What happened
On a daylight afternoon at Montréal/Pierre Elliott Trudeau International Airport, a Sky Regional Airlines Incorporated Bombardier DHC-8, registration C-FSRY, entered Runway 28 without authorization while a Propair Incorporated Beech A100 King Air, registration C-GJLJ, was in the middle of its take-off roll.
The DHC-8 had arrived from Toronto and was taxiing via Taxiway Echo. During the taxi, the crew was instructed by ground control to hold short of Runway 2 and to yield to an Embraer aircraft. While the crew was managing the interaction with the oncoming Embraer, the airport controller cleared the King Air for departure from Runway 28.
Approximately two minutes later, the DHC-8 reached the hold line of Runway 28 but proceeded onto the runway without stopping. The King Air, which was approaching rotation speed, observed the DHC-8 on the runway and immediately initiated a rejected take-off. The King Air veered to the right of the runway centerline, passing roughly 40 feet behind the DHC-8. There were no fatalities or injuries resulting from the event, though the King Air sustained damage to its landing gear.
The investigation
The investigation focused on the actions of both flight crews and the air traffic control environment. It was established that the DHC-8 crew had correctly read back the instruction to hold short, but failed to follow it. The investigation found that the crew's attention was diverted by the need to yield to an Embraer aircraft taxiing in the opposite direction.
Regarding the King Air, investigators examined the decision to continue the flight after the high-speed rejected take-off. While the aircraft suffered a leaking brake fluid line and a damaged outer tire, the crew was unaware of the damage at the time.
Control systems were also reviewed. The investigation found no deficiencies in the airport's facilities or the air traffic control system, noting that the ground controller had not been continuously monitoring the DHC-8 because the crew had provided a correct readback of the hold-short instruction.
Findings
- The DHC-8 crew failed to stop at the hold line because they did not remember the instruction to hold short and did not confirm the instruction with each other.
- The DHC-8 captain's visual scan of the runway was ineffective, failing to detect the King Air due to factors including sun reflection, de-icing structures, and inattentional blindness.
- The DHC-8 crew had tuned to the apron frequency, meaning they could not hear the controller's emergency stop instructions.
- The King Air crew's decision to continue the flight after the rejected take-off was influenced by an optimistic assessment of the aircraft's condition, as they were unaware of the damaged tire and fluid leak.
Safety action
- Sky Regional Airlines issued a safety bulletin regarding the importance of following standard operating procedures for radio frequencies and confirming ATC authorizations.
- Aéroports de Montréal improved runway visibility by painting red squares on Taxiway Echo near the runway intersection.
- NAV CANADA implemented procedures to reduce the use of Runway 10/28 to mitigate the risk of incursions.