What happened
A safety issue investigation by the TSB examined a series of 18 occurrences occurring between 2013 and 2018 at various airports in Quebec and Nunavut. The investigation was prompted by a June 2018 incident at Baie-Comeau Airport, where runway rehabilitation was underway. Upon review, it was discovered that 14 similar incidents had occurred previously.
A recurring pattern emerged: instead of reducing runway length, operators were reducing the runway width to keep the aerodrome operational. In nearly all reviewed cases, aircraft unintentionally maneuvered onto the closed portions of the runway during takeoff or landing, leading to aircraft damage in some instances.
The investigation
The TSB analyzed the construction methods, regulatory frameworks, and communication protocols used during these periods of rehabilitation. The investigation found that neither the Canadian Aviation Regulations (CARs) nor International Civil Aviation Organization (ICAO) standards prohibit reducing runway width rather than length, leaving the decision entirely to the airport operator.
Investigators also examined the effectiveness of Notice to Airmen (NOTAMs) and the adequacy of visual aids used to demarcate closed sections. Furthermore, the Board reviewed the process by which Transport Canada Civil Aviation (TCCA) inspectors approved Plans of Construction Operations (PCO) and evaluated the Safety Management Systems (SMS) of the involved airports.
Findings
Several systemic factors contributed to the runway incursions:
- Inadequate visual aids: The markings used to indicate closed runway sections were inconsistent and unclear, making it difficult for pilots to distinguish between open and closed pavement.
- Deficient communication: NOTAMs, which are limited to text-only formats using uppercase letters and abbreviations, failed to provide pilots with an accurate mental model of the runway changes.
- Lack of standardized construction practices: There is an absence of Canadian standards or guidelines regarding runway construction methods and the safety of operations during such periods.
- Regulatory and oversight gaps: TCCA inspectors lacked specific standards to evaluate PCOs, leading to approvals based on informal procedures without proper risk assessments. Additionally, the SMS at the involved airports was found to be ineffective at preventing these recurring hazards.
Safety action
Following the investigation, the TSB issued Recommendation A2 .21-01, urging NAV CANADA to provide graphic depictions of closures alongside NOTAMs to ensure complex changes to runway operations are easily understood by flight crews.