Too Close for comfort:

A sampling of incidents involving potential air safety problems

*Canada maintains the most secretive Air Safety Incident Reporting System in the world CADORS (link). That page has carried the misleading statement below for the past five years:

IMPORTANT NOTICE :

In response to recent unauthorized disclosures of CADORS information, Transport Canada Civil Aviation (TCCA) is terminating all external access to CADORS except to those agencies named in Info Source.  While it is regrettable that the flow of certain safety related information has to be interrupted, other means of conveying portions of this information to industry stakeholders are being explored and will be communicated to our industry partners in the coming months.

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ENGINE FAILURE
Aircraft:

  • Jetsgo MD-83 out of Toronto
    Passengers: 156
    When: April 28, 2004
    Where: 200 miles northwest of Winnipeg, headed for Edmonton.
    What happened: Jetsgo plane declared an emergency due to a warning light. Pilots shut down one of two engines and diverted to Winnipeg.
    Cause: The engine, which had just been installed, had a "carbon-like" material caught in the oil filter. Checks that should have been done by mechanics were not.

    NEAR COLLISION
    Aircraft:

  • Westjet Boeing 737-200
  • Cessna 172 (owner unknown)
    Passengers: 129
    When: Jan. 28, 2004
    Where: Victoria, B.C.
    What happened: Westjet plane was coming in to land in Victoria and ordered to stay above 3,000 feet until final approach. Westjet was then told to contact the Victoria tower. The Westjet pilot did not completely read back the instructions and the controller did not notice the lack of confirmation. Westjet descended below 3,000 feet. A Cessna was in the area and the much larger Westjet passed just 100 feet above the Cessna, a nautical half mile away horizontally.
    Cause: Transport Canada ruled it was Cessna pilot and controller error. Controller given one day recertification with supervisor.

    LANDING ERROR
    Aircraft:

  • Pinnacle Airlines Regional Jet inbound from Memphis
  • Air Canada Airbus A-320 inbound from Ottawa
    Passengers: 190
    When: April 27, 2005
    Where: Toronto Pearson airport
    What happened: The Air Canada Airbus was told by Toronto controllers to land on runway 24R. Pinnacle Airlines was lined up to land when controllers instructed it to turn in front of the Air Canada jet despite insufficient separation. An emergency alarm sounded on the Air Canada jet, which descended. The two jets came within 500 feet vertically and 1.5 miles laterally (half the safe distance required by aviation rules in that area). Both planes landed safely.
    Cause: Mistake by air traffic controller, who underwent recertification session before returning to duty.

    MID-AIR EMERGENCY
    Aircraft:

  • Canjet Boeing 737 inbound from Ottawa
  • Cessna 172, unknown flight school
    Passengers: 122
    When: July 12, 2005
    Where: Ottawa International airport
    What happened: Ottawa traffic controllers were guiding the Canjet plane from Montreal to Ottawa. When Canjet was 12 nautical miles from the airport, the Cessna suddenly flew over the larger jet, coming within 100 feet of its left wing.
    Cause: Cessna pilot was not in radio contact with controllers as required and lacked a transponder, so the plane was virtually invisible to controllers and the Canjet plane. Flight school denies it made a mistake.

    CONVERGING FIGHT PATHS
    Aircraft:

  • Air Canada Boeing 767-233
  • Air Canada Boeing 767-375
    Passengers: 410
    When: April 15, 2003
    Where: Toronto Pearson airport
    What happened: Air traffic controllers instructed both jets to take off, the first from runway 23, the second from runway 24R. A controller confused the call signs of the jets and instructed the second plane to turn towards the departure "corridor" of the first plane. The flight paths converged and the planes were separated by 600 feet vertically and 1.5 nautical miles horizontally when the controller realized the mistake and turned the planes in opposite directions.
    Cause: Transport Canada said it was a mistake by Nav Canada air traffic controller, who was "counselled" and returned to duty.

    COLLISION ALERT
    Aircraft:

  • Air Canada Jazz DHC 8-102, Kingston to Toronto
  • Canadian Global Air Ambulance Learjet 35A, Toronto to Halifax
    Passengers: 37
    When: March 3, 2005
    Where: East of Toronto
    What happened: The air ambulance, with a patient bound for Halifax, took off and headed east, cleared to climb to 7,000 feet. The Jazz jet, coming from Kingston, was level at 8,000 feet coming in to Toronto. The air ambulance kept climbing past 7,000 feet just as the Jazz jet passed by, roughly 400 feet above. An emergency alert sounded on the Jazz plane. The air ambulance pilot was alerted and descended to 7,000 feet.
    Cause: Transport Canada ruled air ambulance pilot error. Unknown fine imposed.

    RUNWAY CLOSE CALL
    Aircraft:

  • KLM Boeing 747-206
  • Unknown B-767 jet
  • IMP Execaire Canadair Challenger
    Passengers: 516
    Where: Toronto Pearson airport
    When: April 4, 2005
    What happened: Challenger jet was in position to take off on runway 33R, but told to hold position. Controllers then told a ground "tug" it could pull a B-767 jet across the runway in front of the Challenger, and that the KLM jet could also cross the runway, at a spot further down the strip. Without permission, the Challenger jet started rolling down the runway. Controllers tried twice to warn the Challenger but it took off, clearing the tug/jet by 250 feet.
    Cause: Remains under investigation by Transport Canada

    ENGINE FAILURE
    Aircraft:

  • Westjet Boeing 737-204
    Passengers: 125
    When: Nov. 30, 2003
    Where: Edmonton International airport
    What happened: As the WestJet plane was climbing, pilots and passengers heard a muffled bang, then the airplane shuddered. Pilots tried a mid-air test but a flight attendant reported sparks coming out of the engine and it was shut down. Pilots declared an emergency and returned to Edmonton.
    Cause: Previous undetected damage to a turbine blade caused massive damage to engine.
    SOURCE FOR AIR SAFETY EXAMPLES: Civil Aviation Daily Occurrence Reporting System (CADORS) database and Transportation Safety Board. These reports - made to Transport Canada by controllers, pilots and others - describe potential safety problems involving planes. Airlines named in reports would not comment on the incidents when asked by reporters. One major airline explained this is because the reports are considered "observational only".
  • Type of trouble Number of incidents
    2000-2005
    Average frequency
    in Canadian skies
    1. Mechanical: Engine failure, wing parts falling off, brake problems, defective landing gear, decompression of the cabin, etc. 9,523 Once every 5 hours

    2. Runway incursions: Vehicle or plane pulls in front of aircraft on runway. 1,577 Nearly once a day

    3. Conflicts: Planes getting too close int he sky, including losses of separation and near collisions. 1,087 Once every 2 days

    4. Controlled airspace violation: Plane enters controlled airspace or changes course or altitude without permission or without identifying itself. 926 Once every 2 days

    5. Smoke in cabin or cockpit: Plane enters controlled airspace or changes course or altitude without permission or without identifying itself. 550 Once every 4 days

    6. Crashes: Single plane crashes and mid-air collisions.    386 Once every 5 days

    7. Fire: In the engine or other part of plane. 226 Once a week

    8. Icing: On wing or other part of plane. 96 Once every 3 weeks

    Some incidents involve more than 1 kind of problem.
    Source: Analysis of CADORS reports made to Transport Canada.

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