Communiqués

TSB A 13/98

(For release 1 October 1998)

(Hull, Quebec) - The Transportation Safety Board of Canada (TSB) has concluded its investigation into an aviation occurrence involving a Swearingen Metroliner II, operated by Avionair Inc., and an Air Canada Regional Jet that occurred on March 12, 1997 at Ottawa Macdonald-Cartier International Airport.

At 0751 eastern standard time, Air Canada Flight 330, with 15 persons aboard, was cleared to take up a position on runway 25 at the Ottawa airport. Immediately thereafter, the airport controller on duty in the tower was relieved by another controller.

Approximately five minutes later, Avionair Flight 403, a cargo flight (with two in the flight crew) that was conducting an instrument approach to runway 25, was cleared to land by the relieving controller. The Air Canada flight was still holding in position on the runway. While descending through 200 feet above ground, the Avionair flight crew saw the Air Canada aircraft on the runway's threshold. The Avionair flight crew initiated a missed approach and landed uneventfully a few minutes later.

The TSB has determined that a risk of collision occurred as the result of an ineffective controller handover procedure in the Ottawa tower. Contributing to this occurrence were:

- reliance on memory to ensure the completeness of the handover briefing;

- the relieving controller did not adequately monitor incoming radio communications;

- the location of a monitor was inadequate for the airport controller to detect the Air Canada aircraft still on the runway;

- controllers do not follow a standard method to keep track of uncompleted critical actions;

- deficiencies in the management and supervision of the air traffic control unit; and

- NAV CANADA's audit procedures of the unit were inadequate.

The Board's report notes that some safety actions, such as systematic use of a checklist for the airport control position at Ottawa airport, have already been taken by NAV CANADA.

Nevertheless, because misunderstandings between tower controllers during changeover briefings as to the actual air and ground traffic situation could result in accidents, the TSB has recommended that:

NAV CANADA institute without delay a standard method to remind airport controllers of critical actions that have not been completed. (A98-01).

The Board's report expresses concern about NAV CANADA's evaluation of air traffic control units, specifically, the identification of "procedural deviations" in those units. The company's Monitoring and Evaluation Division, for example, did not have a "defined set of audit verification procedures" to check that units were complying with standard practices and procedures. NAV CANADA reports that it is taking corrective action.

The Transportation Safety Board of Canada is an independent agency operating under its own Act of Parliament. 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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