Aviation Investigation A16O0016

Runway incursion

The occurrence

On 30 January 2016, an Air Canada Embraer 190 (ACA726) was taxiing for departure on Runway 24R at Toronto’s Lester B Pearson International Airport (LBPIA). ACA726 taxied onto the runway without a clearance while an Air Canada Airbus A320 (ACA1259) was on short final for landing on Runway 24R. ACA1259 initiated a missed approach as a result of the incursion.

Map of the area

Investigator-in-Charge

Photo of Kevin Roach

Formerly a senior officer in the Canadian Forces, Mr. Kevin Roach has 34 years of military aviation experience as an air traffic controller. He controlled air traffic in several locations, in both visual and instrument flight rules environments, eventually becoming a unit manager.

Mr. Roach joined the Canadian Forces School of Aerospace Control Operations as an air traffic control instructor in 1997, ending his tenure there as chief instructor, responsible for the delivery of air traffic control training for the Royal Canadian Air Force.

Before joining the Transportation Safety Board of Canada in 2013, Mr. Roach was at the Air Traffic Management Coordination Office in Ottawa, where he was responsible for the day-to-day liaison between the Department of National Defence, the Royal Canadian Air Force, Transport Canada and NAV CANADA.

Transportation Safety Board investigation process

There are 3 phases to a TSB investigation:

  1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
  2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
  3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

For more information, see our Investigation process page.