A cargo jet hurtling down the runway and preparing to take off was forced to make an emergency stop to avoid hitting a snowplow at Hamilton's airport, according to a new Transportation Safety Board report.
The Boeing 727 jet managed to stop about 365 metres away from two snow sweepers, who were working near the departure end of a 3,050-metre long runway at John C. Munro International Airport. Nobody was injured.
The TSB considers aborted take-offs to be an "extreme measure" to be taken only to avoid grave hazards.
'As the aircraft began to crest the middle section of the runway, the crew began to notice unusual lights.'- Transportation Safety Board report on Hamilton near miss
How the plane got to that point is the subject of a lengthy TSB report on the events of March 19, 2013, which largely blames an air traffic controller who reported being fatigued at the time of the incident.
The report, recently released, says the controller, who was fully qualified but had only worked at the Hamilton airport since 2012, was working an overtime, overnight shift and was alone in the control tower when the event took place at 2:08 a.m.
The controller's first mistake was a call sign error, approving the departure of Winnipeg-bound flight KFA273, instead of the similarly named flight KFA275, which was also headed to Winnipeg at that hour.
This map shows just how close the Boeing 727 came to the snow sweepers. (Transportation Safety Board)
The controller was aware of the snow sweepers because, as the report notes, he had directed them to clear slush and ice from Runway 30 about 45 minutes prior to the incident.
But, after a busy stretch of work, the controller gave KFA273 the go-ahead to use Runway 30, over-looking an electronic display that showed the runway was blocked in the process.
"As the controller was uttering the words 'cleared for take-off Runway 30', a visual scan of the runway surface was completed, and the snow sweepers were noticed," the report states.
"The controller paused for a second without releasing the push‑to‑talk button (PTT), and then used the non-standard phrase 'actually standby'. When the PTT was released, the controller heard the aircraft respond '273."
After ordering the snow sweepers off the runway, and seeing that KFA273 hadn't begun its takeoff, the air traffic controller turned his attention to issuing taxi instructions to another flight.
Rejected takeoffs rare
But then KFA273 did start its takeoff.
Due to the flight tower's angle, the plane was out of the controllers view for 22 seconds as it began its dash down the tarmac.
Upon spotting the plane, the controller "immediately instructed KFA273 to abort the take-off," the report says.
An image from the TSB report shows the electronic warning, overlooked by an air traffic controller, that the runway was blocked by snow plows. (Transportation Safety Board)
The plane was already 344 metres down the runway.
Aboard the plan, the experienced pilot and his crew considered the takeoff to be "proceeding normally," the report said.
"As the aircraft began to crest the middle section of the runway, the crew began to notice unusual lights."
That's when the co-pilot realized the controller's order to abort takeoff had been intended for them, and the pilots "rejected" the takeoff.
Rejecting a takeoff is an emergency procedure, the TSB notes, which is only done when there's a "grave hazard" to the aircraft. Statistics cited in the report show there's rejected takeoffs occur in only one in 3,000 flights.
"A controller-initiated abort of takeoff should be viewed as an extreme measure to be used only where there is no clear alternate course of action," the report notes.
Changes made in wake of incident
The risk of runway collisions has been on the TSB's official watchlist of concerns since 2010.
Kelowna Flightcraft Air Charter Ltd., the company that was operating KFA273, issued a memo to all flight crews about the incident according to the TSB reports section on safety actions taken.
The operator also said pilots will be trained on how to deal with controller-initiated rejected takeoffs in the future, and that those scenarios will be periodically reviewed.
The TSB report doesn't list any changes made by the airport authority.
The plane departed for Winnipeg just five minutes after the incident, the report says.
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