Pilot fatigue, accidental switch press blamed for plane going off runway at Waterloo Region airport

A Transportation Safety Board report reveals what led to a plane going off the runway at Region of Waterloo’ airport. CTV’s Heather Senoran explains.

The Transportation Safety Board of Canada (TSB) said pilot fatigue and an accidental switch press led to a plane going off the runway at Region of Waterloo International Airport in 2022.

According to an investigation, when the Flair Airlines Boeing 737-800 left Vancouver on Nov. 25, 2022, its left engine thrust reverser was not working.

When the plane approached the runway in Breslau, the captain left the engine autothrottle engaged after disengaging the autopilot.

Shortly before landing, the captain meant to disengage the autothrottle, but accidently pressed the takeoff/go-around (TO/GA) switch, causing the autothrottle to try to increase engine thrust.

The report goes on to say warnings about the change went unnoticed in the cockpit as the flight crew were focused outside the flight deck.

When the aircraft came in for a landing, the right engine was producing reverse thrust while the left engine was heading toward maximum thrust, deactivating systems to help stop the plane, making it difficult to control. The captain was able to keep the plane on the runway and used manual braking to slow down, but eventually they ran out of space and the plane overran the runway by approximately 500 feet and ended up in the mud.

The Transportation Safety Board of Canada said several factors contributed to the incident, including pilot fatigue, the attention of both pilots being focused outside the aircraft during the landing, and audio and visual warnings that were not noticeable enough to indicate the accidental switch press.

“The regulations have been updated as recently as 2018 to try to get a handle on fatigue in the industry. But there’s always going to be room for improvement in that regard,” said Jon Douma, one of the TSB investigators assigned to the case.

The report also notes there was a defect with the aircraft’s left thrust reverser. Although it had been reported six months before the incident in Kitchener, and 22 reports were made with options to troubleshoot the problem, the defect did not meet the technical definition of a ‘recurring defect.’

“If the thrust reverser had not been broken, it would not have happened. If he had not pressed the wrong button, it would not have happened. If the weather had been nice that day, it would not have happened. It’s just one of those things where a whole bunch of different events collide and cause the mishap,” said Douma.

The TSB said the aircraft had very little damage after the incident.

“Just a lot of mud to clean up and a washer was inside the landing gear system that needed to be replaced … Quite minimal considering how deep it got into the mud when it exited the runway,” Douma said.

There were six crew members and 134 passengers on board when the plane went off the runway. No injuries were reported.

Commercial flights in and out of the airport were cancelled for the rest of the day.

Flair responds

Flair Airlines responded to the 2022 incident.

In an emailed statement to CTV News, the airline stated:

“We appreciate the TSB’s thorough, impartial investigation, which reinforces our unwavering commitment to safety. The report affirms that Flair Airlines has always operated in full compliance with all safety regulations and maintenance standards. Flair has industry-standard fatigue management software and refined scheduling practices. In collaboration with ALPA and other industry stakeholders, we continue to enhance safety measures, reinforcing our commitment to operational excellence. At Flair Airlines, safety is not just a regulatory obligation—it is our highest priority. Since the incident mentioned in the report, we have maintained a perfect safety record, with enhanced measures that exceed industry standards. We remain dedicated to leading the way in aviation safety in partnership with our passengers, crew, and partners. We will continue working closely with regulators and industry leaders to drive innovation and ensure the highest level of safety for all our passengers.”

Passenger reacts

Paul Anstett, a Kitchener resident, was on the flight. He said he still remembers it clearly as he was looking out the window when it happened. He said he was shocked to see the plane kept going after hitting the runway.

“[It went] off the runway [and] in the grass. We were bouncing a little bit. Not terribly. I was in the front of the plane. I believe the people in the back of the plane were getting a bit more of a whiplash type effect,” Anstett said, in an interview on Thursday.

Anstett said the incident hasn’t deterred him from flying Flair, but he did read the TSB’s report.

“It’s a little concerning if you’ve got pilot fatigue,” he said.

Anstett said all passengers received a free Flair flight as compensation after the 2022 incident, but unfortunately he wasn’t able to use it as the timing didn’t work out for him and his wife.