Pilots warned to stay alert for Toronto incursion risks

[altiplano]

While of general interest and a good reminder of the risks caused by distraction, it doesn't specifically address these incursions... rather it talks about the distraction issue across all aspects of flight operations.

You are grasping at one point, making broad assumptions, and making claims guys aren't paying attention - which may be an issue or may not be an issue case to case. You do not know.

I'm not saying guys aren't distracted sometimes, or maybe they didn't brief the hotspot because the approach listed on the ATIS was 23 and they were assigned 24L at 12000' and had to hustle to reprogram and slam a quick briefing together - but you're grasping at a single issue which you do not know is the root of this problem and discounting other factors, you are making assumptions and demanding proof of one company's procedures, yet you really aren't offering anything beyond reminding to increase vigilance and try to avoid distraction - which our procedures/bulletins/briefings certainly cover.

[altiplano]

In response to the edit... about blaming the airport...

It's not about assigning blame Pelmet - which is something you seems ripe to do.

Rather it's about all factors that contribute to the problem. That's the way the safety system in our industry is designed...

Crew vigilance/briefings/SOP/charts/communications/ATC/standardized markings/lighting/placement - all those play a factor in keeping it safe.

If the existing infrastructure/safeguards/etc. aren't doing it then we need to recognize that and be adaptable, possibly look at changing it. ie. It's not enough in this circumstance. What more can we do? Additional safeguards?

Clearly the pilot ultimately went over the line... but you are assuming you know why the pilot went over the line... I suggest your assumption isn't always correct. Lots of vigilant people make mistakes. Why? That's the conversation.

[altiplano]

Further to it... I expect we'll be seeing soon what the TSB says...

http://www.bst-tsb.gc.ca/eng/enquetes-i ... 7o0038.asp

Background
In June 2012, the Greater Toronto Airport Authority (GTAA) completed an investigation into runway incursions on the south complex of CYYZ. It identified 40 occurrences of interest between 2004 and the end of 2011, of which 20 were inner runway incursions (incursions between the two parallel runways). The GTAA implemented a runway incursion plan based on its findings, and completed the changes outlined in the plan at the end of 2013.

From the last incursion recorded in the GTAA investigation in December 2011 to May 2017 there have been another 22 inner runway incursions at the CYYZ south complex: 13 prior to the completion of the GTAA's runway incursion plan in 2013, and 9 since then.

The south complex has characteristics not found at other airports in Canada and elsewhere in the world.

[pelmet]

I'm not saying guys aren't distracted sometimes, or maybe they didn't brief the hotspot because the approach listed on the ATIS was 23 and they were assigned 24L at 12000' and had to hustle to reprogram and slam a quick briefing together

As I already mentioned on the first page, if there is a runway change, a few seconds can be taken to make a quick mention about the having to hold short of the parallel runway at that time. Of course the sharp guys will have already mentioned this and other basics of a likely alternative approach during the initial briefing about the not uncommon situation of a runway change such as "By the way, if we have to land on 24L, we have to make sure to hold short of 24R. Remind me as I clear the runway". Five simple seconds to say that ten or twenty minutes before the initial descent. I do that going into SFO in case we get 28R instead of the usual 28L(along with a few other things). A runway change is not a valid excuse for an incursion.

[altiplano]

You again make assumptions. You mention only one piece in the puzzle...

[pelmet]

You again make assumptions. You mention only one piece in the puzzle...

Thanks for the reply. My assumptions are backed up by studies as a very significant piece of the puzzle. I am still hoping you might give some new advice that hasn't been posted previously. It is always nice to hear what others are doing and are certainly welcome.

[altiplano]

Not going anywhere.

Have a good one.

[pelmet]

I am still hoping you might give some new advice that hasn't been posted previously. It is always nice to hear what others are doing and are certainly welcome.

Not going anywhere.

Have a good one.

Hmmm....no advice from either, no surprise.

[Rockie]

All the things you’re harping about Pelmet crews already do...you didn’t invent them. Any procedure you come up with is already being done or already been tried. Stop looking for the silver bullet procedure or trying to find a systemic procedural deficiency because you won’t find it.

Despite all the precautions in taxiing airplanes and briefings and whatnot these events still happen so what to do about it. You mentioned one regarding lights and I agreed with you. Does that not satisfy you? Why do you still need to find some deficiency in AC’s procedures when this type of thing clearly happens to everybody?

It’s like you’re on a mission to discredit AC or something and will not be deterred by anything.

[hamstandard]

Due to your tenacious defence of AC's procedures, I will assume that you are correct

Why do you still need to find some deficiency in AC’s procedures when this type of thing clearly happens to everybody?

It’s like you’re on a mission to discredit AC or something and will not be deterred by anything.

Jesus C_____ Rockie, the guy already said that he accepts your point of view on AC's procedures. Reading through you responses, I was understanding of your point of view on that particular subject but now you are starting to sound like a wingnut ready for the rubber room.

[pelmet]

As stated, I already gave Rockie the benefit if the doubt on his company's procedures as the important thing is to do our best as pilots to prevent a disaster. I suppose some might like to say that everything has been tried and there is nothing else we should do with the inevitable result of the status quo where the incursions continue, but I suggest that if the incursions continue, there is a deficiency in certain procedural areas in at least isolated cases. The deficiency may be as simple as pilots not following SOP but there is a deficiency for something that is really fairly basic.

Therefore, I request that Rockie, in the same way as I requested to Altiplano(or anyone else) with their extensive flying experience to to spend some time to consider(or re-consider) what could be added to my suggestions on how to prevent future incidents and possibly a disaster. It is more important than any back and forth arguing over small items. While I haven't gotten i direct response yet, I remain hopeful.

Thanks for your consideration.

One should mention during the approach briefing to hold short of the parallel and it can quickly be stated after a runway change if that is the case.

Is there a written procedure at your company stating that the after landing flow/checklist can only be done such as after receiving a clearance to taxi in from ground? This is how it is done where I work. I hope you answer this question in the name of safety as this could be a cause factor worth looking into.
Even if you decide not to let us know, I suggest to everyone that this procedure be applied. It may not be 100% effective but it is designed to keep pilots looking outside at potentially critical moments.

Keeping the lights on, flaps and speed brakes extended, and both pilots looking outside the cockpit window seems likely to reduce the chances of accidentally crossing a hold short line and passing by/over hold short lights.

Like most companies, we have an ops manual. As well, there are memos on certain procedures the company wants us to follow. Part of the statement on vacating runways in the manual states..."No switch or lever shall be repositioned after landing until clear of the active runway unless necessary for the safe control of the aircraft." After a incident similar to what has been posted on this thread involving close parallel runways with a hold short clearance which was caused by the captain becoming distracted by the copilot operating the landing lights, a memo was produced about including close parallel runways being included in this practice. Therefore in my experience we always have a taxi clearance prior to the after landing flow. It is just the way it always works out.

[Rockie]

Therefore, I request that Rockie, in the same way as I requested to Altiplano(or anyone else) with their extensive flying experience to to spend some time to consider(or re-consider) what could be added to my suggestions on how to prevent future incidents and possibly a disaster. It is more important than any back and forth arguing over small items. While I haven't gotten i direct response yet, I remain hopeful.

You're not listening Pelmet, but I'll give it one more try before giving up. Your suggestion about a line of red lights (two parallel lines like are on the runway would be better) leading into the highspeed corner up to the red stop bars are the best suggestion I've heard and would be very effective in my opinion in breaking through whatever distractions are preventing crews from adhering to hold short instructions.

Procedures, reminders and other personal tricks people may have are already effective or we would be having many more incursions than we do now. The problem with them is that they will never be 100% effective, and although rare compared to how many times crews do it properly distractions and errors will still occur. Something more dramatic is called for here, and more obvious red lights are my choice.

[pelmet]

Therefore, I request that Rockie, in the same way as I requested to Altiplano(or anyone else) with their extensive flying experience to to spend some time to consider(or re-consider) what could be added to my suggestions on how to prevent future incidents and possibly a disaster. It is more important than any back and forth arguing over small items. While I haven't gotten i direct response yet, I remain hopeful.

Your suggestion about a line of red lights (two parallel lines like are on the runway would be better) leading into the highspeed corner up to the red stop bars are the best suggestion I've heard and would be very effective in my opinion in breaking through whatever distractions are preventing crews from adhering to hold short instructions.

Procedures, reminders and other personal tricks people may have are already effective or we would be having many more incursions than we do now. The problem with them is that they will never be 100% effective, and although rare compared to how many times crews do it properly distractions and errors will still occur. Something more dramatic is called for here, and more obvious red lights are my choice.

I have been listening and providing useful information for the whole thread instead of ferociously defending an SOP with no evidence which doesn't further the conversation. But, I will take your word in order to once again try to get back on the conversation of safety.

A red lights idea could be helpful at some point in the future but that of course could take months or years at minimum plus, the suggestion I made was for Runway Status lights which are not always illuminated and have nothing to do with a hold short clearance. I just thought that you(or someone else) might have a suggestion or two in addition to mine about what pilots might do in the interim or at other locations with a similar layout.

And unfortunately, the reality is that it is inevitable that the enhancements such as the red lights idea will not be installed at many locations we fly to such as LAX and SFO(until possibly after a major disaster). And the incursion rate at YYZ(and likely other locations) is unacceptable, even if considered rare.

Thanks.

As seen by the reply below, you didn't really offer anything new as asked but certainly, a briefing is a good start. Unfortunately, you may be finishing at that point as well. Wig-Wags and hold short lights in the taxiway are already completely obvious. The only way to miss them accidentally is to not be paying attention.

[Rockie]

I just thought that you(or someone else) might have a suggestion or two in addition to mine about what pilots might do in the interim or at other locations with a similar layout.

I wish I did. My own technique is specifically briefing that we will stop and in no circumstances cross the other runway until we are cleared to. My default position is to stop and it seems to have worked so far. But distractions are insidious and I repeat that no one does this on purpose. I'm not immune to errors, and what I do to have the right mindset won't work on everybody and may not work on me sometime in the future.

A blinding series of red lights though? That'll break through even my fog...

[pelmet]

But telling you specifically what our procedures are isn't going to make anything safer. If you really want to know what our procedures are I'll give you an address at flight operations you can write to and ask.

That's strange......you seem awfully willing to immediately quote your FOM when you actually have a written procedure to base your argument upon(as seen on another thread as quoted below).....

You really should read the section in the FOM Altifina. It says "advise if possible", not "ask permission".

I don't understand why you're arguing this, it's black and white. The "Any life threatening situation" is what should give you pause ........
PIC advised (if possible) as per FOM policy.

Get over it.

http://www.avcanada.ca/forums2/viewtopi ... 5#p1024755


......but a total unwillingness to do the same for this thread. Makes one wonder why. I think I know why, but would be delighted to be proven wrong.

And now, a few days later....some details on AC policy concerning evacuations yet nothing to back up what he said on this thread Why? Because he was making up his earlier statements of....

AC's procedures are consistent with other airlines, spelling them out to you will not answer the question why there have been excursions. You'd have to read an investigative report to know that which I haven't. Maybe when you ask our ops to tell you our procedures they'll also tell you what they've found in that regard.

It's not an unwillingness to participate, it's an unwillingness to answer specific questions about our procedures especially when it gains nothing.....

......and that's likely why he won't give further details. Because, there are no procedures like I described earlier.

That's fine. But time to implement some.

We saw the TSB very unhappy with certain procedures at YHZ. Being proactive can be helpful.

[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.