ASN Wikibase Occurrence # 234194
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| Date: | Saturday 7 March 2020 |
| Time: | 09:48 LT |
| Type: |  Embraer ERJ-190AR |
| Owner/operator: | Air Canada |
| Registration: | C-FMZW |
| MSN: | 19000124 |
| Fatalities: | Fatalities: 0 / Occupants: 87 |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | Toronto–Lester B. Pearson International Airport, Ontario (YYZ) -
 Canada
|
| Phase: | Take off |
| Nature: | Passenger - Scheduled |
| Departure airport: | Toronto-Pearson International Airport, ON (YYZ/CYYZ) |
| Denver International Airport, CO (DEN/KDEN) | |
| Investigating agency: | TSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
An Embraer ERJ-190 (C-FMZW), operated by Air Canada as flight AC1037, was conducting a takeoff under visual departure procedures from runway 06L at Toronto-Pearson International Airport, Canada. After the ERJ-190 began its takeoff roll, a Boeing 777-333ER (C-FJZS), operated by Air Canada as flight AC606, was instructed to position and hold onto runway 06L. While the ERJ-190 was on the take-off roll, the Tower controller issued a takeoff clearance to the B777. Moments later, the ERJ-190 had a bird strike at approximately 135 knots. The ERJ-190 flight crew initiated a high-speed abort and made a radio call on the tower frequency that they were aborting the takeoff.
As the ERJ-190 flight crew made their radio call, the B777 flight crew read back the takeoff clearance on the same frequency and commenced its takeoff roll. Shortly afterwards the B777 flight crew observed that the ERJ-190 was still on the runway and aborted the takeoff, reaching a maximum speed of about 110 knots. The B777 flight crew made a radio call on the tower frequency that they were also aborting the takeoff. Both aircraft exited the runway. The ERJ-190 returned to the terminal.
The B777 waited on a taxiway for 45 minutes to allow the brakes to cool and then returned to the terminal. There were no injuries. There was no damage to either aircraft.
The ERJ-190 resumed service 7 hours after the incident; the B777 resumed service 5 hours after the incident.
Findings as to causes and contributing factors
1. In order to achieve an expeditious flow of traffic, the controller was using pilot-applied visual departure separation procedures per NAV CANADA’s Manual of Air Traffic Services. In this occurrence, the operations conducted under the pilot-applied visual departure separation procedure were optimized to a point where separation was not assured.
2. Given the Embraer 190’s speed and position on the runway, the controller was not expecting a high-speed rejected takeoff. He assessed that the aircraft was becoming airborne and no longer required his attention and monitoring. As a result, he issued the take-off clearance to the Boeing 777 even though the Embraer 190 was still on the runway.
3. The Embraer 190 struck a bird and conducted a rejected takeoff at a critical point during its take-off roll, just before the Boeing 777 received its take-off clearance and started its own take-off roll.
4. The first officer of the Embraer 190 made a radio call reporting the rejected takeoff, but this call went undetected by the controller or the Boeing 777 flight crew as it was overlapped by the radio call from the first officer of the Boeing 777 reading back the take-off clearance. As a result, neither the controller nor the Boeing 777 flight crew were aware that the Embraer 190 was rejecting the takeoff.
5. Because the controller was expecting the Embraer 190 to take off without interruption, he shifted his attention and priority to other aircraft movements. Focus on these tasks, combined with operating from the north tower position, reduced the controller's opportunity to detect the Embraer 190’s rejected takeoff and delayed the response to the conflict.
6. The Boeing 777 flight crew visually sighted the Embraer 190, believed it would soon be airborne, and saw no apparent risk of collision; however, they were unaware that it was conducting a rejected takeoff and decelerating. Proceeding as authorized, the Boeing 777 flight crew commenced their take-off roll while the Embraer 190 was still on the runway, which resulted in a runway incursion and risk of collision.
7. The Embraer 190’s transponder transmitted that the aircraft was in air after the aircraft accelerated past 50 knots. As a result, although compliant with current standards, an inaccurate in-air status was transmitted for approximately 52 seconds while the aircraft remained on the ground during its take-off roll and rejected takeoff.
8. The runway incursion monitoring and conflict alert sub-system (RIMCAS) relies on data from aircraft systems designed to provide aircraft flight status data for use by airborne surveillance systems. The use of this data by RIMCAS led to the inaccurate identification of the Embraer 190 and the Boeing 777 as in air while these 2 aircraft were still on the ground. This resulted in late and inaccurate RIMCAS alerts and delayed the response to the risk of collision.
9. A risk of collision occurred when the accelerating Boeing 777 was travelling at 133 knots indicated airspeed and was approximately 5000 feet from the decelerating Embraer 190. The risk was mitigated once the Boeing 777 flight crew rejected their takeoff after recognizing that the Embraer 190 was still on the runway ahead of them.
Accident investigation:
 |
|
Sources:
TSB A20O0029
https://www.flightradar24.com/2020-03-07/14:50/12x/ACA1037/241b627a
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 21-Mar-2020 13:26 | harro | Added |
| 21-Mar-2020 13:28 | harro | Updated [Departure airport, Source] |
| 14-Jun-2022 16:20 | harro | Updated [Narrative, Accident report] |
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