What happened
On a day visual flight rules flight from Victoria, British Columbia, a privately owned Cessna 182, registration C-FTGQ, approached Vancouver International Airport. As the aircraft crossed the threshold of Runway 08R, the tower controller instructed the pilot to exit the active runway via Runway 12. While the pilot acknowledged the instruction, the aircraft's approach speed was approximately 30 knots faster than usual, causing the plane to overshoot the designated intersection.
Simultaneously, a WestJet Airlines Boeing 737, registration WJA168, was taxiing to the same runway for departure. After observing what appeared to be the Cessna turning off the runway, the controller cleared the Boeing 737 for take-off. However, the Cessna 182 remained on the active runway, traveling toward Taxiway A2. As the Boeing 737 accelerated, the pilot flying noticed a light ahead and realized the presence of the smaller aircraft. The Boeing 737 continued its roll, passing approximately 200 feet above and 100 feet to the left of the Cessna 182, avoiding a collision.
The investigation
The investigation examined the actions of the air traffic controllers, the flight crews, and the technical systems in place at the airport. Investigators looked into the controller's visual scanning techniques, the pilot's failure to communicate the missed exit, and the operational status of the airport's surface detection radar. The study also considered the physical characteristics of the Cessuna 182, noting its unpainted aluminum skin, which provided low contrast against the background.
Findings
- The Cessna 182 landed with excessive speed, preventing the pilot from vacating the runway at the instructed intersection.
- The controller cleared the departing aircraft for take-off without verifying that the runway was clear of obstructions.
- The pilot of the Cessna 182 did not notify the tower that they had missed the exit or were unsure of their position on the runway.
- The crew of the Boeing 737 did not detect the Cessna 182 during their initial runway scan, partly due to the small size of the aircraft and the low visual contrast of its unpainted skin.
- The airport's automated runway incursion monitoring system (RIMCAS) was not operational at the time due to ongoing issues with false alerts.
- The controller's attention was momentarily diverted by the administrative task of updating flight data strips.