The Transportation Safety Board of Canada (TSB) made several recommendations after an investigation pointed to similarities in 27 runway incursions that occurred at Toronto Pearson International airport between June 2012 and November 2017.
“Although the vast majority of incursions pose little to no risk, the [TSB] has identified a troubling pattern at Pearson International,” TSB chair Kathy Fox said during a 31 January press briefing, noting that on average 445 runway incursions have occurred in Canada annually over the past few years.
The concerns lie with two southern parallel runways at the airport, she said, which are known as the “south complex” and used simultaneously in peak periods.
These particular runway incursions posed a “substantial risk,” TSB briefing materials said. These situations all involved aircraft that landed on the airport’s outer runway (Runway 06R/24L) and then failed to hold short of the inner runway (Runway 06L/24R) despite intending to stop and being notified by controllers to do so.
Crews of these aircraft “missed the visual cues depicting the runway holding positions,” the report’s executive summary states.
Fox referenced lights, warning signs and pained lines on the ground during the press briefing.
In background material, the TSB notes that several aspects of the taxiway layout of Pearson’s “closely spaced parallel runways” are “uncommon”. Among them are the short distances between the runways, and the way the rapid exit taxiways between runways and runway holding positions are designed.
“The exits lead directly to the ‘inner’ parallel runway, the hold lines are located immediately following a 65° curve and, most notably, they are farther away from the protected runway than is commonly seen elsewhere,” a TSB news release said. “These uncommon features mean that the hold lines are not where crews are expecting to see them.”
US regional jet operators were involved in a “disproportionate” number of these incursions, the report stated, citing the likely cause as unfamiliarity with the taxiway layout between the parallel runways and the speeds at which these aircraft were traveling to the runway holding positions.
“When exiting the landing runway, crews are normally occupied with other tasks and, because they are using a rapid exit taxiway, the aircraft is usually traveling at taxi speeds that are faster than typical,” the TSB materials state. “A flight crew’s unfamiliarity with these uncommon characteristics, the short amount of time and distance available, and distraction due to other tasks reduces their ability to identify the runway holding positions.”
The TSB made four suggestions, including one for the Greater Toronto Airports Authority (GTAA) to physically change the layout of the taxiway.
“This could happen in a number of ways — for instance, changing the design and position of the rapid exit taxiways, creating a perimeter taxiway to go around the other active runway or even constructing a separate intermediate taxiway between the two parallel runways,” Fox said during the press conference.
However, the report recognises that the changes cannot be made overnight, and urges that measures be taken in the meantime.
“In the meantime, until those changes are made, we want to see further improvements to increase the visibility of these hold-short positions, because clearly more needs to be done so that all flight crews see the cues and react as required,” Fox said. The report cites changes to the runway holding position lighting as a possibility for helping crews see signals to stop.
In addition, it recommends Canadian and US aviation authorities work with airlines to change standard operating procedures to do post-landing checks after the aircraft are cleared of these close, active parallel runways. This would aim to cut down on distractions during critical moments.
It also suggests that Canadian civil air navigation service operator Nav Canada change its phraseology guidance so that critical instructions have a better chance of grabbing crews’ attention. This could be done by adding words such as “immediately” or repeating instructions for things like aborted take-offs or go-arounds.