Air transportation safety investigation A18Q0140

Updated in December 2018: This ongoing investigation is in the report phase.

Table of contents

Study on aircraft landings at Quebec airports undergoing runway repaving or reconstruction

The occurrence

On , the Transportation Safety Board of Canada (TSB) launched a safety issue investigation (SII) to closely examine occurrences from 2015 to the present at Quebec airports that involved aircraft landings on runways that were undergoing repaving or reconstruction.

An SII (also known as a Class 1 investigation) analyzes a series of occurrences with common characteristics that have formed a pattern over a period of time. SIIs, which may include recommendations, are generally completed within 730 days. For more information, see the Occurrence Classification Policy.

Background

Since 2015, the TSB has received multiple reports of runway excursions at Quebec airports involving runways that were undergoing repaving or reconstruction. In all of these occurrences the runway's width had been reduced, but pilots were incorrectly perceiving the entire width of the runway to be available.

On 12 July 2018, the TSB issued Aviation Safety Advisory A18Q0094-D1-A1 which concluded that, despite the issuance of notices to airmen (NOTAM) signalling the closure of a portion of a runway's width, pilots were unable to distinguish in real time the usable portion from the closed portion of the runway, and that the runway markings used during repaving and reconstruction work were probably not effective.

The number of incidents that have occurred during these runway rehabilitation works means that it is very likely that similar incidents will occur again. Landing outside the intended limits of a runway can cause not only significant damage to aircraft, but also serious injury to their occupants. It is for this reason that the TSB launched this SII.

Scope

The SII will examine occurrences that have taken place since 2015 involving aircraft landings at Quebec airports that were undergoing runway repaving or reconstruction.

The investigation will specifically look at the regulations and standards applicable to runway construction, the approval process for this type of work, how information is communicated to pilots, and the human performance factors.

The SII will be conducted in three phases.


Investigation information

Investigator-in-charge

Photo of Mario Boulet

Mario Boulet has over 30 years of civil aviation experience. He joined the TSB in 2015 and is now a regional senior investigator based out of Dorval, Quebec.

Before joining the TSB, Mr. Boulet worked during 8 years for Transport Canada as a civil aviation safety inspector after a career in the private sector for various approved maintenance organizations, aircraft manufacturers and airlines where he occupied positions from aircraft maintenance engineer to person responsible for maintenance (PRM), including minister delegate for a major aircraft manufacturer.

Since 2006, Mr. Boulet also became an expert in the manufacturing and operation of unmanned aerial systems (UAS).

Mr. Boulet holds an aircraft maintenance engineer license from Transport Canada and a private pilot license.


  Download high-resolution photos from the TSB Flickr page.

Class of investigation

This is a class 1 investigation. Called safety issue investigations (SIIs), these investigations analyze series of occurrences with common characteristics that have formed a pattern over a period of time. SIIs, which may include recommendations, are generally completed within 730 days. For more information, see the Policy on Occurrence Classification.

TSB investigation process

There are 3 phases to a TSB investigation

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. 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.
  3. 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.

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