What happened
In the early morning at Ottawa/MacDonald-Cartier Airport, a potential runway collision was averted when the crew of an Avionair Inc. cargo flight, C-GBXX, spotted another aircraft on the runway threshold during their descent.
The incident began when an Air Canada Canadair Ltd. CL-600 Regional Jet, registered C-FSKI, was cleared to move onto runway 25. During a shift change, the outgoing airport controller failed to inform the incoming controller that the C-FSKI was holding in position on the runway.
Shortly after, the crew of the Swearingen Aviation SA-226TC Metro II, C-GBXX, was cleared to land on the same runway. As the cargo aircraft descended through approximately 200 feet above ground level, the crew observed the Air Canada jet at the runway threshold. Due to the presence of the aircraft, the crew immediately executed a missed approach and subsequently landed safely after a second attempt. There were no injuries and no damage to either aircraft.
The investigation
The investigation focused on the handover process between the two air traffic controllers. It was established that the transfer of responsibility was flawed, as the outgoing controller did not communicate the position of the Air Canada flight, and the incoming controller did not use a checklist or actively monitor incoming radio traffic during the relief period.
Investigators also examined the controller's reliance on memory rather than standardized job aids. Additionally, the placement of the airport surface detection equipment (ASDE) monitor was found to be poorly positioned for the controller's use. The investigation further looked into management oversight, noting that the relieving controller had not completed required knowledge verification tests for several years.