What happened
In a rapid succession of events lasting less than four minutes, three separate risk of collision incidents occurred at Winnipeg International Airport. The sequence began when a Fairchild Metro III (BLS 4/4), arriving on an instrument flight rules (IFR) flight, was cleared for a visual approach to runway 31. The crew misidentified a preceding Fokker F-28 (TAF 1328) as a different aircraft, resulting in the Metro III passing within 0.7 miles horizontally and 500 feet vertically of the F-28.
Approximately one minute later, while the Metro III was performing a 360-degree turn to rejoin the approach, it passed within 0.4 miles horizontally and with no vertical separation from a Cessna 152 (C-FGEK). The Cessna 152 was conducting a visual flight rules (VFR) traffic observation mission and had previously arranged with the tower to reduce its radio volume.
Thirty seconds after the second near-miss, a third incident occurred when the airport controller cleared the Fokker F-28 to land on runway 31, overlooking a Cessna 414 (C-FSAL) that was holding position for takeoff on the same runway. The F-28 crew subsequently initiated a missed approach after visually spotting the stationary aircraft on the runway.
The investigation
Investigators examined the cockpit actions and air traffic control communications during the period between the Metro III's initial clearance and the F-28's missed approach. The investigation looked into the visual environment, including the impact of similar aircraft configurations and paint schemes, as well as the regulatory requirements for separation during visual approaches. The Board also reviewed staffing levels at the Area Control Centre (ACC) and the status of mandatory annual refresher training for air traffic controllers.