2011 Sky Regional runway incursion "extremely serious": Canadian TSB

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An August 2011 runway incursion involving a Sky Regional Airlines turboprop and Beechcraft A100 King Air at Montreal-Pierre Elliott Trudeau International airport caused an "extremely serious risk of collision," a report issued by the Transportation Safety Board of Canada (TSB) shows.

The Sky Regional DHC-8 turboprop crossed onto an active runway where the King Air was accelerating to take off. The two aircraft did not collide but at one point passed about 40ft (12.1m) from each other.

Sky Regional flight SKV7516 was carrying 25 passengers and four crewmembers after landing on runway 24R in Montreal on 29 August 2011, 20 seconds after 15:30 local time. Ground control instructed the aircraft’s pilots to exit the runway on Taxiway Echo, hold short on Taxiway Bravo and then contact them after doing so.

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Photo credit: Transportation Safety Board of Canada

Fifty seconds after 15:30, the traffic controller then cleared flight PRO104 operated by Propair Incorporated to take off from Runway 28. Three crewmembers were on board the A100 King Air.

The Sky Regional DHC-8 was then instructed 57 seconds after 15:30 to give way to an Embraer aircraft taxiing the opposite direction on Taxiway Echo before continuing, and to hold short of Runway 28. The first officer on the Sky Regional flight repeated back the instruction, the DHC-8 slowed to let the Embraer by, and then taxied again at a speed of about 17 knots.

The King Air reached the Runway 28 threshold sixteen seconds after 15:32, and the crew turned on the landing lights. Without coming to a stop, the aircraft started to take off. Meanwhile, the Sky Regional turboprop was about 650ft from where it was supposed to hold short at Runway 28.

The Sky Regional pilots scanned the runways to the right and left and crossed Runway 28 at 38 seconds after 15:32, at a speed of 19 knots. Ground control expected the aircraft to hold at the Runway 28 line per earlier instructions that the pilots had repeated.

The King Air was accelerating down the runway at 85 knots, close to its set take-off speed of 100 knots.

About six seconds later, flight PRO104 aborted take-off at 102 knots by braking heavily, says the report. When the aircraft was slowing down, it veered to the right of the runway’s centreline at 16 knots and passed the Sky Regional DHC-8 at about 40ft away. No injuries occurred during the incident.

A contributing factor to the incident was the pilots' attention on the Embraer taxiing the other way on Taxiway Echo, the TSB's report states.

"While the ground controller was instructing SKV7516 to hold short of Runway 28, the pilots' attention was focused on an aircraft taxiing in the opposite direction," says the report." As a result, the SKV7516 pilots did not confirm between themselves the ground controller's instruction to hold short of Runway 28, and resumed taxiing."

The Sky Regional pilots believed that they were allowed to cross the runway despite the previous instruction to hold at Runway 28, the report says. The crew did not see the other aircraft and were not informed that PRO104 was cleared for take-off until days later, the investigation showed. Additionally, the crew did not see PRO104 on Runway 28 during their scan and the aircraft crossed the runway without permission to do so.

After the incursion, PRO104’s crew resumed take-off on Runway 28 without delays or incidents during the flight. Later inspections of the aircraft showed that the outside left tire was damaged and brake fluid was leaking from the left side.

Ground control and airport control had attempted to contact the Sky Regional aircraft on their radio frequencies but the aircraft did not receive them, the report says.

Since the incursion, Sky Regional has updated its checklists to limit distractions during taxiing and issued bulletins to pilots, the TSB states. The Montreal airport has also improved signage and established a committee dedicated to runway safety. Nav Canada has also taken steps to limit runway incursions.