Aviation Investigation Report A16O0016
The TSB has completed this investigation. The report was published on 25 February 2018.
Table of contents
Runway incursion and risk of collision
Air Canada, Embraer 190-100IGW, C-FNAW
and
Air Canada, Airbus 320-214, C-FZQS
Toronto/Lester B. Pearson International Airport, Ontario
The occurrence
On 30 January 2016, an Air Canada Embraer 190 (ACA726) was taxiing for departure on Runway 24R at Toronto’s Lester B Pearson International Airport (LBPIA). ACA726 taxied onto the runway without a clearance while an Air Canada Airbus A320 (ACA1259) was on short final for landing on Runway 24R. ACA1259 initiated a missed approach as a result of the incursion.
Media materials
News release
Misinterpretation of taxi instruction led to January 2016 runway incursion and risk of collision at Lester B. Pearson International Airport in Toronto, Ontario
Read the news release
Investigation information
Map showing the location of the occurrence
Investigator-in-charge
Formerly a senior officer in the Canadian Forces, Mr. Roach has 34 years of military aviation experience as an air traffic controller. He controlled air traffic in several locations, in both visual and instrument flight rules environments, eventually becoming a unit manager.
Mr. Roach joined the Canadian Forces School of Aerospace Control Operations as an air traffic control instructor in 1997, ending his tenure there as chief instructor, responsible for the delivery of air traffic control training for the Royal Canadian Air Force.
Before joining the Transportation Safety Board of Canada in 2013, Mr. Roach was at the Air Traffic Management Coordination Office in Ottawa, where he was responsible for the day-to-day liaison between the Department of National Defence, the Royal Canadian Air Force, Transport Canada and NAV CANADA.
Download high-resolution photos from the TSB Flickr page.
Class of investigation
This is a class 3 investigation. These investigations analyze a small number of safety issues, and may result in recommendations. Class 3 investigations are generally completed within 450 days. For more information, see the Policy on Occurrence Classification.
TSB investigation process
There are 3 phases to a TSB investigation
- Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
- Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
- Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.
For more information, see our Investigation process page.
The TSB is an independent agency that investigates air, marine, pipeline, and rail 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.