Pilots warned to stay alert for Toronto incursion risks

[pelmet]

The TSB should be releasing a detailed report on the issue soon. Essentially the hold short lines are at a non standard distance from the runway and right after a corner.

Thanks,

That was mentioned earlier in the thread. One would think that wig-wags flashing back amd forth on either side of the hold short line which also have the low visibility enhanced centerline markings leading up to the hold short line and large red boxes along the hold short line identifying the runway that you are supposed to hold short of, would be sufficient. But if you are doing after landing flows, attempting to contact company, switching landing lights, etc you will be doing something that is distracting.

[tbaylx]

http://www.bst-tsb.gc.ca/eng/rapports-r ... 7o0038.pdf

The report has been released. The executive summary sums it up, but the report as a whole is worth a read if you operate out of YYZ

[pelmet]

Have only read the summary but I was correct all along...they didn't pay attention.

"Given that the approach briefings that were conducted did not describe an adjustment to the normal routine following landing, the flight crews in most cases maintained their standard practice of initiating the post-landing flows and checklists after exiting the landing runway. Those actions diverted the attention of one, and occasionally both, of the crewmembers from the more critical task of locating the runway holding position."

Who needs to do any post-landing checklist at this time. Brief not to do anything but to hold short. Leave the speedbrakes up, flaps extended, lights on, radar on, etc. That is how it works at my company. but as mentioned by the TSB, does not work the same at most if not all of the companies mentioned in the report. The one example I know where it didn't work at my company was due to operation of landing lights by the F/O resulting in input from the captain resulting in them not paying attention and not holding short.

I see that most incursions were by foreign regional carriers.

"Regional airlines that are based in the United States and that operate regional jets were involved in a disproportionate number of the incursions, both in total and in terms of the rate of incursions per landing. This was likely due to foreign flight crews being unfamiliar with the uncommon taxiway layout between the parallel runways at CYYZ and to the increased speed at which their smaller aircraft types often approached the runway holding
positions."

"It is for these reasons that some foreign flight crews did not anticipate the location of the stopping position on each RET and so did not direct their attention outside the aircraft at the required time to identify the visual cues indicating the runway holding positions."

So these foreign crews are said to be unfamiliar with the runway/taxiway layout. How does one become familiar with the runway/taxiway layout at one of the multitude of airports that you fly to? I would say perhaps look at the chart, maybe the the night before or if for whatever reason that is not done such as a busy day, then prior to and while giving a briefing for landing as is standard.

By the way, SFO and LAX have the exact same situation(and I am sure there are other airports in the US as well), so it is not a new concept to have two runways together without a taxiway in between. Now the TSB, once again, want a massively expensive fix which is to create a new taxiway....hundreds of millions of dollars to do that. Perhaps a demand by TC to these foreign airlines implement a cheap e-learning course specific to YYZ and a required briefing package item that has to be reviewed before the flight departs. Plus even larger wig-wag installations and flashing lead red centerline lights leading up to a new double red hold short line and most important....large signs that flash STOP, STOP, STOP continuously on either side of the taxiway which are controlled by ATC and go blank(or say 'cleared to cross') when one is cleared to cross. Sort of like the red line that is used in low vis ops. There....much cheaper and can be up and running in just a few months, instead of years. Sometimes simpler is more effective.

For those who talked about the hold short line being further from the runway than other airports, the TSB mentioned it and maybe it could be moved closer to the runway although that will give ATC less time to warn those who are not paying attention to STOP.

[tbaylx]

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up. Read the whole report before commenting. There aren't "several other airports" in north america without a parallel taxiway and the layout YYZ has. The TSB covered all of that in the report. Before you rip on them maybe read the whole thing. They covered all of the items you brought up in detail.

LAX USED to have the same setup with no parallel taxiway in between years ago and funny enough had most of the same issues with incursions that YYZ now has. Except they only had 800' between the runways. They tried all the same stuff Toronto did and eventually tore up a runway and moved it over at the cost of millions $$ so they could put a parallel taxiway in between. Same as the TSB recommends that YYZ does now, except YYZ doesn't have to move a runway so its quite a bit cheaper. They've run awareness campaigns and it's a band aid solution that helps reduce the number of incursions temporarily.

The only permanent effective solution is a parallel taxiway. Same as LAX did. When the south complex construction starts up in teh next couple of years i'll bet there is a parallel taxiway appearing.

[pelmet]

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up.

If they were paying attention/focusing to their hold short instructions and missed wig-wags, a hold short line. nice red signs, red painted runway ID markings, and enhanced centerline markings......then you are right as there is a competence issue as well. That being said, one can easily be heads up and not paying attention to the only thing that really matters.....holding short. It is easy to become distracted by company calls(lets keep com 2 on 121.5 instead), after landing checks(which was specifically mentioned as a distraction in multiple cases), etc.

Read the whole report before commenting.

Thanks. I believe it was you who stated for us...….

The executive summary sums it up, but the report as a whole is worth a read if you operate out of YYZ

Now that you see that the summary proves me right, it appears that you have changed your mind. I have started reading the report by the way, but that will take a while.

There aren't "several other airports" in north america without a parallel taxiway and the layout YYZ has.

In just the last two months I have flown into LAX, SFO, and SEA. I suggest you google taxiway diagrams for each and then report back to us on whether your statement is correct. Three airports in two months with the exact same setup of parallels with no taxiway in between, and this is just my personal experience. This also means that your further statement on LAX not having a similar setup is wrong.

However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).


What do you think.

[rookiepilot]

Have only read the summary ---

That about covers it

[pelmet]

Have only read the summary ---

That about covers it

I am aware that the fact that what I previously stated was proven correct is meaningless to you. It would be nice for your input though on what you might think are good mitigation procedures for pilots flying into YYZ in the near future. Who knows, your idea might be read and save a hundred lives, which I assume is your primary reason for posting on this thread .

Once again, here is how a major disaster happens and how it can be avoided.....

viewtopic.php?f=118&t=118732&p=1068622#p1063158

[rookiepilot]

viewtopic.php?f=54&t=130320

I've already posted on this topic.

Additional description:

https://www.skybrary.aero/index.php/Run ... hts_(RWSL)

In response to your sarcastic comment to me -- here is one potential solution used worldwide.

I think it's potentially a better one, than to simply kick the foreign carrier crews you refer to, in the ass.
But that's my opinion.

[TeePeeCreeper]

[/quote]
However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).


What do you think.
[/quote]

I think it’s a great idea. I really do. However I doubt various airport authorities or their accounting departments would agree that it would be an “inexpensive solution”!

[pelmet]

viewtopic.php?f=54&t=130320

I've already posted on this topic.

Additional description:

https://www.skybrary.aero/index.php/Run ... hts_(RWSL)

In response to your sarcastic comment to me -- here is one potential solution used worldwide.

I think it's potentially a better one, than to simply kick the foreign carrier crews you refer to, in the ass.
But that's my opinion.

I don't think I was any more sarcastic than you.

Thanks for the link, I will take a look at the skybrary thing after finishing the TSB report.

Stating that harsh truth is not kicking anyone in the ass. It is stating the harsh truth of not paying attention. It happened to me many years back and is the reason for many of the occurrences here. Unfortunately, there seem to be some pilots who don't like other pilots mistakes being pointed out. Perhaps a 'stick together' mentality regardless of the truth and the consequences of ignoring that truth. It is a dangerous trait to have. This trait can be seen several posters on this thread.

Safety is increased by harsh analysis and facts instead of worrying about hurt feelings from someone being "kicked in the ass" when in reality it is just finding the truth to reduce the risks of it happening again.

[pelmet]

However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).

What do you think.


I think it’s a great idea. I really do. However I doubt various airport authorities or their accounting departments would agree that it would be an “inexpensive solution”!

Thanks,

You may be quite correct, but I wonder how much it costs for a new taxiway versus the signage idea. I am making an assumption when I say that the signage would be less but I have no idea what the overall costs would be. Perhaps "relatively inexpensive solution" would be a better way of saying it. Actually, looking at my earlier post....I did say that.

[pelmet]

For clarification purposes as I read through the report......

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up. Read the whole report before commenting.

"Unless otherwise stated, the remainder of this report focuses on these 11 most recent occurrences.
• The flight crews were aware that they were approaching a runway and needed to stop. In all cases, both crew members understood exactly which exit they were on and that the aircraft was approaching an active runway and had to stop.
• The attention of 1 or both of the flight crew members was briefly diverted. In 10 of the 11 cases, the attention of at least 1 crew member was partially diverted when approaching the runway holding position, usually while completing postlanding tasks or checklists. For the most part, the first officer began the post-landing tasks once clear of the landing runway."

[pelmet]

There can be interesting parts of this report. For example.....

"When both parallel runways on the south complex at CYYZ are in use, the ATIS message advises flight crews of the following:
• High-intensity runway operations are in effect.
• Crews should minimize runway occupancy times and be alert to runway crossing clearances.
• Readback of all runway holding instructions is required.

The intent of the message is, in part, to alert crews to the risk of incursion on the inner runway. In the occurrences studied in this investigation, most of the inbound flight crews involved received that message digitally, rather than over the radio, and many did not interpret it as an incursion warning. In some cases, crews who were interviewed following an incursion indicated that they had been concerned with exiting the landing runway in a timely manner, as advised by the ATIS message, and were attempting to ensure that they had adequately passed the exiting runway holding position."

Does "be alert for runway crossing clearances" and Readback of all runway holding instructions" statements not make it clear that this is for prevention of runway incursions? I suspect that the entire ATIS is not being read. It is easy to happen and have found myself doing it as well. I suspect that after seeing the weather and runway in use, some are not carefully reading the rest of the ATIS. Mind you, it is only telling pilots what they should already know.


Another interesting thing to note is...."U.S.-based regional carriers made up only 8.8% of the traffic; however, they accounted for 74% of the examined incursions." I have gotten a little inside info about some of the regional carriers diligence but still, it does seem rather excessive.

[pelmet]

According to the report, the FAA has even put out some extremely good advice on this exact subject....

"The FAA circular states: After landing, nonessential communications and nonessential flightcrew actions should not be initiated until clear (on the inbound (terminal) side) of all runways in accordance with sterile cockpit procedures (e.g., changing radio frequencies and repositioning flaps, trim and speedbrakes)."

Sounds like good advice that was not followed in almost every incusion case...

"In all but one of the 11 incursions, at least 1 crew member was performing other flightrelated duties, such as post-landing flows and/or checklists, while the aircraft was on the Rapid Exit Taxiway. In all of those cases, the captain was taxiing the aircraft and the first officer was performing these duties. In some cases, those tasks were ordered by the captain, and, in others, they were initiated by the first officer."

[tbaylx]

You really missed a lot if you think that not paying attention was the root cause. That was only one factor, and there were incursions where both pilots were heads up.

If they were paying attention/focusing to their hold short instructions and missed wig-wags, a hold short line. nice red signs, red painted runway ID markings, and enhanced centerline markings......then you are right as there is a competence issue as well. That being said, one can easily be heads up and not paying attention to the only thing that really matters.....holding short. It is easy to become distracted by company calls(lets keep com 2 on 121.5 instead), after landing checks(which was specifically mentioned as a distraction in multiple cases), etc.

Read the whole report before commenting.

Thanks. I believe it was you who stated for us...….

The executive summary sums it up, but the report as a whole is worth a read if you operate out of YYZ

Now that you see that the summary proves me right, it appears that you have changed your mind. I have started reading the report by the way, but that will take a while.

There aren't "several other airports" in north america without a parallel taxiway and the layout YYZ has.

In just the last two months I have flown into LAX, SFO, and SEA. I suggest you google taxiway diagrams for each and then report back to us on whether your statement is correct. Three airports in two months with the exact same setup of parallels with no taxiway in between, and this is just my personal experience. This also means that your further statement on LAX not having a similar setup is wrong.

However, I will look further into what the TSB recommended for mitigation of this issue. I still think my idea of large electronic signs with a flashing, bright HOLD on either side of the taxiway at the hold short line(controlled by ATC like the low vis red lines) is a practical and relatively inexpensive solution).


What do you think.

I think none of those airports have a 65 degree curve followed by a hold line set back 90M from the runway edge and are not anywhere near the setup that YYZ has. So i'd say you dont' understand the differences at YYZ if you think LAX has the same setup currently.

GTAA has tried lights, paint, more lights, more paint and pilots are still missing the hold line for all of the reasons the TSB outlines in its report. Only one of which happens to be a distracted pilot. The captain who is heads up and not distracted is missing the hold line so a pilot completing the after landing flow is not the main issue here. Nor is pilot competence as was also covered in the report.

[pelmet]

I think none of those airports have a 65 degree curve followed by a hold line set back 90M from the runway edge and are not anywhere near the setup that YYZ has. So i'd say you dont' understand the differences at YYZ if you think LAX has the same setup currently.

GTAA has tried lights, paint, more lights, more paint and pilots are still missing the hold line for all of the reasons the TSB outlines in its report. Only one of which happens to be a distracted pilot. The captain who is heads up and not distracted is missing the hold line so a pilot completing the after landing flow is not the main issue here. Nor is pilot competence as was also covered in the report.

Each airport has its unique characteristics. I guess YYZ is a 65 degree curve. The report states that in all but one case at least one of the pilots was distracted by unnecessarily doing after landing checklists/flows. I suspect both pilots were distracted in these cases.

If you are a captain who is heads up, aware of the need to hold short, not distracted, and looking for a hold short line yet unable to identify 1) elevated runway guard lights, 2) inset stop-bar lights, 3) supplemental elevated stopbar lights, 4) enhanced taxiway centreline markings(used to show that the hold short markings are being approached), 5) runway holding position markings (often referred to as “hold lines”), 6) mandatory instruction sign markings (often referred to as “runway boxes” which are large, red ground markings that identify the designation of the runway ahead, and 7)runway designation signs....I would say that you have a bit of a competence issue. I suspect the reality is that even though they were heads up, the captains were distracted by thinking about something else, yet did not mention this to the investigators. Perhaps they are thinking about the routing to follow after crossing the runway, how much time they have during the turnaround or one of a myriad of things that can distract eone who is still taxiing without really thinking about it yet not concentrating on holding short. How many of you have ever been daydreaming while driving without really thinking about maintining your lane yet you do stay in your lane using what is perhaps a lower level of your brain and then discover that you missed your exit. You were daydreaming/thinking of something else. Same thing here.

I am only 3/4 of the way through the report but have gotten to the part about the new taxiway proposal which does have merit as it is inevitable that more pilots will continue to let themselves be distracted by things that are likely not nearly as important as holding short. I would suggest having the first exit closer to the threshold.

Another good idea is the Runway Status lights. But, I suggest a modification in that these lights be made to flash when in operation. Flashing things get ones attention much more than non-flashing. I encountered a situation in the sim recently by accident. Somehow, for the airport we were at, Takeoff Hold Lights were accidentally left on by the sim instructor. I didn't even notice them until the other pilot mentioned them. A hundred red lights illuminated staring back at me(although they were not that bright) and I don't even notice them as I look down the runway ready to start the takeoff. Then when mentioned, it seems fairly obvious. Obviously, I wasn't paying attention. It is nice to think that I would have noticed before starting the roll but I had not yet.

[pelmet]

An interesting side note to the fact that the majority these incidents happening to American Regional pilots who make up such a small percentage of the overall flights.

I have flown with several Japanese pilots over the last few years. They have a reputation for being meticulous about procedures. I guess one has to be when their major airline has a two year training upgrade to become captain and the F/O's can expect to be berated by many captains with questions during their flights. Having to calculate the sunrise time was an interesting expectation I heard mentioned more than once.

One Japanese F/O I flew with lived in America and had flown for not one but three regional airlines in the US, all subsequent to his Japanese air carrier flying.. Therefore, his English was better than most of them. I was curious what he thought about the standards of the flying in the US as compared to Japan. While I expected him to mention that the Americans were fairly slack as compared to his home country, I was surprised when he said that almost none of the captains he flew with checked the notams. Their reasoning was that ATC would let them know about any closed taxiways etc. While different than the issue being discussed at YYZ in this thread, I wonder how many of these regional crews are doing a thorough review of hotspots, reading the ATIS fully, etc. They are flying short hops and a tiring schedule as well, limiting time available. Maybe they are expected to clean the cabin as well during turnarounds like one of our airlines seems to like their crews to do.

[rookiepilot]

viewtopic.php?f=54&t=130320

I've already posted on this topic.

Additional description:

https://www.skybrary.aero/index.php/Run ... hts_(RWSL)

In response to your sarcastic comment to me -- here is one potential solution used worldwide.

I think it's potentially a better one, than to simply kick the foreign carrier crews you refer to, in the ass.
But that's my opinion.

I don't think I was any more sarcastic than you.

Thanks for the link, I will take a look at the skybrary thing after finishing the TSB report.

Stating that harsh truth is not kicking anyone in the ass. It is stating the harsh truth of not paying attention. It happened to me many years back and is the reason for many of the occurrences here. Unfortunately, there seem to be some pilots who don't like other pilots mistakes being pointed out. Perhaps a 'stick together' mentality regardless of the truth and the consequences of ignoring that truth. It is a dangerous trait to have. This trait can be seen several posters on this thread.

Safety is increased by harsh analysis and facts instead of worrying about hurt feelings from someone being "kicked in the ass" when in reality it is just finding the truth to reduce the risks of it happening again.

Why isn't the technology I referenced already in place in YYZ and others APs?

[pelmet]

It is easy to become distracted by company calls(lets keep com 2 on 121.5 instead), after landing checks(which was specifically mentioned as a distraction in multiple cases), etc.

I think none of those airports have a 65 degree curve followed by a hold line set back 90M from the runway edge and are not anywhere near the setup that YYZ has. So i'd say you dont' understand the differences at YYZ if you think LAX has the same setup currently.

I believe that the 65 degree turn is a red herring for the real cause and instead pilots are letting themselves become distracted and miss the hold short line. Very few real details are given on any of these incursions for us to get a close to full picture of what was going on in the cockpit aside from the fact that frequently one pilot was not focused on the need to look for the hold short markings due to doing after landing checks. But what about the most important thing which is the guy taxiing the aircraft. I have been able to find some expanded details of one YYZ incident that was posted earlier...

viewtopic.php?f=118&t=118732&p=1070131#p1063158

And, I found another detailed example in the latest issue of Callback which has a classic example of why these incursions happen....just like I said.....letting yourself get distracted during critical times. You might remember that I mentioned earlier that SFO had a similar layout as YYZ(parallel runways with no taxiway in between).

Read this one to see why the pilot taxiing the aircraft did not hold short...

"At the end of a long day which included a fuel stop, a late hotel pickup, and weather, we landed on [Runway] 19L in San Francisco (SFO) and were cleared to hold short of 19R. We acknowledged the clearance. As we taxied off 19L, my iPad shut down on its own as it had done the last two days. As I reached over to restart it,…I lost location SA (Situational Awareness), and our nose taxied onto 19R. Just then the First Officer (FO) said, “Wait. Where are we?” and he told the Tower that we had started taxiing onto Runway 19R. The Tower said, “Yes, continue crossing 19R and contact Ground.” The rest of the taxi was uneventful"

So the guy is supposed to hold short of a nearby parallel runway and he is playing with an iPad instead of looking for a hold short line. Now you know why these incidents happen. I do agree with the TSB, a new parallel taxiway is needed because of pilots in control of the aircraft are doing stuff like playing with ipads among many other things instead of concentrating on holding short at critical times. Why not just ignore the iPad for now.

https://asrs.arc.nasa.gov/docs/cb/cb_469.pdf

As for the F/O's...you have to be ready to apply brakes yourself if required, temporarily ignore the call to do the after landing checklist, etc. And call out the holdshort line/requirement if it is not obvious that the aircraft is being slowed down for it.