History
Three risk-of-collision (ROC) incidents occurred within about two minutes at Winnipeg International Airport, Manitoba, involving four aircraft: a Fairchild Metro III (BLS 404), a Fokker F-28 (TAF 1328), a Cessna 152 (C-FGEK), and a Cessna 414 (C-FSAL). The incidents happened between 1625 and 1627 central standard time, approximately half an hour before sunset. All flights were conducted under visual flight rules or visual approaches. No injuries or aircraft damage were reported.
First Risk of Collision
The Fairchild Metro III, arriving from Brandon on an IFR flight, was cleared for a visual approach to runway 31, instructed to follow the F-28. The Metro crew identified a different aircraft and later, alerted by the arrival controller about the speed difference, turned right and passed 0.7 nautical miles behind the F-28 with 500 feet of vertical separation. The investigation determined this incident occurred because the Metro crew misidentified the preceding aircraft. Contributing factors included confusing visual cues, lack of separation standards for IFR aircraft on visual approaches, and the arrival controller's reluctance to intervene. Possible contributing factors were the lack of an approach sequence number, reduced staffing at the Area Control Centre, and omitted annual refresher training for controllers.
Second Risk of Collision
After the first incident, the Metro crew called the airport controller and were instructed to perform a left 360-degree turn to rejoin the approach. During the turn, the Metro passed 0.4 nautical miles horizontally and at the same altitude as a Cessna 152 that was conducting traffic observations east of the approach path. The Cessna pilot had previously arranged with the tower to reduce radio volume. The investigation determined this incident occurred when the Metro crew altered course east of the approach path to increase separation from the F-28. Contributing factors included the airport controller's delay in instructing the Metro to turn and the Cessna pilot's arrangement to turn down radio volume.
Third Risk of Collision
While the airport controller was preoccupied with the first two incidents, a Cessna 414 was cleared to hold position on runway 31. Shortly after, the F-28 was cleared to land on the same runway. The F-28 crew initiated a missed approach at about half a mile from the runway, at approximately 300 feet above ground, after visually confirming the Cessna on the runway. The investigation determined this incident occurred because the airport controller overlooked the Cessna 414 holding on the runway. A contributing factor was the controller's preoccupation with the earlier incidents.
Conclusions
The first incident was caused by the Metro crew misidentifying the preceding aircraft. The second occurred when the Metro crew altered course to increase separation. The third happened because the airport controller overlooked the Cessna on the runway.