Error in flight plan data led to January 2019 loss of separation near Kelowna, British Columbia

News release

Richmond, British Columbia, 2 April 2020 — The Transportation Safety Board of Canada (TSB) today released its investigation report (A19P0002) into a loss of separation that occurred in 2019 between a Westjet Encore Bombardier Q400 and a Piaggio P.180 twin turbo-prop aircraft in the vicinity of Kelowna, British Columbia. The investigation found that an error in flight plan data and other factors resulted in a loss of separation when the required vertical separation minimum of 1000 feet or lateral separation minimum of 5 nautical miles was not maintained.

On 03 January 2019, a flight operated by Westjet Encore left the Calgary International Airport, Alberta enroute to Nanaimo Airport, British Columbia. At the same time, a privately registered Piaggio was travelling from Spokane International Airport, Washington, USA, to Kamloops Airport, British Columbia. Both aircraft were being provided air traffic control services from an air traffic controller at the Vancouver Area Control Centre (ACC) and were flying at Flight Level 220 (approximately 22 000 feet above sea level) prior to the occurrence.

The flight data processers (FDP) in the Vancouver ACC had undergone a software update prior to the occurrence, but previous information in the FDPs had not been purged, leading to a disparity error between the flight plan data and the radar identified flight path of the Piaggio. The controller was not familiar with such disparity errors and in his attempts to resolve the discrepancy for the Piaggio, did not identify the potential conflict between the Westjet Encore and Piaggio flight plans.

Additionally, the disparity error meant the Medium Term Conflict Detection software designed to predict traffic conflicts, and which the controller had come to rely on, was unavailable to predict the loss of separation. Traffic volume in the airspace had increased, leading to a high workload for the controller. The controller did not see or hear the visual and audible warnings as the two aircraft approached one another.

The traffic alert and collision avoidance system (TCAS) on board the Westjet Encore flight alerted the crew to decrease altitude. The pilot of the Piaggio maintained altitude and saw the Westjet Encore aircraft descending. The separation between the aircraft was reduced to 1000 feet vertically and 0.9 nautical miles laterally. Both flights continued to their destination without further incident.

The investigation also identified risks regarding controller familiarity with equipment errors, and the adequacy of controller workload monitoring by team supervisors.

Following the occurrence, NAV CANADA implemented a number of safety actions including making improvements to the checklist for completing software updates and purging flight data from FDPs. A new directive was issued to controllers regarding the minimum volume setting for audible alerts. Additional directives were issued regarding airspace sectorization to ensure that traffic levels remain manageable and appropriate supervisory oversight.

See the investigation page for more information.

The TSB is an independent agency that investigates marine, pipeline, railway and aviation transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.


For more information:
Transportation Safety Board of Canada
Media Relations

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