TSB Report - Air Canada EMB190 near miss with Sunwing Van

[JigglyBus]

http://goo.gl/qFhmqV

Runway incursion and risk of collision
Sunwing Airlines vehicle and
Air Canada EMB190 C FLWH
Toronto Lester B. Pearson International Airport, Ontario
11 March 2013
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Summary

A Sunwing Airlines Inc. maintenance van was left unattended with the engine running and in drive gear near a company aircraft at gate H16 at Toronto–Lester B Pearson International Airport (YYZ), Ontario. The driverless van began to move from the gate area toward the threshold of Runway 24R; when it reached the center of the runway threshold, air traffic control noticed a ground radar target. Air traffic control then instructed Air Canada 178, an Embraer EMB190-100 (registration C-FLWH, serial number 19000094) on short final for Runway 24R to pull up and go around. The flight crew did not respond to the call, and air traffic control again instructed the aircraft to pull up and go around. The flight crew did not respond, and at 2339 Eastern Daylight Time flew directly overhead the van separated by approximately 35 feet, and landed on Runway 24R.

[Pop n Fresh]

Huh. Sounds like the van stopped instead of just rolling past the threshold. Seems peculiar. I hope some video shows up.

[pdw]

Nope, went right underneath it at the exact time it crossed 35ft overhead and got lodged in the grass on the other side of 24.

Had to read it twice too ...

[linecrew]

This thread was started shortly after the incident last year:

http://www.avcanada.ca/forums2/viewtopi ... 54&t=87854

[Pop n Fresh]

Ah, well it's a good one worth a new thread.

Nope, went right underneath it at the exact time it crossed 35ft overhead ...

Maybe but I doubt it. I do see the full report states, it continued past into the grass.

[JigglyBus]

flew directly overhead the van separated by approximately 35 feet

[Pop n Fresh]

Ok, but.

Both controllers quickly scanned the electronic flight progress strips and looked outside in an attempt to identify or confirm the target. The third controller scanned the area with binoculars; however, as the area in question is approximately 1.4 nautical miles (nm) from the tower and in darkness the view is saturated with various lights from Terminal 1, visual identification was impossible.

The tower controller eventually established contact with Air Canada 178, now on the landing rollout, and asked if they had seen anything. The crew of Air Canada 178 replied that they had not. Shortly after, the controllers organized with the airport authority to have the area inspected, and the van was located in the grass.

I think the crew did not see the van as it was off to the side. Of course the potential for me to be wrong is reasonable.

[pdw]

The investigation also determines too low a beacon bulb wattage in the van's orange rotating roof-mount rotating light (as per TC standard) .. only a "7 Watt" .. instead of the "37.5 Watt" ...

Right, it was off to the side ... far enough from the controllers, and then also likely how the PIC doesn't see it coming from the right, where understandably the roof mounted ladders are doing their job hiding the van's poorer amber light among the taxiway lights from both entities.

Was it going forward 1-5mph ... or reverse ? It might be easier to understand the shifter not locked all-the-way over into park, ... a little more difficult to grasp that it's simply left in drive when getting out.

[Pop n Fresh]

Regardless of wether it was directly under or off to the side the story is terrific.

The vehicle was located 14 minutes later, with the engine running, headlights, taillights, and beacon on, and the automatic transmission in drive.

That suggests forward to me. The guy did not even attempt to shift it. Oops.

[JigglyBus]

I agree it's quite a story whether it's 'on top' or 'off to the side', but the report is pretty clear with 'directly overhead' (Which was probably determined from the ASDE recordings).

[Pop n Fresh]

I wonder if they reviewed the cockpit voice recordings.
It would be pretty classic if they revealed, "Think we can clear that van?" "Oh yeah, easily!"

[JigglyBus]

Other findings
1.The guidance provided to maintenance crews regarding the procedure to isolate the digital voice–data recorders was unclear and as a result, important data relevant to the investigation was lost.

[C-FABH]

Try reading the link next time

[Pop n Fresh]

The link?

[pdw]

Yeah, linecrew in the 4th post gave us the link of earlier discussion ... after the incident / before the report. What a difference ... to see the 'before' ideas of what happened and the 'after'.

Now that the final report is out:

The driver didn't know / couldn't see where the van went, neither ground nor the tower; nor did the pilots glimpse it crossing into their path onto the runway from their right. Reads like no-one saw it in time and interesting they're really identifying a greater risk existed due to the poor lumens of it's rotating beacon circling a beam apparently with less than 20% of the brilliance it is mandated to have for that purpose, while also further dimmed/shaded to some directions by the ladders fastened to the roof rack.

[Pop n Fresh]

Ah, the link in the fourth post. I definitely should have read that first. So if they had the right bulb this probably would have been prevented?



Don't hate me forever Jiggly, I realize I'm being a bad person™ today.

[JigglyBus]

Ha... no ill will Pop.

Regarding the beacon thing, the report I read didn't seem to suggest it was the primary cause, or even secondary.... just another hole in the cheese.

[pdw]

Yeah it's only one "hole". The report goes on to inform that any subpar (1/2 amp/7watt) bulbs on other van's would be replaced. Interesting if the brighter 12-13volt/3 amp (37 watt) bulbs were too blinding to work around ... in certain situations ?

Do they need to be brighter when moving ... and a reduced wattage when parked, like a dimming option ?

Seeing it was just after dusk and wasn't found for a quarter of an hour ... were the driving lights even on ?

[JigglyBus]

The vehicle was located 14 minutes later, with the engine running, headlights, taillights, and beacon on, and the automatic transmission in drive.

[pdw]

guess i better to learn to read

Headlights are automatically on at approximately half strength for most vehicles when the engine is running / in drive, which are low power daytime running light beams.

If tailights are on as well, the light switch is advanced at least to the first stage (just parking lights), so not full headlights until the final notch. Doubt that would have made a difference though, as the direction the headlights would be facing is straight out into the infield (nobody there).