History of the Flight
Air Canada Flight 330 (ACA330), a passenger flight with 2 flight crew, 1 cabin crew, and 12 passengers, was scheduled to depart Ottawa for Washington, DC, at 0700 EST but was delayed for de-icing. At 0749, the crew reported holding short of runway 25 and ready for takeoff. At 0751, the airport controller cleared ACA330 to position on runway 25. Between 0751:46 and 0752:05, a controller handover occurred. The outgoing controller did not inform the relieving controller that ACA330 was on the runway.
At approximately 0754:36, Avionair Flight 403 (ANU403), a cargo flight from Mirabel, Quebec, was handed to tower. It was inbound on a localizer back course approach to runway 25. At 0755:38, the relieving controller cleared ANU403 to land. ANU403 acknowledged in French. During the approach, the crew leveled at minimum descent altitude (800 feet asl, 427 feet agl). Due to low visibility, they did not see the runway until about one mile from the threshold, then resumed descent. At about 200 feet agl, they saw ACA330 on the threshold. The crew initiated a go-around, completed a second approach, and landed uneventfully at 0818.
Injuries and Damage
There were no injuries to any persons. Neither aircraft sustained damage.
Personnel Information
Both flight crews were certified and qualified. The relieved controller (age 30, 10 months experience) had re-qualified after two operating irregularities. The relieving controller (age 48, 16 years experience) was also the tower supervisor and unit training officer. He had not completed the mandatory Knowledge Verification Test (KVT) for over three years, though no exemption existed for his role.
Meteorological Information
Forecast called for temporary ½ statute mile visibility in light snow and vertical visibility 1,200 feet. Special weather reports at 0754 reported ¾ mile visibility in light snow showers. By 0805, visibility improved to 10 miles. A pilot report at 0750 indicated the runway threshold was visible from about one mile.
Communications
All communications equipment was serviceable. The tower is bilingual; ANU403 communicated in French. ACA330 was unilingual English. The controller cleared ANU403 in French; ACA330 did not understand. Approximately 10 seconds later, the controller asked ACA330 if they were ready; ACA330 confirmed they were in position. The controller acknowledged and said there would be a short delay for another aircraft to land. ACA330 assumed that aircraft was landing on runway 32. ANU403 did not react to these transmissions.
Analysis
The Board determined that a risk of collision occurred as the result of an ineffective controller handover procedure. Contributing factors included: no method other than memory to ensure completeness of the handover briefing; the relieving controller did not adequately monitor incoming communications; inadequate location of the airport surface detection equipment monitor; no standard method to track uncompleted critical actions; deficiencies in management and supervision; and inadequate NAV CANADA audit procedures.
Probable Cause
Ineffective controller handover procedure.