What happened
At approximately 11:53 Pacific standard time, a risk of collision occurred at Vancouver International Airport involving two aircraft. A Boeing 747-400, operated by Japan Airlines, was beginning its take-off roll on Runway 26R. Simultaneously, a Shorts SD 360, operated by Pacific Coastal Airlines, was on final approach to Runway 12. The two aircraft's flight paths intersected when the Shorts SD 360 passed approximately 0.5 nautical mile in front of and below the departing Boeing 747-400. At the time of the incident, the aircraft were being managed by different controllers within the Vancouver Tower.
The investigation
The investigation focused on the coordination between the tower north and tower south controllers. Due to ongoing technical work and equipment reconfiguration in the tower, the controllers were positioned in non-standard locations. Specifically, the tower advisory controller was operating from the ground north location, adjacent to the tower north controller.
At the time, Runway 2 and 26L were active, but Runway 26R was also being used for departures due to a construction project involving cranes near the end of Runway 26L. Because Runway 26R is rarely used for departures, not all controllers had experience managing this specific type of operation. The investigation also examined the radar display information, which showed only generic altitude and speed data for several aircraft, including the Shorts SD 360, without providing flight numbers or aircraft types.
Findings
Several factors contributed to the near-miss:
- Inadequate coordination between the tower north and tower south controllers regarding specific traffic information and follow-up procedures.
- A lack of specific published procedures or guidance for managing departures from Runway 26R during the construction period.
- The tower south controller failed to inform the tower north controller of all relevant arrival traffic for Runway 12.
- The tower north controller did not perform an effective visual scan of the departure path for Runway 26R before issuing the take-off clearance.
- The tower advisory controller did not relay arrival information to the tower north controller, as there was no requirement to do so.
- Radar display limitations prevented controllers from easily distinguishing the Shorts SD 360 from other traffic, as the display lacked aircraft identification and intentions.