Occurrence Summary
On an evening at Toronto/Lester B. Pearson International Airport, a Learjet 35A (registration N70AX, serial number 155) operated by R & M Aviation Inc. was taxiing from the north general aviation ramp for departure on Runway 06L to Chicago/Rockford, Illinois. The crew received instructions to taxi on Taxiway Juliett, hold short of Taxiway Papa, then proceed on Taxiway Foxtrot and hold short of Runway 05. At 2206:34 eastern standard time, the aircraft arrived at the hold position for Runway 05 but did not stop, entering the runway at 2206:43. At that time, an Israel Aircraft Industries IAI 1124 Westwind (registration C-FJOJ, serial number 271), operated by Fast Air, was in the landing roll on Runway 05. The Westwind crew observed the Learjet and maneuvered to pass behind it, with the two aircraft coming within 60 feet of each other.
Aircraft and Crew Information
The Learjet N70AX had departed its home base in Aurora, Illinois, at 0953 central standard time with flight and medical crews to transport a patient from Miami, Florida, to Toronto. After delays, the flight arrived in Toronto at 1803 eastern standard time and departed at 2220. Both pilots were certified and qualified under U.S. Federal Aviation Administration regulations. The pilot-in-command had extensive experience on type (360 hours), while the co-pilot had 15 hours on type, this being his third mission. Neither pilot was familiar with Toronto; the pilot-in-command had been there twice before, both times during daylight, and the co-pilot had not previously visited. The crew had been on duty for approximately 12 hours and would approach their maximum allowed duty day of 14 hours upon return to home base.
During taxi, the co-pilot obtained the air traffic control clearance and read back instructions correctly. The pilot-in-command taxied while looking for the Runway 05 holding point and responding to checklist items from the co-pilot. The pilot-in-command saw lights he believed were Runway 05 and crossed what appeared to be a taxiway but was actually Runway 05. Neither pilot was aware of entering the runway, and neither saw the Westwind until notified by ATC. The co-pilot had his head down performing the checklist.
Air Traffic Control
The control tower at Toronto Pearson was staffed by 10 controllers, with 7 active and 3 available. Workload was considered light to moderate. The North Tower controller was handling the Westwind C-FJOJ on approach; the runway was clear when landing clearance was given and when the aircraft crossed the threshold. The North Ground controller was controlling N70AX and four other aircraft on the east side of Runway 15L-33R. Within 10 seconds of the incursion, the North Ground controller scanned back to N70AX, which was traveling directly toward the tower about one mile away. Initially appearing that N70AX would stop, the North Tower expressed doubt, and the North Ground controller checked the airport surface detection equipment (ASDE) display and determined that N70AX was entering the runway. Around the same time, an aural conflict alarm sounded.
A sequence of events derived from ATC communications and ASDE recordings shows that at 2206:34, N70AX crossed the hold line short of Runway 05; at 2206:43, it crossed the runway edge; and at 2206:46, it was fully onto the runway. The Westwind, at 2206:43, was on landing roll at about 64 knots, approximately 430 feet from the intersection. Upon seeing N70AX, the Westwind crew braked and steered left, passing behind the Learjet with about 60 feet between the aircraft by 2206:49.
Air traffic controllers have a duty to monitor aircraft progress. A NAV CANADA staff instruction emphasizes full-time attentive flight monitoring, requiring controllers to prioritize in a multi-tasking environment. Controllers are to visually scan the maneuvering area before issuing clearances and at frequent intervals. For landing aircraft, the expectation is that the runway is clear of obstacles by the time the landing aircraft crosses the threshold. The ASDE system, which provides real-time display of traffic, should be used at night or when visibility is restricted, but visual scanning is the primary technique.
Airport Lighting and Markings
Taxiway Foxtrot had a painted taxiway centerline and green centerline lights leading to the intersection with Runway 05. The intersection was marked on each side with runway designation/location signs. The holding position, approximately 200 feet before the runway edge, was marked with two solid yellow lines and two dotted lines painted on a black background across the taxiway, plus runway guard lights (two yellow lights that alternate at each edge adjacent to the hold line). Stop bars (flush-mounted red lights) were present but not illuminated at the time. These markings and lights complied with an exemption to the Canadian Aviation Regulations and were in good condition and unobstructed, with only the stop bars not functioning.
Background on Runway Incursion Prevention
Runway incursions have been recognized as a worldwide safety issue. In July 1999, Transport Canada's National Civil Aviation Safety Committee formed a sub-committee on runway incursions to develop a national strategy. Transport Canada and NAV CANADA undertook studies resulting in more than 20 recommendations. A runway incursion prevention action team (IPAT) oversaw implementation, including standardization of markings and signage, terminology, requirement for explicit clearance to cross runways, and read-back of taxi and hold short instructions. In 2005, after a decrease in incursions, IPAT was disbanded. A Runway Safety and Incursion Prevention Panel (RSIPP), chaired by NAV CANADA, was formed later to provide continued oversight. Canada and the United States jointly developed an enhanced taxiway marking system to warn flight crews approaching a runway holding position.
The ASDE/RIMCAS system at Toronto is at its limits, with no possibility of enhanced warning capabilities due to the age of the software and operating system. An upgraded system installed at other NAV CANADA sites reportedly provides greater protection.