Air transportation safety investigation A14W0127
The TSB has completed this investigation. The report was published on 4 November 2015.
Table of contents
Risk of collision
Canadian North Inc. Boeing 737-36Q, C-GICN
and
Jazz Aviation LP (dba Air Canada Express)
de Havilland DHC-8-402, C-GGDU
Fort McMurray, Alberta
The occurrence
The Canadian North Inc. B737-36Q (registration C-GICN, serial number 29405) was operating as flight MPE9131 from Winnipeg, Manitoba, to Fort McMurray, Alberta. At the top of the descent, the flight crew briefed for a visual approach to Runway 25. When MPE9131 was at approximately 4 nautical miles on final, the airport environment was visually acquired and the flight crew inadvertently lined up with Taxiway J. At 1838:23 Mountain Daylight Time, in daylight, MPE9131 was abeam the threshold of Runway 25 and at 46 feet above ground level, while a Jazz Aviation LP de Havilland DHC-8-402, operating as flight JZA391, was proceeding eastbound on Taxiway J for departure on Runway 25. MPE9131 conducted a missed approach and returned for landing on Runway 25. Separation between the aircraft was 230 feet vertically and 46 feet laterally.
Media materials
News release
Visual approach in low visibility and taxiway design led to August 2014 risk of collision between two aircraft at Fort McMurray, Alberta airport
Read the news release
Investigation information
Map showing the location of the occurrence
Investigator-in-charge
Mike Adam joined the Transportation Safety Board of Canada (TSB) in early 2014, bringing with him extensive experience in aviation line maintenance and quality assurance for transport category air carriers. Mr. Adam also has experience with various single and twin engine aircraft, both piston and turbine powered, as well as amateur-built aircraft.
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.