What happened
On a scheduled flight from London, Ontario, to Winnipeg, Manitoba, a WestJet Boeing 737-200, registration WJA107, departed Runway 33 at approximately 1433 EDT. During its climb, the aircraft encountered intermittent cloud cover. Simultaneously, a Cessna 172, registration C-GFEJ, was conducting a simulated instrument flight rules (IFR) approach to the opposite runway, Runway 15, as part of a training flight.
As the WestJet crew climbed, they received a traffic advisory from the Toronto area control centre (ACC) and subsequently a resolution advisory from the traffic alert and collision avoidance system (TCAS) to monitor their vertical speed. Radar data later confirmed that the two aircraft passed within 0.6 nm laterally and 5-00 feet vertically of each other. The WestJet crew maintained visual contact with the Cessna as the two planes passed in close proximity.
The investigation
The investigation examined the coordination between the London tower and the ACC, as well as the adherence to local operating manuals. It was established that the tower controller had not informed the WestJet crew that the Cessna was performing an approach to the opposite end of the airport. Furthermore, the tower controller instructed the Cessna to turn to a heading that actually increased the duration of the conflict with the departing Boeing 737.
Investigators also looked into the lack of oversight at the London tower. At the time, the position of Unit Operations Specialist had been vacant for two years, leaving the tower manager without specialized support to review or update local procedures. The investigation also noted an informal, unwritten practice regarding helicopter training circuits that lacked formal safety guidelines.
Findings
- The tower controller failed to notify the crew of WJA107 that the Cessna was conducting an approach to the opposite end of the departure runway.
- The tower controller's instruction to the Cessna to fly eastbound increased the period of conflict with the departing aircraft.
- The tower controller did not alert the ACC controller to the potential conflict, which delayed necessary corrective actions.
- The Cessna pilot, operating in Class E airspace, received traffic information but did not take action to avoid the departure path of the Boeing 737.
- A lack of supervisory oversight and the use of non-conforming, ad-hoc procedures contributed to the risk of collision.