TSB Report - Air Canada EMB190 near miss with Sunwing Van

[JigglyBus]

http://goo.gl/qFhmqV

Runway incursion and risk of collision
Sunwing Airlines vehicle and
Air Canada EMB190 C FLWH
Toronto Lester B. Pearson International Airport, Ontario
11 March 2013
Show table of contents
Summary

A Sunwing Airlines Inc. maintenance van was left unattended with the engine running and in drive gear near a company aircraft at gate H16 at Toronto–Lester B Pearson International Airport (YYZ), Ontario. The driverless van began to move from the gate area toward the threshold of Runway 24R; when it reached the center of the runway threshold, air traffic control noticed a ground radar target. Air traffic control then instructed Air Canada 178, an Embraer EMB190-100 (registration C-FLWH, serial number 19000094) on short final for Runway 24R to pull up and go around. The flight crew did not respond to the call, and air traffic control again instructed the aircraft to pull up and go around. The flight crew did not respond, and at 2339 Eastern Daylight Time flew directly overhead the van separated by approximately 35 feet, and landed on Runway 24R.

[Pop n Fresh]

Huh. Sounds like the van stopped instead of just rolling past the threshold. Seems peculiar. I hope some video shows up.

[pdw]

Nope, went right underneath it at the exact time it crossed 35ft overhead and got lodged in the grass on the other side of 24.

Had to read it twice too ...

[linecrew]

This thread was started shortly after the incident last year:

http://www.avcanada.ca/forums2/viewtopi ... 54&t=87854

[Pop n Fresh]

Ah, well it's a good one worth a new thread.

Nope, went right underneath it at the exact time it crossed 35ft overhead ...

Maybe but I doubt it. I do see the full report states, it continued past into the grass.

[JigglyBus]

flew directly overhead the van separated by approximately 35 feet

[Pop n Fresh]

Ok, but.

Both controllers quickly scanned the electronic flight progress strips and looked outside in an attempt to identify or confirm the target. The third controller scanned the area with binoculars; however, as the area in question is approximately 1.4 nautical miles (nm) from the tower and in darkness the view is saturated with various lights from Terminal 1, visual identification was impossible.

The tower controller eventually established contact with Air Canada 178, now on the landing rollout, and asked if they had seen anything. The crew of Air Canada 178 replied that they had not. Shortly after, the controllers organized with the airport authority to have the area inspected, and the van was located in the grass.

I think the crew did not see the van as it was off to the side. Of course the potential for me to be wrong is reasonable.

[pdw]

The investigation also determines too low a beacon bulb wattage in the van's orange rotating roof-mount rotating light (as per TC standard) .. only a "7 Watt" .. instead of the "37.5 Watt" ...

Right, it was off to the side ... far enough from the controllers, and then also likely how the PIC doesn't see it coming from the right, where understandably the roof mounted ladders are doing their job hiding the van's poorer amber light among the taxiway lights from both entities.

Was it going forward 1-5mph ... or reverse ? It might be easier to understand the shifter not locked all-the-way over into park, ... a little more difficult to grasp that it's simply left in drive when getting out.

[Pop n Fresh]

Regardless of wether it was directly under or off to the side the story is terrific.

The vehicle was located 14 minutes later, with the engine running, headlights, taillights, and beacon on, and the automatic transmission in drive.

That suggests forward to me. The guy did not even attempt to shift it. Oops.

[JigglyBus]

I agree it's quite a story whether it's 'on top' or 'off to the side', but the report is pretty clear with 'directly overhead' (Which was probably determined from the ASDE recordings).

[Pop n Fresh]

I wonder if they reviewed the cockpit voice recordings.
It would be pretty classic if they revealed, "Think we can clear that van?" "Oh yeah, easily!"

[JigglyBus]

Other findings
1.The guidance provided to maintenance crews regarding the procedure to isolate the digital voice–data recorders was unclear and as a result, important data relevant to the investigation was lost.

[C-FABH]

Try reading the link next time

[Pop n Fresh]

The link?

[pdw]

Yeah, linecrew in the 4th post gave us the link of earlier discussion ... after the incident / before the report. What a difference ... to see the 'before' ideas of what happened and the 'after'.

Now that the final report is out:

The driver didn't know / couldn't see where the van went, neither ground nor the tower; nor did the pilots glimpse it crossing into their path onto the runway from their right. Reads like no-one saw it in time and interesting they're really identifying a greater risk existed due to the poor lumens of it's rotating beacon circling a beam apparently with less than 20% of the brilliance it is mandated to have for that purpose, while also further dimmed/shaded to some directions by the ladders fastened to the roof rack.

[Pop n Fresh]

Ah, the link in the fourth post. I definitely should have read that first. So if they had the right bulb this probably would have been prevented?



Don't hate me forever Jiggly, I realize I'm being a bad person™ today.

[JigglyBus]

Ha... no ill will Pop.

Regarding the beacon thing, the report I read didn't seem to suggest it was the primary cause, or even secondary.... just another hole in the cheese.

[pdw]

Yeah it's only one "hole". The report goes on to inform that any subpar (1/2 amp/7watt) bulbs on other van's would be replaced. Interesting if the brighter 12-13volt/3 amp (37 watt) bulbs were too blinding to work around ... in certain situations ?

Do they need to be brighter when moving ... and a reduced wattage when parked, like a dimming option ?

Seeing it was just after dusk and wasn't found for a quarter of an hour ... were the driving lights even on ?

[JigglyBus]

The vehicle was located 14 minutes later, with the engine running, headlights, taillights, and beacon on, and the automatic transmission in drive.

[pdw]

guess i better to learn to read

Headlights are automatically on at approximately half strength for most vehicles when the engine is running / in drive, which are low power daytime running light beams.

If tailights are on as well, the light switch is advanced at least to the first stage (just parking lights), so not full headlights until the final notch. Doubt that would have made a difference though, as the direction the headlights would be facing is straight out into the infield (nobody there).

[freakonature]

How did they not hear the two pull up and go around calls from the tower?

[Married a Canadian]

How did they not hear the two pull up and go around calls from the tower

My understanding from reading the report is the first call came at the same time an altitude call in the cockpit...the second one...the pilots did not think it was for them.

I skimmed through the old thread for this topic and still can't believe that "some" posters

1 thought that the tower controllers did not use the full callsign (liveatc.net is so accurate for that type of thing). When I said they did I was asked how I knew!?

2 Don't think it is an issue when crews either "miss" or "ignore" calls.

In this case the crew thought it was a sterile runway ahead when this investigation showed otherwise.
Very interesting report..and from a groundside ops point of view..a lot to learn.

[JigglyBus]

How did they not hear the two pull up and go around calls from the tower?

Findings....
4.The first air traffic control go around instruction was masked in the cockpit by a louder overlying enhanced ground proximity warning system automated callout, and the crew did not hear it.
5.The second ATC go-around instruction issued by the tower controller was truncated by the transmitting and receiving radios. This, in combination with a rapid speech rate and elision, caused the aircraft call sign to be absent from the received transmission.
6.Although the crew heard a “go-around” transmission, without other supporting cues such as visually sighting an obstacle, the crew did not interpret the instruction to apply to them. Consequently, the communication was insufficient to challenge the flight crew’s mental model of the situation, or their expectation of an uneventful landing.

[pdw]

Yes, "the communication was insufficient to challenge the flight crews mental model of the situation". In those moments their main field of focus is cast center-line and well ahead of the 24 numbers anyway ... towards which the dim-beaconed/snail-paced van is creeping among similar-colored taxi-lights at approx 90-deg from the right (near the east edge of the runway/airport prior to them overflying it by "35ft" about 10 seconds earlier and 100-200').

In this case the crew thought it was a sterile runway ahead ....

This was the case when crossing the threshold at 40-45ft ("35ft" above the van or AGL?). So how much of the runway/airport/taxiway where this was transpiring is still in the concerned view of the PIC below the nose of such aircraft ... here at 1/4 mile final and 200ftAG where the touchdown is still 1500ft in.

[single_swine_herder]

I'd have liked to hear the initial investigation recording of the van driver with his union rep present .....