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ASN Wikibase Occurrence # 163110
Last updated: 8 October 2019
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Date:29-AUG-2011
Time:15:33
Type:Silhouette image of generic BE10 model; specific model in this crash may look slightly different
Beechcraft A100 King Air
Owner/operator:Propair
Registration: C-GJLJ
C/n / msn: B-235
Fatalities:Fatalities: 0 / Occupants: 3
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Montreal-Pierre Elliott Trudeau International Airport, QC (YUL/CYUL) -   Canada
Phase: Take off
Nature:Training
Departure airport:Montreal-Pierre Elliott Trudeau International Airport, QC (YUL/CYUL)
Destination airport:Montreal-Pierre Elliott Trudeau International Airport, QC (YUL/CYUL)
Investigating agency: TSB Canada
Narrative:
A Bombardier DHC-8 (registration C-FSRY) operating as Sky Regional Airlines Incorporated flight SKV7516 departed Toronto, Ontario, and landed on runway 24R at Montreal-Pierre Elliott Trudeau International Airport, QC (YUL/CYUL). The aircraft crew was then instructed by the ground controller to taxi on taxiway Echo and hold short of runway 28; SKV7516 read the instructions back correctly. As SKV7516 entered Taxiway Echo, the airport controller cleared a Beech A100 King Air (registration C-GJLJ) operating as Propair Incorporated flight PRO104 to take off from runway 28. Approximately 2 minutes later, SKV7516 reached the hold line of runway 28, and entered runway 28 without stopping. PRO104, which was approaching rotation speed, aborted take-off as soon as it saw SKV7516 on the runway. PRO104 veered to the right of the runway centreline and passed about 40 feet behind SKV7516.

Findings as to causes and contributing factors:
1. While the ground controller was instructing SKV7516 to hold short of Runway 28, the pilots’ attention was focused on an aircraft taxiing in the opposite direction. As a result, the SKV7516 pilots did not confirm between themselves the ground controller’s instruction to hold short of Runway 28, and resumed taxiing.
2. The SKV7516 flight crew members incorrectly believed that they were permitted to cross Runway 28 notwithstanding the first officer’s accurate readback of the instruction to hold short of Runway 28. As a result, SKV7516 did not stop at the hold line and entered the runway.
3. The visual scan conducted by the SKV7516 captain was ineffective and did not identify that PRO104 was on Runway 28.
4. SKV7516 crossed Runway 28 without permission in front of PRO104, which was approaching its take-off rotation speed. Consequently, the runway incursion resulted in an extremely serious risk of collision.

Findings as to risk:
1. If an aircraft inspection is not conducted following a high-speed rejected take-off, there is a risk that a flight crew may take off with a damaged aircraft.
2. If a flight crew is tuned to an incorrect frequency as that crew’s aircraft crosses a runway, there is an increased risk that the ground controllers and airport controllers will not be able to contact the flight crew.
3. In the absence of additional strategies to safeguard against runway incursions, the risk of collisions on runways will persist.


Sources:

http://tsb.gc.ca/eng/rapports-reports/aviation/2011/a11q0170/a11q0170.asp

Accident investigation:
cover
  
Investigating agency: TSB Canada
Status: Investigation completed
Duration:
Download report: Final report


Images:


Revision history:

Date/timeContributorUpdates
09-Jan-2014 19:40 harro Added
09-Jan-2014 19:50 Anon. Updated [Photo, ]

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