/operator: | Air Canada |
Registration: | C-GEOJ |
MSN: | 61237/7568 |
Year of manufacture: | 2019 |
Fatalities: | Fatalities: 0 / Occupants: |
Aircraft damage: | None |
Category: | Serious incident |
Location: | Toronto–Lester B. Pearson International Airport, Ontario (YYZ) -
Canada
|
Phase: | Approach |
Nature: | Passenger - Scheduled |
Departure airport: | Edmonton International Airport, AB (YEG/CYEG) |
Destination airport: | Toronto-Pearson International Airport, ON (YYZ/CYYZ) |
Investigating agency: | TSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:At 00:12 EDT, MTC31, a Greater Toronto Airports Authority maintenance vehicle which was westbound on taxiway Juliet, entered the threshold of runway 15R at Toronto-Pearson International Airport, ON (YYZ) despite having recieved and read back a clearance to hold short of that runway. At the same time, C-GEOJ, an Air Canada Boeing 737 MAX 8 opearating as flight AC174, had been cleared to land on runway 15R, and was inside 1 mile final. The tower controller noticed the incursion, and instructed AC174 to go around. The AC174 flight crew complied, received vectors to restart the approach, and landed on runway 15R at 00:25 EDT.
VFR conditions prevailed at the time of the incursion. The lowest altitude reached by AC174 was approximately 150 feet AGL. The vehicle had entered the displaced portion of the threshold for runway 15R, and was approximately 400 feet from the displaced threshold.
Findings as to causes and contributing factors
1. The occurrence driver’s attention was split between his driving duties and the planning of the upcoming painting tasks that he would be supervising. As a result, he was paying less attention to monitoring the route for hazards.
2. Because the driver had crossed Runway 15R at the displaced threshold many times without stopping, the mental model he developed did not include stopping at the holding position, even though he read back the instruction to stop.
3. Although contrary to the Greater Toronto Airports Authority’s Airport Traffic Directives, drivers normally used the manoeuvring areas as opposed to the North Service Road because these areas are perceived to be quicker given the typical runway operations on the east/west runways.
4. Given the driver’s split attention, the visual cues that were available to designate the holding position were not salient enough to alter his mental model and stop him from entering the runway. The result was a runway incursion and a risk of collision with the aircraft on approach.
Accident investigation:
|
| |
Investigating agency: | TSB |
Report number: | A22O0146 |
Status: | Investigation completed |
Duration: | 1 year and 2 months |
Download report: | Final report |
|
Sources:
TSB
https://www.flightradar24.com/data/flights/ac174#2dd8db71 Revision history:
Date/time | Contributor | Updates |
21-Dec-2023 10:22 |
harro |
Updated [Other fatalities, Narrative, Accident report] |
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