What happened
During an instrument flight rules training session at the Vancouver Area Control Centre, a loss of separation occurred between two aircraft approaching Victoria airport. The first aircraft, a Piper Twin Comanche registered C-FFMW, was operating an IFR training flight from Pitt Meadows. Simultaneously, a Piper PA-24 Comanche, registration N6857P, was flying inbound to Victoria from the south.
As the trainee controller managed the arrivals, C-FFMW began deviating west of its intended track. Because the controller did not correct this deviation, the aircraft turned toward the localizer earlier than expected, causing it to close the gap with the aircraft ahead. This resulted in the two aircraft coming within 1.87 nautical miles laterally and only 300 feet vertically, violating the minimum required separation of 3 nautical miles and 1000 feet.
To resolve the conflict, the on-the-job instructor (OJI) took control of the traffic. However, the instructor's actions—which included vectoring N6857P north and parallel to the localizer—created a secondary conflict with a third aircraft, a Fairchild Merlin 3 registered C-GMET, which was on a left downwind for runway 27. After the instructor implemented new vectors, separation was eventually re-established, and all three aircraft landed safely.
The investigation
The investigation examined the performance of the trainee and the OJI, as well as the communication between the arrival controller and Victoria tower. It was noted that the trainee had been previously cautioned by the instructor regarding the potential for C-FFMW to turn in on a tighter track, yet no corrective action was taken.
Furthermore, the investigation looked into the physical setup of the training environment. The OJI was monitoring the trainee from an adjacent console but was using a headset plugged into the trainee's communication jack. This limited the instructor's ability to access the landline communications panel to coordinate with the Victoria airport controller. The investigation also found that the Victoria terminal data controller attempted to relay information regarding N6857P to the tower via a landline, but the message was not clearly understood or prioritized by the ground controller.
Findings
- The trainee failed to correct the flight path of C-FFMW, which was consistently west of the intended radial.
- The trainee cleared both aircraft to the same altitude of 3000 feet while they were on converging tracks.
- The OJI did not intervene to correct the flight path deviation despite prior warnings.
- The OJI lacked immediate access to the communications panel needed to coordinate with other agencies.
- There was no established formal procedure or action plan for the transition of control between the trainee and the OJI.
- Coordination between the arrival controller and Victoria tower was ineffective due to improper use of non-standard communication methods and a lack of clarity in the relayed information.