Air transportation safety investigation A22O0146
The TSB has completed this investigation. The report was published on 20 December 2023.
Table of contents
Runway incursion
Greater Toronto Airports Authority
Maintenance Vehicle 31
Toronto/Lester B. Pearson International Airport, Ontario
The occurrence
On , at 0013 Eastern Daylight Time, during the hours of darkness, the maintenance vehicle designated as Maintenance 31, operated by the Greater Toronto Airports Authority at Toronto/Lester B. Pearson International Airport, Ontario, crossed the runway holding position marking for the east side of Runway 15R on Taxiway J, even though the driver had received and read back a taxi clearance that included an instruction to hold short of the runway.
At the time of the runway incursion, an Air Canada Boeing 737 operating as flight ACA 174 was on short final approach for Runway 15R, approximately 0.5 nautical miles from the runway.
The tower controller, who was watching the approaching aircraft through the window of the tower cab, observed the incursion as it was happening and issued instructions for the aircraft to go around. The flight crew complied and, after receiving instructions to rejoin the approach, the aircraft landed uneventfully at 0025 Eastern Daylight Time.
Media materials
News release
TSB releases investigation report into 2022 runway incursion and risk of collision at Toronto/Lester B. Pearson International Airport
Read the news release
Investigation information
Map showing the location of the occurrence
Investigator-in-charge
Jon Douma is a Senior Regional Investigator - Operations with the Ontario Region of the Air Investigations Branch. He joined the TSB in 2019 following 12 years in the business aviation sector, where he flew multiple jet and turboprop types and operated throughout North America, the Caribbean, and Eastern and Western Europe.
Prior to business aviation, he spent several years as a flight instructor, and has maintained an interest in general aviation since then, building and flying multiple amateur-built aircraft with his grandfather.
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.