Air transportation safety issue investigation report A17O0038
The TSB has completed this investigation. The report was published on 31 January 2019.
Runway incursions between the parallel runways
Toronto/Lester B. Pearson International Airport
View final report
This investigation examined 27 runway incursions that occurred between June 2012 and November 2017 at 2 closely spaced parallel runways known as the “south complex” at Toronto/Lester B. Pearson International Airport (CYYZ), Ontario. The 27 cases studied were not the only incursions at CYYZ during that period. However, their number and similarity raised concern and led the TSB to examine them more closely as a group, in order to determine their systemic underlying causes and contributing factors and to assess the degree of ongoing risk.
All of the incursions occurred on the inner runway (Runway 06L/24R) after the flight crews involved had landed on the outer runway (Runway 06R/24L), had been instructed by air traffic control (ATC) to hold short of Runway 06L/24R, and, despite intending to stop, had missed the visual cues depicting the runway holding positions.
The taxiway layout between the runways has several characteristics that are uncommon compared to those at other airports, both within North America and internationally. The runways are spaced a relatively short distance (305 m [1000 feet]) apart, and the rapid exit taxiways (RETs) provide direct access to the adjacent runway without first progressing to another transitional surface. The runway holding positions are located immediately following a 65° curve and are situated at greater distances from the protected inner runway than they are at other airports.
Regional airlines that are based in the United States and that operate regional jets were involved in a disproportionate number of the incursions, both in total and in terms of the rate of incursions per landing. This was likely due to foreign flight crews being unfamiliar with the uncommon taxiway layout between the parallel runways at CYYZ and to the increased speed at which their smaller aircraft types often approached the runway holding positions.
It is for these reasons that some foreign flight crews did not anticipate the location of the stopping position on each RET and so did not direct their attention outside the aircraft at the required time to identify the visual cues indicating the runway holding positions.
Most of the flight crews were aware of the south complex areas at increased risk for runway incursions because they are designated as “hot spots” on the airport charts supplied to crews. However, that guidance, together with limitations in operators' requirements for taxi briefings, did not bring crews' attention to specific strategies to mitigate the risk of incursion. Instead, the crews followed their usual routines after exiting the landing runway and proceeded with their post-landing checks. The timing of those tasks distracted them at a point when limited time was available to recognize the visual cues requiring them to stop, and contributed to their overlooking those cues.
In the occurrences examined in this study, ATC recognized the incursions quickly and took appropriate actions that either caused the incurring aircraft to stop or reduced the severity of the consequences. As a result, most of the aircraft did not reach the inner runway surface. Of the 3 that did reach the surface, 2 were at an intersection beyond the point at which the departing aircraft presented a risk of collision. In the 3rd case, ATC cancelled the takeoff clearance for the departing aircraft before it began its take-off roll.
In another occurrence, ATC instructed the incurring aircraft to stop before it had reached the runway surface, then immediately told the departing aircraft to abort its takeoff. The crew of the departing flight did not recognize the instruction to abort because the phraseology was unfamiliar and because it was not repeated as they were used to; as a result, they continued their departure. The incurring aircraft stopped before reaching the runway surface, and the departing aircraft overflew the intersection without further event.
International guidance for the prevention of runway incursions recommends that, once areas presenting a hazard of incursion have been identified, strategies to manage or mitigate that risk should be implemented and should include awareness campaigns, additional visual aids, alternate routings, or, ultimately, the construction of new taxiways.
Various awareness campaigns and advisories have been issued since 2012, and visual aids have undergone progressive but significant improvements. Those strategies have likely resulted in periodic, but not permanent, reductions in the incidence of incursions.
Revising the post-landing procedures of flight crews may lead to increased vigilance and reduced distraction, but it is unlikely to eliminate crews' expectations that visual cues will be situated in common locations or induce crews to reduce their taxiing speeds so that they have more time to recognize the cues.
All but one of the applicable strategies recommended by international guidance have been implemented on the south complex; the remaining strategy is to make physical changes to the taxiway layout. A change of this scale may be required to increase the distance and taxiing time between runway holding positions, reduce the taxiing speeds of aircraft approaching hold-short locations, and prevent direct access to adjacent runways from RETs. Among the possible reconfigurations for achieving these objectives is the addition of an intermediate taxiway between the runways and parallel to them, as found at numerous airports with parallel runways, and the re-situating of visual cues in common locations.
TSB Recommendation A18-04: NAV CANADA amend its phraseology guidance so that safety-critical transmissions issued to address recognized conflicts, such as those instructing aircraft to abort takeoff or pull up and go around, are sufficiently compelling to attract the flight crew's attention, particularly during periods of high workload.
TSB Recommendation A18-05: the Department of Transport work with operators to amend standard operating procedures so that post-landing checks are sequenced only after landing aircraft are clear of both active runways when closely spaced parallel runway operations are in effect, rather than the current common practice of sequencing the checks once landing aircraft are clear of the landing surface.
TSB Recommendation A18-06: the United States Federal Aviation Administration work with operators to amend standard operating procedures so that post-landing checks are sequenced only after landing aircraft are clear of both active runways when closely spaced parallel runway operations are in effect, rather than the current common practice of sequencing the checks once landing aircraft are clear of the landing surface.
TSB Recommendation A18-07: the Greater Toronto Airports Authority make physical changes to the taxiway layout to address the risk of incursions between the parallel runways and, until these changes can be made, make further improvements to increase the conspicuity of the runway holding positions.
TSB makes four recommendations to improve runway safety at Canada’s busiest airport
Read the news release
Investigation findings for TSB Air Transportation Safety Issue Investigation Report A17O0038
TSB recommendations to address the risk of runway incursions (A17O0038)
Opening remarks: News conference for Air Transportation Safety Issue Investigation Report A17O0038
Kathy Fox, TSB Chair
Ewan Tasker, Manager, Air Investigations Ontario Region
Rapid Exit Taxiways at the “South complex”
Safety Issues Investigation A17O0038 - News conference
Ewan Tasker has over 20 years of civil aviation experience. He joined the TSB in 2008, and is now a regional senior investigator based out of Richmond Hill, Ontario. Since joining the TSB, he has been the investigator-in-charge of more than 250 occurrences, including 11 major investigations.
Before joining the TSB, Mr. Tasker flew commercially throughout North and South America, accrued over 7000 hours of flight time, and obtained airline transport pilot licences from 3 different regulatory bodies. During his “from-the-ground-up” career, he has worked every position, from baggage handler to chief pilot. Mr. Tasker is also a Transport Canada–licensed air traffic controller.
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Class of investigation
This is a class 1 investigation. These investigations—also known as safety issue investigations (SII)—analyze a series of occurrences with common characteristics that have formed a pattern over a period of time. These investigations, which may result in recommendations, are generally completed within 730 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
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- 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.