A310 / C421, en-route, northeast of Montréal Canada, 2018

A310 / C421, en-route, northeast of Montréal Canada, 2018

Summary

On 16 May 2018, an Airbus A310 and a Cessna 421 being positioned for ILS approaches to adjacent parallel runways at Montréal by different controllers lost separation. One controller incorrectly believed that he had transferred control of the Cessna to the other when the shift supervisor re-opened a sector which had been temporarily combined with his. The Investigation attributed the conflict to multiple deviations from standard procedures, memory lapses relating to controller information exchange of information and a loss of full situational awareness compounded by the shift supervisor also acting as an instructor whilst being distracted by his other duties.

Description

On 16 May 2018, prescribed vertical and horizontal separation was lost in day VMC between an Airbus A310 (C-GFAT) being operated by Air Transat on an instrument flight rules flight from Toronto to Montréal as TSC485 and a privately-operated Cessna 421 (C-GADG) on an IFR flight from Trois-Rivières to Montréal as both were being positioned to ILS approaches on adjacent parallel runways, minimum separation being 500 feet and 1.7 nm as both were being turned away from each other by different sector controllers.

Investigation

An Investigation was carried out by the Canadian Transportation Safety Board (TSB). Sufficient relevant recorded data and testimony was available to enable a detailed reconstruction of the events leading up to the loss of separation. It was noted that the visibility had been good and there had been no cloud below 10,000 feet so that the prevailing weather conditions had played no part in the investigated event.

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