Identification mix-up led to loss of separation between aircraft at Vancouver International Airport in April 2011
Gatineau, Quebec, 20 June 2013 – An aircraft identification mix-up, combined with a loss of situational awareness likely brought on by fatigue, are the central contributing factors in a loss-of-separation occurrence between 3 aircraft (2 departing and 1 landing), a Transportation Safety Board of Canada (TSB) investigation (A11P0073) has concluded. Aircraft are required to maintain a minimum distance from each other to reduce the risk of collision and a possible encounter with aircraft-generated turbulence.
On 15 April 2011 at the Vancouver International Airport, a Jazz Airlines de Havilland DHC-8 took off from the mid-point of Runway 26L at the intersection of taxiway E, while a Westjet Boeing 737 was waiting to take off from the threshold of the same runway. An identification mix-up resulted in a delay in getting the departing aircraft airborne in time to allow for the landing of an arriving Westjet Boeing 737. Realizing that a conflict between the 2 Boeing 737s was developing, the air traffic controller directed the arriving 737 to carry out a go-around. The 2 Boeing 737s lost their required separation when they came within approximately 2000 feet lateral spacing, with the departing aircraft climbing through the altitude of the aircraft carrying out the go-around. The minimum required separation is 30 degrees on a divergent course until the aircraft have achieved at least 1000 feet vertical spacing, and this separation was not restored in a timely manner.
In this investigation, the TSB found that the air traffic controller's loss of situational awareness resulted in an operational decision that led to a loss of separation between the two 737s. The investigation also found that it is likely that the air traffic controller was suffering the effects of fatigue at the time of the occurrence. That would have made it more difficult for the controller to recognize the developing situation and to take timely corrective action to ensure that separation was maintained.
NAV CANADA has taken additional measures to enhance safety at the Vancouver International Airport. It has prohibited departures of aircraft from a runway at a point other than the threshold. NAV CANADA is also looking to improve its existing Fatigue Management Program with a goal of better managing controller fatigue in a 24-hours-per-day, 7-days-per-week operation.
The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.
For more information, contact:
Transportation Safety Board of Canada
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