Pilots warned to stay alert for Toronto incursion risks

[pelmet]

Distractions happen Pelmet, you may just be the very last person to realize that. The challenge is negating those distractions, and procedures are only one of the methods of doing that. Since no operator to my knowledge encourages crews to ignore ATC instructions, and yet these incidents still happen, other methods of keeping crews cognizant of hold short requirements need to also be employed.

A good example of a failure to hold short nearly causing a major disaster due to not paying attention to critical hold short instructions is shown below....How important is that After Landing Checklist compared to holding short. An example of an unnecessary pilot induced distraction. I'd say that your assertion that I am the last to recognize that distractions happen is....another wrong argument. I am well aware that there are uncontrolled distractions but many distractions are self-induced.

I'd also say that it is best to concentrate exclusively on holding short in this kind of situation. No harm in verbalizing that requirement again during the latter portion of the rollout. The checklist can be done on after crossing the runway. Same with calling company.

"From the Embraer 145 Captain’s Report
The flight was involved in a runway incursion…on high speed exit taxiway D3 (Hotspot 5) from Runway 06R toward Runway 6L (stopped past a runway hold short marking) while a B737 was rotating from Runway 06L. We taxied to our parking terminal after the runway was cleared.

We were slowing down to a safe taxi speed on Runway 06R from the ILS Runway 06R approach and landing. As I was taking over the aircraft from the FO…at around 80 knots, ATC instructed us to plan to exit on high speed D3 (hotspot 5) and hold short of Runway 06L, which my FO [read] back correctly and I acknowledged. Both windshield wipers were at high speed due to moderate precipitation. As we were exiting on D3, I asked my FO to run the After Landing Checklist after we had cleared the runway. I had noticed that the B737 was on the [takeoff] roll on Runway 06L, but my primary concern at that high speed exit…was to be on center line (I do not recall if green taxi lights were on) on taxiway D3 and identifying the hold short line or lights for Runway 06L on D3. ATC called, “Stop,” as I was slowing to taxi speed to keep looking for the hold short line on Taxiway D3.… The FO was finishing up the After Landing Checklist. We immediately stopped the aircraft on D3 before the runway and saw the B737 lifting off from the takeoff roll. It seems [that the] hold short lines for the adjacent parallel runway come up quicker than I was expecting to see them, even though I have reviewed the Jeppesen publications for special pages and the airport diagram.

(I should) pay more attention to reviewing the airport taxi plan and diagram. stop the aircraft any time in doubt on a taxiway. Enhancing visual references for the hold short line on such a short intersecting taxiway [would be helpful]."

From the B737 First Officer’s Report: Because of the wind gusts and rain, we elected to make a maximum thrust takeoff on Runway 06L,…which gave us a V1 speed of approximately 111 knots. We were cleared for takeoff, and everything was normal. Aircraft were landing on Runway 06R, and at V1 speed, I noticed an Embraer 145 that had landed clearing onto taxiway D3.… It was supposed to hold short of our runway, but at approximately 130 to 140 knots, we could see that it had missed its hold short area. If the aircraft continued onto our runway, I think we could have rotated and cleared it, but it would have been close. The Tower called for them to stop, and they did so just on the edge of our runway. I steered our aircraft just to the left of centerline to give us some extra room, and we took off at our normal rotate speed. After we changed frequency, ATC asked us a couple of questions, and we continued to destination without other incident.

https://asrs.arc.nasa.gov/publications/ ... b_466.html

Sort of answers this question...

How much over the stop line were the incursions?
Did anyone get onto the runway? Or just past the line and still less than the 90meter ICAO standard?

and this one.....

I wonder if after landing flows/check are being done prior to crossing the adjacent runway.

[pelmet]

Since no operator to my knowledge encourages crews to ignore ATC instructions, and yet these incidents still happen, other methods of keeping crews cognizant of hold short requirements need to also be employed.

Looking further into reasons why hold short lines are not being held short of.......it appears that this recent incident happened because the flight crew were not familiar with how hold short lines look. Perhaps one method would be to review these markings in an on-line e-learning program......

N89313, an Embraer ERJ-170-200, flight 6196, operated by Mesa Airlines, landed on runway 06R at Toronto/LPIA (CYYZ). The aircraft was instructed to exit on taxiway D5, a high-speed exit, and hold short of runway 06L. The flight crew did not read back the instructions correctly, so ATC reiterated the requirement to hold short of runway 06L, after which the flight crew correctly read back the instructions. At this time Air Canada flight 722, (Airbus A320) was cleared for departure from runway 06L. ATC observed N89313 rapidly approaching the hold-short line for runway 06L on D5, and instructed the aircraft to STOP STOP STOP. N89313 came to a stop past the hold short line, but not on the runway surface. Air Canada 722 was airborne prior to D5, between D1 and D3. It was reported that the flight crew of N89313, mistook the 06L hold short line for the 06R exit line.

[tbaylx]

Since no operator to my knowledge encourages crews to ignore ATC instructions, and yet these incidents still happen, other methods of keeping crews cognizant of hold short requirements need to also be employed.

Looking further into reasons why hold short lines are not being held short of.......it appears that this recent incident happened because the flight crew were not familiar with how hold short lines look. Perhaps one method would be to review these markings in an on-line e-learnig program......

N89313, an Embraer ERJ-170-200, flight 6196, operated by Mesa Airlines, landed on runway 06R at Toronto/LPIA (CYYZ). The aircraft was instructed to exit on taxiway D5, a high-speed exit, and hold short of runway 06L. The flight crew did not read back the instructions correctly, so ATC reiterated the requirement to hold short of runway 06L, after which the flight crew correctly read back the instructions. At this time Air Canada flight 722, (Airbus A320) was cleared for departure from runway 06L. ATC observed N89313 rapidly approaching the hold-short line for runway 06L on D5, and instructed the aircraft to STOP STOP STOP. N89313 came to a stop past the hold short line, but not on the runway surface. Air Canada 722 was airborne prior to D5, between D1 and D3. It was reported that the flight crew of N89313, mistook the 06L hold short line for the 06R exit line.

There are issues with the hold short lines in YYZ on the south parallels that compound the issue

[pelmet]

Since no operator to my knowledge encourages crews to ignore ATC instructions, and yet these incidents still happen, other methods of keeping crews cognizant of hold short requirements need to also be employed.

Looking further into reasons why hold short lines are not being held short of.......it appears that this recent incident happened because the flight crew were not familiar with how hold short lines look. Perhaps one method would be to review these markings in an on-line e-learning program......

N89313, an Embraer ERJ-170-200, flight 6196, operated by Mesa Airlines, landed on runway 06R at Toronto/LPIA (CYYZ). The aircraft was instructed to exit on taxiway D5, a high-speed exit, and hold short of runway 06L. The flight crew did not read back the instructions correctly, so ATC reiterated the requirement to hold short of runway 06L, after which the flight crew correctly read back the instructions. At this time Air Canada flight 722, (Airbus A320) was cleared for departure from runway 06L. ATC observed N89313 rapidly approaching the hold-short line for runway 06L on D5, and instructed the aircraft to STOP STOP STOP. N89313 came to a stop past the hold short line, but not on the runway surface. Air Canada 722 was airborne prior to D5, between D1 and D3. It was reported that the flight crew of N89313, mistook the 06L hold short line for the 06R exit line.

There are issues with the hold short lines in YYZ on the south parallels that compound the issue

Thanks,

Any details would be welcome. Keep in mind that wig-wags and red painted runway number markings are on the taxiway at each hold short line. Out of interest, I read this one just yesterday which is not located at the south parallel....

"N951DJ (US registration), a Falcon 50 aircraft inbound from Orlando Intl - Orlando (KMCO) was landing at Lester B. Pearson Intl - Toronto (CYYZ)when it was instructed by ATC to taxi via RWY 33R and hold short of RWY 23. The instruction was read back correctly by the flight crew. The aircraft was observed crossing the hold short line and was instructed by the controller to stop. WJA710 a WestJet Boeing 737-800 Max had just touched down on RWY 23 when the incursion took place."

I still suspect that distraction instead of focus on holding short is the problem.

[tbaylx]

The TSB should be releasing a detailed report on the issue soon. Essentially the hold short lines are at a non standard distance from the runway and right after a corner.

[pelmet]

The TSB should be releasing a detailed report on the issue soon. Essentially the hold short lines are at a non standard distance from the runway and right after a corner.

Thanks,

That was mentioned earlier in the thread. One would think that wig-wags flashing back amd forth on either side of the hold short line which also have the low visibility enhanced centerline markings leading up to the hold short line and large red boxes along the hold short line identifying the runway that you are supposed to hold short of, would be sufficient. But if you are doing after landing flows, attempting to contact company, switching landing lights, etc you will be doing something that is distracting.

[tbaylx]

http://www.bst-tsb.gc.ca/eng/rapports-r ... 7o0038.pdf

The report has been released. The executive summary sums it up, but the report as a whole is worth a read if you operate out of YYZ

[pelmet]

Have only read the summary but I was correct all along...they didn't pay attention.

"Given that the approach briefings that were conducted did not describe an adjustment to the normal routine following landing, the flight crews in most cases maintained their standard practice of initiating the post-landing flows and checklists after exiting the landing runway. Those actions diverted the attention of one, and occasionally both, of the crewmembers from the more critical task of locating the runway holding position."

Who needs to do any post-landing checklist at this time. Brief not to do anything but to hold short. Leave the speedbrakes up, flaps extended, lights on, radar on, etc. That is how it works at my company. but as mentioned by the TSB, does not work the same at most if not all of the companies mentioned in the report. The one example I know where it didn't work at my company was due to operation of landing lights by the F/O resulting in input from the captain resulting in them not paying attention and not holding short.

I see that most incursions were by foreign regional carriers.

"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."

So these foreign crews are said to be unfamiliar with the runway/taxiway layout. How does one become familiar with the runway/taxiway layout at one of the multitude of airports that you fly to? I would say perhaps look at the chart, maybe the the night before or if for whatever reason that is not done such as a busy day, then prior to and while giving a briefing for landing as is standard.

By the way, SFO and LAX have the exact same situation(and I am sure there are other airports in the US as well), so it is not a new concept to have two runways together without a taxiway in between. Now the TSB, once again, want a massively expensive fix which is to create a new taxiway....hundreds of millions of dollars to do that. Perhaps a demand by TC to these foreign airlines implement a cheap e-learning course specific to YYZ and a required briefing package item that has to be reviewed before the flight departs. Plus even larger wig-wag installations and flashing lead red centerline lights leading up to a new double red hold short line and most important....large signs that flash STOP, STOP, STOP continuously on either side of the taxiway which are controlled by ATC and go blank(or say 'cleared to cross') when one is cleared to cross. Sort of like the red line that is used in low vis ops. There....much cheaper and can be up and running in just a few months, instead of years. Sometimes simpler is more effective.

For those who talked about the hold short line being further from the runway than other airports, the TSB mentioned it and maybe it could be moved closer to the runway although that will give ATC less time to warn those who are not paying attention to STOP.

[tbaylx]

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up. Read the whole report before commenting. There aren't "several other airports" in north america without a parallel taxiway and the layout YYZ has. The TSB covered all of that in the report. Before you rip on them maybe read the whole thing. They covered all of the items you brought up in detail.

LAX USED to have the same setup with no parallel taxiway in between years ago and funny enough had most of the same issues with incursions that YYZ now has. Except they only had 800' between the runways. They tried all the same stuff Toronto did and eventually tore up a runway and moved it over at the cost of millions $$ so they could put a parallel taxiway in between. Same as the TSB recommends that YYZ does now, except YYZ doesn't have to move a runway so its quite a bit cheaper. They've run awareness campaigns and it's a band aid solution that helps reduce the number of incursions temporarily.

The only permanent effective solution is a parallel taxiway. Same as LAX did. When the south complex construction starts up in teh next couple of years i'll bet there is a parallel taxiway appearing.

[pelmet]

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up.

If they were paying attention/focusing to their hold short instructions and missed wig-wags, a hold short line. nice red signs, red painted runway ID markings, and enhanced centerline markings......then you are right as there is a competence issue as well. That being said, one can easily be heads up and not paying attention to the only thing that really matters.....holding short. It is easy to become distracted by company calls(lets keep com 2 on 121.5 instead), after landing checks(which was specifically mentioned as a distraction in multiple cases), etc.

Read the whole report before commenting.

Thanks. I believe it was you who stated for us...….

The executive summary sums it up, but the report as a whole is worth a read if you operate out of YYZ

Now that you see that the summary proves me right, it appears that you have changed your mind. I have started reading the report by the way, but that will take a while.

There aren't "several other airports" in north america without a parallel taxiway and the layout YYZ has.

In just the last two months I have flown into LAX, SFO, and SEA. I suggest you google taxiway diagrams for each and then report back to us on whether your statement is correct. Three airports in two months with the exact same setup of parallels with no taxiway in between, and this is just my personal experience. This also means that your further statement on LAX not having a similar setup is wrong.

However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).


What do you think.

[rookiepilot]

Have only read the summary ---

That about covers it

[pelmet]

Have only read the summary ---

That about covers it

I am aware that the fact that what I previously stated was proven correct is meaningless to you. It would be nice for your input though on what you might think are good mitigation procedures for pilots flying into YYZ in the near future. Who knows, your idea might be read and save a hundred lives, which I assume is your primary reason for posting on this thread .

Once again, here is how a major disaster happens and how it can be avoided.....

viewtopic.php?f=118&t=118732&p=1068622#p1063158

[rookiepilot]

viewtopic.php?f=54&t=130320

I've already posted on this topic.

Additional description:

https://www.skybrary.aero/index.php/Run ... hts_(RWSL)

In response to your sarcastic comment to me -- here is one potential solution used worldwide.

I think it's potentially a better one, than to simply kick the foreign carrier crews you refer to, in the ass.
But that's my opinion.

[TeePeeCreeper]

[/quote]
However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).


What do you think.
[/quote]

I think it’s a great idea. I really do. However I doubt various airport authorities or their accounting departments would agree that it would be an “inexpensive solution”!

[pelmet]

viewtopic.php?f=54&t=130320

I've already posted on this topic.

Additional description:

https://www.skybrary.aero/index.php/Run ... hts_(RWSL)

In response to your sarcastic comment to me -- here is one potential solution used worldwide.

I think it's potentially a better one, than to simply kick the foreign carrier crews you refer to, in the ass.
But that's my opinion.

I don't think I was any more sarcastic than you.

Thanks for the link, I will take a look at the skybrary thing after finishing the TSB report.

Stating that harsh truth is not kicking anyone in the ass. It is stating the harsh truth of not paying attention. It happened to me many years back and is the reason for many of the occurrences here. Unfortunately, there seem to be some pilots who don't like other pilots mistakes being pointed out. Perhaps a 'stick together' mentality regardless of the truth and the consequences of ignoring that truth. It is a dangerous trait to have. This trait can be seen several posters on this thread.

Safety is increased by harsh analysis and facts instead of worrying about hurt feelings from someone being "kicked in the ass" when in reality it is just finding the truth to reduce the risks of it happening again.

[pelmet]

However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).

What do you think.


I think it’s a great idea. I really do. However I doubt various airport authorities or their accounting departments would agree that it would be an “inexpensive solution”!

Thanks,

You may be quite correct, but I wonder how much it costs for a new taxiway versus the signage idea. I am making an assumption when I say that the signage would be less but I have no idea what the overall costs would be. Perhaps "relatively inexpensive solution" would be a better way of saying it. Actually, looking at my earlier post....I did say that.

[pelmet]

For clarification purposes as I read through the report......

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up. Read the whole report before commenting.

"Unless otherwise stated, the remainder of this report focuses on these 11 most recent occurrences.
• The flight crews were aware that they were approaching a runway and needed to stop. In all cases, both crew members understood exactly which exit they were on and that the aircraft was approaching an active runway and had to stop.
• The attention of 1 or both of the flight crew members was briefly diverted. In 10 of the 11 cases, the attention of at least 1 crew member was partially diverted when approaching the runway holding position, usually while completing postlanding tasks or checklists. For the most part, the first officer began the post-landing tasks once clear of the landing runway."

[pelmet]

There can be interesting parts of this report. For example.....

"When both parallel runways on the south complex at CYYZ are in use, the ATIS message advises flight crews of the following:
• High-intensity runway operations are in effect.
• Crews should minimize runway occupancy times and be alert to runway crossing clearances.
• Readback of all runway holding instructions is required.

The intent of the message is, in part, to alert crews to the risk of incursion on the inner runway. In the occurrences studied in this investigation, most of the inbound flight crews involved received that message digitally, rather than over the radio, and many did not interpret it as an incursion warning. In some cases, crews who were interviewed following an incursion indicated that they had been concerned with exiting the landing runway in a timely manner, as advised by the ATIS message, and were attempting to ensure that they had adequately passed the exiting runway holding position."

Does "be alert for runway crossing clearances" and Readback of all runway holding instructions" statements not make it clear that this is for prevention of runway incursions? I suspect that the entire ATIS is not being read. It is easy to happen and have found myself doing it as well. I suspect that after seeing the weather and runway in use, some are not carefully reading the rest of the ATIS. Mind you, it is only telling pilots what they should already know.


Another interesting thing to note is...."U.S.-based regional carriers made up only 8.8% of the traffic; however, they accounted for 74% of the examined incursions." I have gotten a little inside info about some of the regional carriers diligence but still, it does seem rather excessive.

[pelmet]

According to the report, the FAA has even put out some extremely good advice on this exact subject....

"The FAA circular states: After landing, nonessential communications and nonessential flightcrew actions should not be initiated until clear (on the inbound (terminal) side) of all runways in accordance with sterile cockpit procedures (e.g., changing radio frequencies and repositioning flaps, trim and speedbrakes)."

Sounds like good advice that was not followed in almost every incusion case...

"In all but one of the 11 incursions, at least 1 crew member was performing other flightrelated duties, such as post-landing flows and/or checklists, while the aircraft was on the Rapid Exit Taxiway. In all of those cases, the captain was taxiing the aircraft and the first officer was performing these duties. In some cases, those tasks were ordered by the captain, and, in others, they were initiated by the first officer."

[tbaylx]

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up.

If they were paying attention/focusing to their hold short instructions and missed wig-wags, a hold short line. nice red signs, red painted runway ID markings, and enhanced centerline markings......then you are right as there is a competence issue as well. That being said, one can easily be heads up and not paying attention to the only thing that really matters.....holding short. It is easy to become distracted by company calls(lets keep com 2 on 121.5 instead), after landing checks(which was specifically mentioned as a distraction in multiple cases), etc.

Read the whole report before commenting.

Thanks. I believe it was you who stated for us...….

The executive summary sums it up, but the report as a whole is worth a read if you operate out of YYZ

Now that you see that the summary proves me right, it appears that you have changed your mind. I have started reading the report by the way, but that will take a while.

There aren't "several other airports" in north america without a parallel taxiway and the layout YYZ has.

In just the last two months I have flown into LAX, SFO, and SEA. I suggest you google taxiway diagrams for each and then report back to us on whether your statement is correct. Three airports in two months with the exact same setup of parallels with no taxiway in between, and this is just my personal experience. This also means that your further statement on LAX not having a similar setup is wrong.

However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).


What do you think.

I think none of those airports have a 65 degree curve followed by a hold line set back 90M from the runway edge and are not anywhere near the setup that YYZ has. So i'd say you dont' understand the differences at YYZ if you think LAX has the same setup currently.

GTAA has tried lights, paint, more lights, more paint and pilots are still missing the hold line for all of the reasons the TSB outlines in its report. Only one of which happens to be a distracted pilot. The captain who is heads up and not distracted is missing the hold line so a pilot completing the after landing flow is not the main issue here. Nor is pilot competence as was also covered in the report.