Air transportation safety investigation A14H0002
The TSB has completed this investigation. The report was published on 15 July 2015.
Table of contents
Runway incursion and risk of collision
7506406 Canada Inc. Agusta AW 139 (helicopter), C-GYNM
and
Federal Express Airbus 300B4-622R N748FD
Ottawa Macdonald-Cartier International Airport
Ottawa, Ontario
The occurrence
On 5 June 2014, the Ornge AW139 Helicopter, flight LF4 Medevac, taxiing for departure at Ottawa Macdonald-Cartier International Airport, had received and read back the restriction to hold short Runway 25. A risk of collision occurred when the helicopter crossed the runway stop line without authorization, while a Federal Express Airbus, A300B4-622R was landing on Runway 25. Air Traffic Control had to instruct the helicopter to stop before it entered the runway. The TSB is conducting an investigation.
Media materials
News release
Use of non-standard phraseology and not following standard operating procedures contributed to risk of collision at Ottawa’s Macdonald-Cartier International Airport
Read the news release
Investigation information
Map showing the location of the occurrence
Investigator-in-charge
Formerly a senior officer in the Canadian Forces, Mr. Roach has 34 years of military aviation experience as an air traffic controller. He controlled air traffic in several locations, in both visual and instrument flight rules environments, eventually becoming a unit manager.
Mr. Roach joined the Canadian Forces School of Aerospace Control Operations as an air traffic control instructor in 1997, ending his tenure there as chief instructor, responsible for the delivery of air traffic control training for the Royal Canadian Air Force.
Before joining the Transportation Safety Board of Canada in 2013, Mr. Roach was at the Air Traffic Management Coordination Office in Ottawa, where he was responsible for the day-to-day liaison between the Department of National Defence, the Royal Canadian Air Force, Transport Canada and NAV CANADA.
Class of investigation
This is a class 3 investigation. These investigations analyze a small number of safety issues, and may result in recommendations. Class 3 investigations are generally completed within 450 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.