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Date: | Saturday 2 February 2019 |
Time: | 16:22 UTC |
Type: | Bombardier CRJ-200ER |
Owner/operator: | SkyWest Airlines |
Registration: | N902EV |
MSN: | 7620 |
Fatalities: | Fatalities: 0 / Occupants: 25 |
Aircraft damage: | None |
Category: | Serious incident |
Location: | Montreal-Pierre Elliott Trudeau International Airport, QC (YUL/CYUL) -
Canada
|
Phase: | Approach |
Nature: | Passenger - Scheduled |
Departure airport: | Chicago-O'Hare International Airport, IL (ORD/KORD) |
Destination airport: | Montreal-Pierre Elliott Trudeau International Airport, QC (YUL/CYUL) |
Investigating agency: | TSB |
Confidence Rating: | Information verified through data from accident investigation authorities |
Narrative:A Bombardier CRJ-200 aircraft operated by SkyWest Airlines, operated flight SKW3130 from Chicago/O'Hare Intl (KORD), IL to Montreal/Pierre Elliott Trudeau Intl (CYUL), QC. Operations of snow removal had been completed on runway 24R, and the convoy of vehicles was proceeding towards runway 24L via taxiway Alpha. The convoy received and correctly repeated the instruction to stay away from runway 24L. SKW3130 was on short final for runway 24L when a vehicle made an incursion on runway 24L, followed by two other vehicles; the rest of the convoy remained away from the runway. The air traffic controller instructed SKW3130 to discontinue its approach. The crew of SKW3130 went around, and returned to land on runway 24R. There were no injuries.
Findings as to causes and contributing factors
1. A runway incursion occurred when the convoy lead, focused on the tasks of driving, snow removal, and planning the convoy’s next snow removal pass on Runway 24L, missed the runway holding position lighting, signage and markings, forgot about the requirement to hold short, and proceeded past the runway holding position onto Runway 24L.
2. Three other vehicles in the convoy did not hold short and followed, out of habit, the lead vehicle past the runway holding position, which increased the severity of the incursion.
3. The Aéroports de Montréal team leader procedures in place at the time of the occurrence did not specify if team leaders or supervisors should lead a convoy onto a runway. As a result, the team leader could not ensure that the convoy complied with the air traffic control instruction and the requirement to hold short and therefore could not prevent the runway incursion.
4. The ground controller was multitasking and conducting an operational phone call, which led to a breakdown of his scanning and monitoring, delayed his response to the runway incursion, and increased the severity of the incursion.
Accident investigation:
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| |
Investigating agency: | TSB |
Report number: | |
Status: | Investigation completed |
Duration: | 11 months |
Download report: | Final report |
|
Sources:
TSB A19Q0015
Images:
Aerial view of holding bay 24L, with inset images showing the runway holding position lighting, signage, and markings (Main image source: Google Earth, with TSB annotations. Inset images source: Aéroports de Montréal)
Revision history:
Date/time | Contributor | Updates |
15-Feb-2019 18:38 |
harro |
Added |
15-Feb-2019 18:39 |
harro |
Updated [Time, Location] |
21-Jan-2020 19:49 |
harro |
Updated [Total occupants, Narrative, Photo, Accident report, ] |
21-Jan-2020 19:52 |
harro |
Updated [Source, Accident report, ] |