Westjet Encore DH8D at Winnipeg on Aug 4th 2014, runway incursion

Last Update: December 23, 2015 / 18:27:02 GMT/Zulu time

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Incident Facts

Date of incident
Aug 4, 2014

Classification
Incident

Cause
Runway incursion

Airline
Westjet Encore

Flight number
WEN-3112

Departure
Winnipeg, Canada

Destination
Thunder Bay, Canada

Aircraft Registration
C-FOEN

Aircraft Type
De Havilland Dash 8 (400)

ICAO Type Designator
DH8D

A Westjet Encore de Havilland Dash 8-400, registration C-FOEN performing flight WEN-3112 from Winnipeg,MB to Thunder Bay,ON (Canada) with 39 people on board, was taxiing for departure along runway 31 and had been instructed to hold short of runway 36.

A Westjet Boeing 737-700, registration C-FLWJ performing flight WS-318 from Edmonton,AB to Winnipeg,MB (Canada) with 99 people on board, was on short final to Winnipeg's runway 36, when Winnipeg tower observed the Dash 8 taxied past the hold short line near the intersection runway 31 and runway 36 and instructed the Boeing to go around.

The Boeing went around from about 1100 feet MSL (350 feet AGL) and positioned for another approach resulting in a safe landing about 14 minutes later.

The Canadian TSB reported the crew of the Dash 8 had acknowledged the instruction to hold short of runway 36 while taxiing along runway 31, but then entered the runway 36 environment at the intersection with runway 31. Winnipeg tower observing the Dash 8 entering the runway 36 environment instructed the Boeing to go around. An investigation has been opened.

Winnipeg Airport reported the occurrence as a near collision on the runway, which resulted in major media coverage across Canada.

On Dec 23rd 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 hold-short line painted on Runway 31 southeast of Runway 36 was significantly degraded, with 123 feet of the line missing. As a result, the crew of WEN3112 did not see it and stopped in the runway protected area.

- The daily airport inspections at Winnipeg Richardson International Airport (CYWG) did not identify the degraded condition of the hold-short line, allowing continued use of the hold-short position.

- The orientation of the runway holding position signs was optimized for traffic on Runway 31, which likely contributed to the pilots not identifying the hold-short position.

- The fact that the left runway guard light (RGL) was aimed 15 degrees away from Runway 31, the orientation of the right RGL relative to the aircraft’s position, and the reduced RGL intensity setting likely contributed to the pilots not identifying the hold-short position.

Findings as to risk

- If there are no checklists or documented procedures for airport inspections, then there is an increased risk that non-compliance with regulatory requirements or safety deficiencies will not be identified.

The TSB reported that to shorten their taxi time the crew requested departure from runway 36 intersection runway 31, their taxi clearance was amended to taxi onto runway 31 via taxiway V and hold short of runway 36. The captain (ATPL, 4,300 hours total, 500 hours on type), pilot flying, was aware that they were approaching runway 36, slowed the aircraft while looking out for the hold short line but not seeing the hold short line and stopped the aircraft when they thought they were at an adequate distance from runway 36.

The tower controller however recognized the aircraft had entered the protected area of runway 36, verified that assessment via the airport surface detection equipment (ASDE) and instructed the approaching Boeing to go around.

The TSB reported that the hold short line southeast of runway 36 on runway 31 was significantly degraded with 123 feet of paint missing. The line had been last painted on Oct 19th 2013. Due to resurfacing works and the closure of runway 36 in the spring the spring paint on runway 31 did not happen due to single runway operations. The next paint was scheduled for Aug 5th 2014 and happened before the TSB could acquire photos of the degraded hold short line, the TSB therefore used a satellite image to identify the degraded hold short line.

In addition, the daily runway inspections did not recognize that the runway guard lights were misaligned and thus were hardly visible from the aircraft while being operated at lowest intensity during the occurrence.

The ASDE revealed that the Dash stopped before runway 36, the nose was 47 meters from the runway edge with the runway protected area expanding 60 meters from the runway edge.

The TSB analysed: "On 03 August 2014, when the satellite image was taken, the hold-short line painted on Runway 31 southeast of Runway 36 was significantly degraded, with 123 feet of the line missing (Appendix A). The missing portion of the hold-short line was located on the centre section of the runway; the line was still present on the edges of the runway. As a result, the crew of WEN3112 did not see it and stopped in the runway protected area."

The TSB continued analysis: "The taxi route led WEN3112 to Runway 31 directly toward the degraded portion of the hold-short line. The first officer’s attention was likely diverted from searching for the hold-short line to communicate with the tower controller. The captain was actively looking for the hold-short line as the primary reference for the hold-short position and was slowing the aircraft. The captain did not see the remaining paint of the hold-short line because it was located on the edges of Runway 31. The aircraft was taxiing straight ahead on the centreline, and both pilots assessed that they had stopped at an adequate distance from Runway 36. The aircraft stopped 59 m from the active runway (Appendix A). However, due to the angle between Runway 31 and the active Runway 18/36, the aircraft was only 47 m from the edge of Runway 18/36 when it stopped within the 60 m runway protected area. The crew of WEN3112 did not identify the hold-short position, and taxied into and stopped in the runway protected area."
Aircraft Registration Data
Registration mark
C-FOEN
Country of Registration
Canada
Date of Registration
KpgckAiipdqm Subscribe to unlock
Certification Basis
Fbdd gij bhieglgqkqhjkf jqqpifhjAbcengdhqfhjjm Subscribe to unlock
TCDS Ident. No.
Gghf Subscribe to unlock
Manufacturer
Dehavilland
Aircraft Model / Type
DHC-8-402
ICAO Aircraft Type
DH8D
Year of Manufacture
Mfjk Subscribe to unlock
Serial Number
N A Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
K lkgm Subscribe to unlock
Maximum Take off Mass (MTOM) [kg]
Pfnp Subscribe to unlock
Engine Count
D Subscribe to unlock
Engine Type
KnkeqgAmAp Subscribe to unlock
Main Owner
Ahlikblg me qnfijfAeqgbcgnAqdciipbblAqeegfifnniggpkcneinkdleeAnnnAkqmmhf Subscribe to unlock

Aircraft registration data reproduced and distributed with the permission of the Government of Canada.

Incident Facts

Date of incident
Aug 4, 2014

Classification
Incident

Cause
Runway incursion

Airline
Westjet Encore

Flight number
WEN-3112

Departure
Winnipeg, Canada

Destination
Thunder Bay, Canada

Aircraft Registration
C-FOEN

Aircraft Type
De Havilland Dash 8 (400)

ICAO Type Designator
DH8D

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