Air Georgian B190 at Calgary on Mar 29th 2014, runway incursion, B737 took off climbing over B190

Last Update: April 28, 2015 / 16:32:33 GMT/Zulu time

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Incident Facts

Date of incident
Mar 29, 2014

Classification
Incident

Cause
Runway incursion

Airline
Air Georgian

Aircraft Registration
C-GWGA

Aircraft Type
BEECH C-12J

ICAO Type Designator
B190

An Air Georgian Beech 1900D registration C-GWGA was taxiing for an engine ground run at runway 29 and after requesting taxi clearance from apron to holding point runway 29 had been cleared to taxi from apron 5 via taxiway N and runway 26, hold short of taxiway Y. The crew acknowledged correctly. About 4 minutes and 50 seconds later, at 00:23L (06:23Z), the crew called they had committed a taxi error and were on the threshold of runway 35L.

A Westjet Boeing 737-700, registration C-GWSP performing flight WS-2312 from Calgary,AB (Canada) to Cancun (Mexico), had been cleared for takeoff from runway 17R about 2 minutes 50 seconds prior to the Beech crew's error report and had already commenced takeoff.

NAV Canada reported the Boeing 737 was already airborne and south of the aerodrome when the Beech crew called reporting their taxi error. NAV Canada could not state what flight the Beech was conducting, only the tail number of the aircraft involved was known.

On Apr 2nd 2014 the Canadian TSB announced that they have dispatched investigators to Calgary to investigate a runway incursion, without stating further details.

Air Georgian had scheduled a flight ZX-7231 from Calgary,AB to Medicine Hat,AB (Canada) departing on Mar 28th 2014 at 23:40L, the flight is shown cancelled. All other scheduled flights departed earlier, there has been no departure of an Air Georgian flight after 00:23L until next morning.

On Apr 28th 2015 the Canadian TSB released their final report concluding the probable causes of the serious incident were:

Findings as to causes and contributing factors

- The company training received by the aircraft maintenance engineer (AME) was inadequate to prepare him for the complex nature of taxiing an aircraft around a large airport at night, and resulted in a runway incursion.

- C-GWGA was not assigned a transponder code as prescribed in the Calgary Tower Unit Operations Manual. This resulted in the controller not having a clear picture of where the aircraft was taxiing and, therefore, being unable to intervene prior to the aircraft crossing the hold line.

- Except for reduced/low visibility operations, the Calgary Airport Authority does not require positive control over vehicles operating on a taxiway. This resulted in the controller making an incorrect assumption that C-GWGA was a vehicle.

Findings as to risk

- If the virtual stop bar feature on ASDE (airport surface detection equipment) is not enabled, there is an increased risk that the controller will not be alerted to an unauthorized movement across the runway hold line.

- If a company does not have a system to effectively control and record training requirements, there is a risk that employees may be assigned to perform tasks for which they are not trained.

The TSB reported that the aircraft was taxiing to conduct an engine ground run, the ground run was intended to take place at the holding bay of runway 29. An aircraft maintenance engineer (AME) was taxiing the aircraft for the ground run, it had been the first time he was directed to that location for a ground run. The AME requested taxiing clearance and was instructed to taxi along taxiway N, runway 26 and hold short of taxiway Y, the clearance was read back correctly. No transponder code was assigned and the transponder was not activated.

The TSB wrote: "Approximately 1 minute later, C-GWGA departed from its position in front of the Air Georgian Limited hangar on Apron V. The controller was providing air traffic services to arriving and departing aircraft when C-GWGA began to taxi. It was the controller’s experience that maintenance personnel did not initiate taxiing as quickly as operational flight crews after receipt of instructions. Therefore, the controller did not expect C-GWGA to start taxiing so soon after being cleared."

The AME however did not turn onto taxiway N departing from Apron V, but turned left onto taxiway M, joined taxiway Y southbound and crossed runway 17R just before the runway end, entering the runway just when C-GWSP had become airborne. C-GWSP passed the runway end at a height of 500 feet.

The TSB reported that the tower controller, before clearing the Boeing 737 for takeoff, had scanned the runway visually from south to north, then scanned the Airport Surface Detection Equipment (ADSE) from north to south. He noticed a primary target on taxiway Y near taxiway M and believed this was a vehicle aiming for an access road that passes south of runway 17R end and cleared the Boeing for takeoff.

After crossing the hold short line runway 17R the AME continued taxiing and stopped the aircraft on the runway radioing tower that he had committed a taxi error and was on runway 35L. Tower visually confirmed the aircraft was on runway 35L and issued taxi instructions to vacate the taxiway C. The Beech subsequently taxied to the holding area runway 29 without further incident and conducted the ground run.

The TSB analysed: "The taxi training given to the AME consisted of only basic procedures to start and manoeuvre the aircraft. The AME had not received training related to taxiing on the manoeuvring area. Consequently, the AME did not follow the intended taxi route even though he encountered numerous taxiway signs, airport lighting and landmarks that indicated the aircraft was not where it should have been. The fact that the AME was not aware of the requirement to activate the transponder for taxiing also points to a lack of training. The company training received by the AME was inadequate to prepare him for the complex nature of taxiing an aircraft around a large airport at night, and resulted in a runway incursion."

The TSB continued analysis: "The occurrence controller had grown accustomed to aircraft operated by maintenance personnel not proceeding as promptly following receipt of taxi instructions as aircraft under normal operations. This led to the controller not monitoring the area where C-GWGA was operating as he had to deal with other traffic. The controller had not assigned a discrete code or instructed the AME to use transponder code 1000. Without a transponder tag, it was more difficult for the controller to notice that the aircraft was taxiing in the wrong direction. When the controller scanned the ASDE (airport surface detection equipment) display, he saw the primary target that C-GWGA produced as it approached Runway 35L, but as it was not tagged, he disregarded it as it appeared to be a vehicle. C-GWGA had not been assigned a transponder code as prescribed in the Calgary Tower Unit Operations Manual. This resulted in the controller not having a clear picture of where the aircraft was taxiing and, therefore, being unable to intervene prior to the aircraft crossing the hold line. ... Except for reduced/low visibility operations, the Calgary Airport Authority does not require positive control over vehicles operating on a taxiway. This resulted in the controller making an incorrect assumption that C-GWGA was a vehicle."

Metars:
CYYC 290800Z 23005KT 5SM BR FEW004 SCT009 BKN190 M07/M08 A2955 RMK SC2SC2CI1 SLP068
CYYC 290745Z 23006KT 4SM BR SCT004 BKN009 M07/M08 A2956 RMK SC3SC3 SLP071
CYYC 290724Z 22006KT 4SM BR BKN004 OVC009 M06/M07 A2956 RMK SC5SC3 SLP072
CYYC 290700Z 20008KT 5SM BR BKN007 BKN160 M06/M07 A2957 RMK SC5AC1 SLP074
CYYC 290600Z 19006KT 5SM BR OVC007 M06/M07 A2959 RMK SC8 SLP082
CYYC 290500Z 20008KT 5SM BR BKN008 OVC190 M06/M07 A2962 RMK SC7CI1 SLP092
CYYC 290453Z 20007KT 5SM BR BKN008 OVC190 M06/M07 A2962 RMK SC7CI1 SLP094
CYYC 290411Z 20009KT 10SM SCT008 BKN190 M06/M08 A2964 RMK SC3CI3 SLP100
CYYC 290400Z 19008KT 7SM BKN008 BKN190 M06/M08 A2964 RMK SC5CI1 SLP101
CYYC 290300Z 16010KT 10SM VCSH OVC009 M06/M07 A2967 RMK SC8 SH S-W/ VIS S-SW 5 SLP111
CYYC 290200Z 15012KT 7SM OVC008 M06/M07 A2968 RMK SC8 SLP117
Incident Facts

Date of incident
Mar 29, 2014

Classification
Incident

Cause
Runway incursion

Airline
Air Georgian

Aircraft Registration
C-GWGA

Aircraft Type
BEECH C-12J

ICAO Type Designator
B190

This article is published under license from Avherald.com. © of text by Avherald.com.
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