Things could have been so much worse.

Our report today on a near collision between two planes at Lynden Pindling International Airport in September makes for sobering reading.

Two planes at opposite ends of the same runway started heading towards each other – and the pilot of one only knew about the other when it flew directly over his plane.

With 25 people on one aircraft and only the pilot on the other, it is horrific to think of what might have been.

The report conducted by the Air Accident Investigation Department seems thorough and gives us many answers – but also raises some questions.

The largest share of the blame falls on the shoulders of the pilot of the smaller plane. Having been given – and acknowledged - instructions by the air traffic control crew, he then defied those instructions by taking off on the wrong runway. When asked why, he said he “forgot” to follow the right instructions. As a result, he has had his licence re-examined, and it is presently suspended pending a medical assessment.

Beyond the pilot’s fault, however, there are lessons we can learn over the system at air traffic control.

The air traffic controller at the time was monitoring two separate radio frequencies and using a system that demanded extra training – all during a shift change. Beyond that, the controller’s paperwork was not in order – his medical certificate was expired and he had not air traffic control licence. He wasn’t alone in this – none of the air traffic controller staff had the required licence and with no system to monitor the medical status of controllers, several were operating without current certificates.

Investigators wanted these issues fixed – quite rightly – and also want more frequent refresher training for controllers. The controller in the incident hadn’t had a refresher course since 2007. Eleven years without more training in a job as crucial to public safety as an air traffic controller.

Add to that a shortage of manpower and it’s perhaps no surprise that such a near collision took place. Indeed, it’s a minor miracle that it didn’t happen sooner – and that we aren’t talking about a greater disaster.

We welcome the investigators’ report and its recommendations. Controllers have to be better managed in order to do their job, and for employers to be sure controllers are up to carrying out that job. They should be better trained, better monitored and better staffed. So now comes the next part of the task – will those in charge follow through on these recommendations?

We have long heard about staff shortages among air traffic controllers – along with many other matters that have hindered travel with delays and diversions over the years. This report should be a wake-up call about the potentially deadly consequences of trying to run an air traffic control system with too few people and a weak management structure. It is time – beyond time – for the Ministry of Transport and Aviation to lead the way in calling for reform of this sector to tackle its failings.

Recommendations are one thing – without action to remedy these problems, we can only hope to avoid further near collisions. Or worse.