On June 13, 2004, at 09:33:44 EDT, an Airbus A320 was cleared for takeoff on Runway 24 of Québec/Jean Lesage International Airport, Que. Sixteen seconds later, the controller instructed a Cessna 172 to taxi to position on Runway 30. At 09:34:50, the controller saw the Cessna 172 roll and take off toward the intersection of Runways 30 and 24. Immediately, the controller ordered the Airbus A320 to abort takeoff twice. Seeing that the Airbus A320 was continuing its take-off run, he ordered the Cessna 172 three times to turn left. None of these attempts to contact the pilots was successful because the transmit function of the airport control radio had been previously disabled by the controller in an attempt to improve radio reception quality. Approximately 1 000 ft from the intersection, at rotation speed, the captain of the Airbus A320 saw the Cessna; he immediately ordered the co-pilot not to take off until they had crossed Runway 30. The Cessna flew over the Airbus A320, about 200 ft above it, at the intersection of the two runways. There were no injuries.

Findings as to causes and contributing factors

1.        The Cessna 172 took off without clearance from Runway 30, causing a risk of collision with the Airbus A320.

2.        The controller instructed the Cessna 172 to taxi to position on Runway 30, but did not instruct it to wait and did not advise that the Airbus A320 was taking off on Runway 24. The controller did not anticipate that the Cessna 172 might take off without clearance, causing a risk of collision with the Airbus A320.

3.        Given that the controller deactivated the transmit button for the air frequency, neither the Airbus A320 nor the Cessna 172 could hear the controller’s instructions to abort takeoff.

Findings as to risk

1.        The Air Traffic Control Manual of Operations (ATC MANOPS) does not clearly define criteria for numbering aircraft in the departure sequence.

2.        Some controllers in the Québec tower misunderstood the operation of some functions of the radio console.

3.        Canadian and U.S. phraseologies used to clear an aircraft onto a runway are similar in wording to International Civil Aviation Organization (ICAO) phraseology to hold an aircraft short of a runway. Those similarities open the door to misinterpretation by crews, with potential for catastrophic consequences.

Other findings

1.        The absence of simulation of emergency situations and equipment failures in ongoing training contributed to the controller’s inability to solve the problem that he was confronted with.

2.        A review by the TSB of NAV CANADA’s evaluations revealed that the division responsible for NAV CANADA’s evaluations did not realize that some controllers were not complying with standard practices and procedures.

Safety actions taken

NAV CANADA has indicated that the following safety actions have been taken since this incident:

1.        Improvements have been made in the area of individual competency verifications in the Québec tower in the last year. Observations of operational skills application are to be of a minimum of four hours, based on major operational duties as per the unit task analysis. Any discrepancies identified as being critical, result in removal from operational duties followed by retraining, as required. Activities related to the monitoring of the application of operational communication skills have also been bolstered, and results are mathematically calculated according to a grid based on the errors detected and the relative seriousness of each error. In all cases where individual controllers do not maintain unit standards, they are removed from operational duties and provided with remedial training, as required.

2.        As a result of a NAV CANADA Head Office Unit evaluation, the Québec tower manager has issued Operations Bulletin Number 04 40, published on 15 July 2004, outlining the results of the recent Head Office evaluation concerning identified deficiencies in phraseology. In addition, the control tower supervisors were instructed to increase their monitoring and to make direct interventions whenever it was observed that controllers were not conforming to approved phraseology. Supervisors
were also directed to be more rigorous in the evaluation of communication skills, and a grid was implemented to facilitate the rating of individual performance in this area and facilitate the establishment of corrective actions when required.

3.        Through recent changes implemented in the operations safety investigations reporting process on staff utilization, NAV CANADA will further assess the decision-making processes of operational supervisors and implement changes where necessary.

4.        NAV CANADA undertook a major rewrite of the basic visual flight rules air traffic control (VFR ATC) training course delivered at its training facility and implemented the new curriculum in June 2004. Emergency procedures are taught using instructor-led classroom activities that include the associated phraseology. Non-compliance situations by a pilot are taught in the classroom and are practised in a number of exercises in the dynamic 360-degree airport simulator throughout the course.