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Although there were available cues that could have alerted the flight crew to the misunderstanding, the cues were either not sufficiently compelling or were considered and explained away. Findings as to risk - If air traffic controllers are not required to use standard phraseology that reinforces the need to hold short of a departure runway, there is an increased risk of miscommunication leading to runway incursions.
On May 24th the TSB released their final report concluding the probable causes of the serious incident were: If air traffic controllers are not required to use standard phraseology that reinforces the need to hold short of a departure runway, there is an increased risk of miscommunication leading to runway incursions.
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