ASN Wikibase Occurrence # 227130
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| Date: | Wednesday 16 May 2018 |
| Time: | 19:01 |
| Type: |  Airbus A310-304 |
| Owner/operator: | Air Transat |
| Registration: | C-GFAT |
| MSN: | 545 |
| Year of manufacture: | 1991 |
| Engine model: | GE CF6-80C2A2 |
| Fatalities: | Fatalities: 0 / Occupants: 215 |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | near Montréal/Pierre Elliott Trudeau International Airport -
 Canada
|
| Phase: | Approach |
| Nature: | Passenger - Scheduled |
| Departure airport: | Toronto-Pearson International Airport, ON (YYZ/CYYZ) |
| Montreal-Pierre Elliott Trudeau International Airport, QC (YUL/CYUL) | |
| Investigating agency: | TSB |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
An Air Transat Airbus A310-304 aircraft, operating as flight TS485, was conducting an instrument flight rules flight from Toronto/Lester B. Pearson International Airport, Ontario, to Montréal/Pierre Elliott Trudeau International Airport, Quebec. At about the same time, a privately owned Cessna 421-B aircraft (registration C-GADG, serial number 421B0802) conducting an instrument flight rules flight, was returning to Montréal/Pierre Elliott Trudeau International Airport from Trois-Rivières Airport, Quebec. The Airbus was inbound from the west, and its flight path would take it north of the airport to commence an approach to land on Runway 24R. The Cessna was inbound from the northeast to commence an approach to land on Runway 24L.
At 19:01:17 Eastern Daylight Time, when the aircraft were approximately 18 nautical miles northeast of Montréal/Pierre Elliott Trudeau International Airport, a loss of separation occurred. Neither the required vertical separation minimum of 1000 feet nor the lateral separation minimum of 3 nautical miles was maintained. When the loss of separation occurred, they were 200 feet and 2.8 nautical miles from each other. At the closest point, the 2 aircraft came within 500 feet vertically and 1.7 nautical miles laterally of each other. At 19:02:22, following instructions from the controllers, the required separation was re-established, and the 2 aircraft landed without incident.
Findings as to causes and contributing factors
1. Combining the sectors in the Montréal terminal specialty because of short staffing, compounded by the sudden illness of the low arrivals controller and the closing and reopening of the low arrivals sector, increased the controllers' areas of responsibility as well as the workload and the level of complexity of the workload.
2. The transfer of control responsibility of the Cessna from the Rawdon sector controller directly to the north arrivals controller was a deviation from the procedures in the Montreal Terminal Operations Manual.
3. A structured and consistent operational environment was not maintained, and the north arrivals controller became responsible for an aircraft outside of his area of responsibility.
4. Control responsibility for the Cessna was not transferred from the north arrivals controller to the low arrivals controller-in-training before the Cessna entered the low arrivals sector airspace. Consequently, neither the north arrivals controller nor the low arrivals controller on-the-job instructor observed the Cessna entering the low arrivals sector airspace on the Canadian Automated Air Traffic System Situation Display until it was pointed out by the low arrivals controller-in-training.
5. Once the north arrivals controller provided information about the Cessna to the low arrivals controller during the transfer of position responsibility briefing, the north arrivals controller believed the low arrivals controller was now responsible for the aircraft, although control responsibility had not been transferred to the low arrivals controller.
6. Following the transfer of position responsibility of the low arrivals sector, the north arrivals controller concentrated on his usual area of responsibility, which did not include the airspace to the northeast of the airport where the Cessna was flying, and forgot to transfer the Cessna.
7. During the verbal briefing and exchange of aircraft information between the low arrivals controller on-the-job instructor and the low arrivals controller-in-training, information about the Cessna was not provided. Therefore, the low arrivals controller-in-training did not have an opportunity to incorporate knowledge of the converging instrument flight rules traffic into his awareness of the traffic situation.
8. The low arrivals controller on-the-job instructor was distracted from his on-the-job instructor responsibilities, from the Canadian Automated Air Traffic System Situation Display, and from the operation; as a result, he did not adequately monitor the developing situation or the operation.
Accident investigation:
 |
|
Sources:
TSB
History of this aircraft
Other occurrences involving this aircraft
| 27 September 2018 | C-GFAT | Air Transat | 0 | over North Atlantic Ocean |  |
non |
| Turbulence | ||||||
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 14-Jul-2019 12:27 | harro | Added |
Corrections or additions? ... Edit this accident description
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