What happened
On a morning in 2002, a Cessna TU206G amphibious float-equipped aircraft, registration C-GGSG, was on approach to Runway 05 at Toronto/Lester B. Pearson International Airport. The aircraft was operating a charter flight from Georgian Bay with one pilot and three passengers. During the final approach, the pilot identified a landing gear malfunction, as the right main gear indicator failed to illuminate.
Simultaneously, a Northwest Airlines McDonnell Douglas DC-9-51, registration N773NC, was cleared to take off from Runway 33L. The air traffic controller, attempting to manage a heavy departure queue, utilized an unauthorized Land and Hold Short Operation (LAHSO) procedure, allowing the two aircraft to use the intersecting runways at the same time.
After touching down on Runway 05, the pilot of the Cessna TU206G announced an immediate go-around due to the gear issue. The controller instructed the pilot to perform a hard left turn but failed to warn the pilot of the departing McDonnell Douglas DC-9-51 or to instruct the aircraft to remain clear of Runway 33L. The flight crew of the N773NC observed the approaching Cessna and initiated an emergency right turn. The two aircraft passed within approximately 100 feet of each other, both laterally and vertically, over the threshold of Runway 15R. There were no injuries during the incident.
The investigation
The investigation examined the controller's use of simultaneous operations and the mechanical state of the aircraft. Investigators found that the controller used a procedure that was not authorized for this specific runway pairing. The investigation also looked into the maintenance of the Cessna TU206G, discovering that a broken actuator link in the right main landing gear had caused the gear failure. Furthermore, the investigation reviewed the clarity of aeronautical charts and the communication between the tower and the flight crews.
Findings
- The controller used unauthorized land and hold short operations to expedite traffic flow.
- The controller failed to notify the Cessna pilot of the departing heavy aircraft or the presence of conflicting traffic.
- The pilot of the Cessna TU206G did not inform the controller that the landing gear malfunction might prevent the aircraft from stopping before the runway intersection.
- The controller did not adequately consider the possibility of a go-around when authorizing the simultaneous use of the runways.
- The aircraft's landing gear failure was caused by a broken actuator link due to fatigue from repeated usage cycles.