What happened
On a daylight flight, a Samaritan Air Learjet 35A, registration C-FHLO, was traveling from Toronto/Lester B. Pearson International Airport to Hamilton Airport at 5,000 feet. Simultaneously, a Jetall Convair 3D40/580, registration C-GJTU, was flying in the opposite direction from Hamilton to Toronto, also at 5,000 feet.
Approximately 25 nautical miles southwest of Toronto, the two aircraft passed each other with insufficient separation. The lateral distance between them was roughly two miles, and the vertical separation was only 600 feet, failing to meet the required five miles of lateral or 1,000 feet of vertical spacing. There were no injuries and no damage to either aircraft, which both carried three occupants.
The investigation
The investigation focused on the actions of the Terminal and Hamilton sector controllers. It was established that the Terminal controller cleared the C-FHLO to 5,000 feet because the flight plan displayed a requested altitude of 5,000 feet on the Automated Departure Display System (ADDS). This altitude was improper, as IFR flights should use even thousands of feet.
At the time of the event, training was underway in the Hamilton sector. The investigation found that the Hamilton controller re-instructed the C-GJTU to maintain 5,000 feet after observing the Learjet's departure, assuming the Learjet would enter his sector at 6,000 feet per standard procedure. However, the controller failed to notice the Learjet's specific altitude request on the ADDS.
Findings
- Lack of coordination between the Terminal and Hamilton sector controllers was a primary factor.
- Terminal controllers failed to follow established procedures outlined in the sector manual.
- The Hamilton sector controller did not communicate the change in altitude instruction for the C-GJTU to the Terminal controller.
- The Terminal Data controller coordinated an altitude of 6,000 feet for the Convair, which contradicted established procedures.
- The Learjet flight crew filed an incorrect altitude of 5,000 feet on their flight plan.
- The Hamilton sector manual lacked specific procedures for aircraft departing Hamilton and landing at LBPIA.