The Traffic Safety Board recommends changing the two-point schedule at the largest Canadian airport to reduce the risk of collision between the aircraft.
The recommendation was one of the three that was included in the report of the Independent Safety Authority after its investigations into 27 separate intruders at the Toronto Pearson International Airport between June 2012 and November 2017.
The TSB defines an incursion as an incident in which an aircraft or off-road vehicle "misbehaves an active runway". As the worst possible scenario, there would be a direct collision between two planes.
According to investigators, all incidents in Pearson occurred between two "narrowly spaced parallel tracks" at the southern end of the airport area. Two pistes are merged with several "quick exits" – small planes on the track can be used to move from one to another.
Both trails are used at peak times in Pearson, which has about 400,000 flights a year.
Problems arise when the plane landed on the longest slope and tried to take one of the runways to the adjacent slopes, TSB says.
In its report, the TSB notes that the layout of the runway "differs from almost every other major airport in North America".
This has resulted in confusion among flight crew and increased the risk of a major collision, says TSB. The report cites design problems at airports and busy flying crews that miss the different signs.
"All 27 insurgents inspected included flight crews who realized they had to stop and approach the active track," Kathy Fox, chairman of the board at the press conference at Richmond Hill, Ont.
"Despite all the visual signs, including lights, signaling and color markers, professional crews did not stop in time as needed, risking collision with other aircraft on the other track."
Fox said that in at least five cases, air traffic controllers intervened in the last second to prevent potentially serious collisions between the aircraft.
Other TSB recommendations include:
- Change the language that air traffic controllers use to convey commands that are critical to security.
- Work with Transport Canada and the US State Aviation Administration to modify the standard operating procedures so that crews will only start checking after landing after the aircraft landing has cleared all active tracks.