Use of non-standard phraseology and not following standard operating procedures contributed to risk of collision at Ottawa’s Macdonald-Cartier International Airport
Ottawa, Ontario, 15 July 2015 – Today the Transportation Safety Board of Canada (TSB) released its investigation report (A14H0002) into the June 2014 runway incursion and risk of collision at the Macdonald-Cartier International Airport. There were no injuries.
On 5 June 2014, Ornge's Agusta AW 139 helicopter, operating as Life Flight 4 Medevac (LF 4 Medevac), was departing Ottawa's Macdonald-Cartier International Airport destined for Pembroke, Ontario, on an Instrument Flight Rules (IFR) flight plan. As instructed, LF 4 Medevac contacted the tower when holding short of Runway 25. The airport controller amended LF 4 Medevac's IFR clearance, and then observed LF 4 Medevac taxiing across the hold line while a Federal Express Airbus 300 was landing on Runway 25. The airport controller instructed LF 4 Medevac to stop. The runway incursion and risk of collision occurred when LF 4 Medevac crossed the hold line on Taxiway Echo at the intersection of Runway 25, after the Airbus had landed.
The TSB investigation found that Air Traffic Control used non-standard phraseology when issuing instructions to the pilot and that LF 4 Medevac taxied across the hold line on Taxiway Echo without authorization. It also found that, if flight crews do not follow company standard operating procedures before taxiing onto a runway, there is an increased risk of collision between aircraft.
Immediately after the incident, Ornge issued two bulletins reminding flight crews to be diligent when receiving and acknowledging air traffic control clearances. For its part, NAV CANADA reviewed the occurrence during Ottawa tower refresher training in November 2014, with emphasis on the importance of using standard phraseology.
The risk of collisions on runways has been identified as one of the risks to Canada's transportation system and is included on the TSB's 2014 Watchlist. The TSB is calling for improved procedures and enhanced collision warning systems must be implemented at Canada's airports.
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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