CAUSE & CIRCUMSTANCE
When a Bombardier Global Express struck objects on the runway while landing at a Montreal airport, no one was more surprised than the business jet’s captain. The fact that half the runway was closed longitudinally and that temporary runway edge lights were installed along the centerline of the full-width runway was unknown to him. How that came to happen is a tale of serial miscommunication involving the NOTAMs (Notice to Airmen), the ATIS (Automated Terminal Information Service) and the unquestioning acceptance of an unusual landing clearance by both pilots. I think it is also an example of how the dysfunctional NOTAM system can start a chain of errors that results in an accident.
The Flight
The BD-700-1A10 Global Express departed New Jersey’s Teterboro Airport (KTEB) on May 15, 2017, destined for Montreal/Saint-Hubert Airport, Quebec (CYHU) with three crewmembers and one passenger aboard. The flight was operated by Zetta Jet USA under the provisions of FAR Part 135. The aircraft lifted off at 0958 EDT, climbed to FL 330 and cruised at that altitude for about 25 minutes. Before commencing descent, the captain, who was the pilot flying (PF), briefed the approach. It was to be the RNAV (GNSS) Runway 06L approach, and the briefed decision altitude (DA) was 400 ft. AGL. After the briefing, the first officer (FO) tuned the ATIS frequency, listened to it, and then briefed the captain.
The ATIS information for 1000 EDT was an automated observation, wind, 360 deg. at 12 kt. gusting to 17 kt.; visibility, 9 sm; sky, 11,000 ft. AGL overcast; temperature, 14C; dew point, 9C; altimeter, 29.68; RNAV Runway 06L approach in use; departing and landing Runways 06L and 06R. The ATIS stated that the first 2,801 ft. of Runway 24R were closed, and that the available takeoff run, takeoff, accelerate-stop and landing distances were 5,000 feet. The ATIS also indicated that 75 ft. of the south side of Runway 06L/24R were open over a distance of 5,000 feet from the Runway 06L threshold, and that 75 ft. of the north side were closed along the entire length of the runway.
When the FO briefed the captain, he omitted the information about the dimensions of the available runway.
Approaching the initial approach fix LOBDO at 1049:45, the crew checked in with the tower controller, who replied that the winds were 010 deg. at 16 kt. gusting to 22 kt. Tower then asked the crew if they had read the NOTAMs about the construction work on Runway 06L. The FO replied that they had. Tower cleared the flight to land on the south side of Runway 06L at 1050:51, and the FO read back the clearance except for the part about the south side.
The captain then questioned the FO about the NOTAMs. The FO explained that the runway length was reduced to 5,000 ft. but said nothing about the width of the runway or the fact that the entire north side of the runway was closed.
The captain disengaged the autopilot at 500 ft. AGL, lined up with the runway’s normal full width and touched down at 1054:38. The touchdown point was 850 ft. beyond the runway threshold. The nosewheel was 36 ft. to the left of the temporary runway centerline and 1.5 ft. to the right of the temporary left edge of the runway; the left main landing gear was 5.2 ft. outside the confines of the temporary runway. Once on the ground, the captain realized they had struck something and moved the aircraft to the right, stopping 300 ft. from the end of the runway and slightly to the right of the temporary centerline.
No one was injured. The passenger exited the airplane and was escorted to the terminal, while the crew remained at the aircraft until investigators could arrive. The runway was closed until temporary repairs could be made to the airplane, which was late on the night of the incident.
The Investigation
The Transportation Safety Board (TSB) of Canada conducted the investigation. Upon arrival at the aircraft, investigators discovered that the two tires of the left main landing gear (MLG) had burst on contact with the temporary runway edge lights, and there was substantial damage to the left MLG wheels, the gear door, the trailing edge of the wing, the left inboard flap, the left engine nacelle and the center rear fuselage. Tire debris was ingested into the left engine and there were punctures to the inlet area acoustic panel. In addition, five of the temporary runway lights were damaged and had to be replaced.
The flight crew held the necessary certificates and qualifications for the flight. Both pilots held ATP certificates and type ratings for the BD-700, and they had a similar amount of total flying time, 3,485 hr. for the captain and 3,305 hr. for the FO. The captain had more time in type, 1,172 hr. vs. 382 hr. for the FO, but in other measures they were alike: Both had 15 hr. in type in the last seven days; both had 2.9 hr. on duty the day of incident and 11.5 hr. off duty the night prior; and both had almost the same amount of flight time in type in the previous six months, 271 hr. for the captain and 258 hr. for the FO. The captain was due for recurrent training soon and the FO had just completed his recurrent training less than two months before the incident.
The tower controller had more than seven years of experience in his present unit, was rated as an expert speaker of both English and French, and was well rested.
The Global Express aircraft was manufactured in 2002 and was properly certified, equipped and maintained. Weight and CG were within limits. Designed for long-range flight, the airplane’s maximum takeoff wight was 93,500 lb. and its wingspan was 93.5 ft. The actual landing weight, approach speed and expected landing distance were not given in the report.
Due to the construction being done on and near the runway, the only instrument approach in use was the RNAV approach flown by the crew. A NOTAM was issued limiting the approach to an LNAV minimum descent altitude of 600 ft. AGL, rather than the lower 400-ft. AGL LPV minimums used by the crew. Since ceiling and visibility were VFR, the crew’s choice was not consequential except as an indication of not complying with the NOTAM.
The TSB found that the communications between the tower controller and the crew were clear and not interfered with. When the FO failed to read back the part of the landing clearance pertaining to the south side of the runway, the controller did not challenge him.
The airport was operated by a non-profit corporation known as Développement Aéroport Saint-Hubert de Longueuil (DASH-L). The airport had three runways, only one of which, 06L/24R, was suitable for business or commercial jets such as the Global Express. [Nearby Trudeau Airport (CYUL) had three suitable runways: 7,000, 9,600 and 11,000 ft. in length.)
The repairs that were being performed on Runway 06L/24R and three nearby taxiways were part of a plan developed by DASH-L and approved by Transport Canada. Work on Phase 2 of the repairs had begun on April 15, 2017, a month before the incident, and were scheduled to end on July 15, 2017. The repair plan identified 11 risks and provided 13 mitigations. The mitigations included temporary lighting, threshold markings and lights, illuminated Xs and Xs on the ground, and a temporary PAPI relocated to the threshold of Runway 06L. The “06L” white paint marking on the approach end of the runway was moved and centered on the active, south side of the runway, and two arrows pointed to the runway markings. A thin white line was painted around the useable 75-by5,000-ft. rectangle of the runway.
One additional mitigation was implemented. Temporary runway edge lights were installed along the old centerline. They were not illuminated during the day, and were difficult to see by a crew on final approach. The incident crew never noticed them. The TSB found that the lights were not secured so as to be frangible, allowing them to move and damage the airplane.
From the date construction started in 2016 until one month after the incident, CYHU had experienced 10 reported incidents related to the temporary runway modifications. These included four aircraft that struck the temporary lights but did not experience major damage, two aircraft that had inadvertently landed on the parallel taxiway and two aircraft that had traveled on the closed portion of the runway.
The TSB also cited a similar landing accident at another Canadian airport in 2015 in which a NOTAM had been issued for a similar longitudinal runway width reduction and yet another landing aircraft had struck temporary lights.
According to the TSB report, the operator of the Global Express in the incident at CYHU, Zetta Jet USA, offered personalized, on-demand, worldwide service. The company was based in Singapore, had another location in Burbank, California, and had a fleet of 21 aircraft, including 13 BD-700s and six Gulfstreams. Zetta Jet ceased operations six months after this incident amidst published concerns about financial irregularities.
Why You Need To Understand NOTAMs
Canada’s Transportation Safety Board (TSB) does not publish CVR transcripts, so we don’t have a word-for-word record of what exactly was said by the pilots of the Bombardier Global Express involved in the landing incident at Montreal/Saint-Hubert Airport on May 15, 2017. The TSB also does not provide probable cause statements of the kind issued by the NTSB, but it does provide findings. In its analysis, the TSB addressed crew situational awareness, flight planning, approach and landing preparation, marking of runways under construction, and conciseness and clarity of notices to airmen (NOTAMs).
The TSB said that despite the information provided to the crew about half of the runway being closed, “this information does not seem to have been compelling to or absorbed by the flight crew, and they adopted a mental model that was resistant to change and to the apprehension of elements that are critical to a safe landing.” The TSB was unable to determine why the crew read but not did grasp the meaning of the NOTAMs, why the FO did not understand or share the critical ATIS information about the runway with the captain, or why the crew did not recognize the temporary runway markings.
Regarding NOTAMs, the TSB only said they are complex to decipher and that sometimes crews may simply skim or forget them. They recommend the words “reduced width” should be incorporated in NOTAMs when appropriate. They also noted that neither the crew nor the company provided the 48 hr. prior notice to DASH-L that was required by NOTAM for airplanes with a wingspan in excess of 78 ft.
Questions I have that went unanswered include supervisory and organizational factors. Was there someone at Zetta Air who had flight planning responsibility and should have been aware of the long-standing restrictions to operations at CYHU? Was the crew notified in sufficient time before the trip to be able to assess the airport safety factors before they launched? Would the captain have been criticized if he decided to divert to the more suitable Trudeau Airport? Did the management at Zetta Air spend more time finding the right caviar for customers than planning safe flights?
The facts presented by the TSB report clearly show the errors made by the crew. The crew had enough information to avoid the incident, and just didn’t heed it. They were careless. Having said that, I think there is more to the story.
The Problem With NOTAMs
If the incident crew or anyone at Zetta Air had actually read the NOTAMs, they would have realized they weren’t in compliance with the 48-hr. prior notice requirement. They would have requested special permission to land or made the flight to another airport. The flight started off on the wrong foot. An obvious reason is because NOTAMs are such a chore to read.
Bloated, jargon-filled NOTAMs have been the accepted international standard since before Charles Lindbergh. According to fixingnotams.org, the 5-bit ITA2 upper-case code used for NOTAMs was begun in 1924 and has remained essentially unchanged. Despite recurring complaints from pilots and reputable organizations, the system has only gotten worse. According to OpsGroup, a flight planning and information sharing organization, the states that generate the NOTAMs prioritize legal self-defense over usability by pilots. Thus unnecessary notices drown out meaningful information.
The problem surfaced during the 2018 NTSB meeting for the Air Canada Flight 759 incident, a near-catastrophic low pass over a taxiway full of idling jetliners. The crew had missed a NOTAM about a runway closure, and that triggered the incident. Then-NTSB Chairman Robert Sumwalt said NOTAMs were “just a bunch of garbage” and “the system was really messed up.” The Safety Board issued recommendation A-18-24, which said “Establish a group of human factors experts to review existing methods for presenting flight operations information to pilots, including flight releases and general aviation flight-planning services (preflight) and aircraft communication addressing and reporting system messages and other inflight information; create and publish guidance on best practices to organize, prioritize and present this information in a manner that optimizes pilot review and retention of relevant information; and work with air carriers and service providers to implement solutions that are aligned with the guidance.”
In response, the FAA said in 2020 that they had established a committee to look into the problem.
One positive development has been the collaboration of OpsGroup with the International Civil Aviation Organization (ICAO) to address the NOTAM problem. They’ve created an artificial intelligence “bot” called “Norm” to evaluate all of the NOTAMs issued around the world. On a typical day, there are 35,000 NOTAMs in effect, and Norm scores them all for length, timeframe, format and other criteria to come up with a NOTAM quality score. There’s a “NOTAMeter” on the ICAO website that you can access to see how different regions and countries rate. Produced in bright colors, it looks like a large beach ball on the deck of the grey battleship that is the ICAO website. Go to https://www.icao.int/safety/iStars/Pages/Notameter.aspx
As this is written, the NOTAMeter says only 12.41% of worldwide NOTAMs meet all quality criteria. The Russian Federation has 30.72% of its NOTAMs meeting the quality criteria, and China manages 18.43%. In North America, you will find 4.24% meet the criteria, with the U.S. bringing up the rear at just 3.42%. The U.S. wins the prize for worst NOTAM in the region, a truly incomprehensible mélange pertaining to flight planning (I think).
If you have the time and an internet connection, you can go to the FAA’s NOTAM search website and pull up the NOTAMs for your destination airport. You can select individual NOTAMS, and in some cases even get a plain-language translation. Just pulling up CYHU today, I find 15 NOTAMs. They are still dense (TWY B BTN ENA AND 240FT FR ENA CLSD) and lack plain-language versions.
If you are on a short callout for a trip to a major airport, you will have a problem sorting out the real hazards from the dross in the destination NOTAMs. For example, today Chicago O’Hare Airport (KORD) has 89 NOTAMs. You can spend 20 min. reading them and still not be sure you understand everything. That is not a good situation. Let’s hope the FAA will start to realize that excessive and unreadable NOTAMs are a real safety issue.
