Report: Serious runway confusion incident at Amsterdam-Schiphol Airport

December 21, 2011

The Dutch Safety Board published the final report of their investigation into a serious runway confusion incident at Amsterdam-Schiphol Airport involving a Boeing 737-300.

On February 10, 2010 KLM flight KL1369 was cleared for takeoff on runway 36C at Amsterdam-Schiphol International Airport (AMS/EHAM). Instead, the crew took off from the parallel taxiway B.

At the time of the incident, about 20:30,  it was dark and it was snowing. The airplane had just been de-iced and was instructed to taxy down taxiway Alpha towards runway 36C. This meant that the crew had to use taxiway Alpha in the opposite direction, contrary to published procedures. Air traffic control is allowed to use this taxiway in the opposite direction if deemed necessary. This is sometimes the case when an aircraft leaves the Juliet platform after de-icing, just like KL1369.

The crew were very familiar with the airport and did not use a taxiway map although they were supposed one. The air traffic controller then offered the flight to enter the runway through intersection W-8. At that time a preceding Boeing 747 had taxied the wrong way and  was blocking the taxiway. The KLM flight crew accepted the offer because this also meant an opportunity for an expedited takeoff.

At that point the crew started losing positional awareness. The workload increased because the an entry in the FMS now had to be changed because the crew had anticipated using  intersection W-9. Meanwhile the captain was distracted by radio communications between the air traffic controller and the pilot of the Boeing 747. The crew had to cross parallel taxiway Bravo to enter runway 36C. However, they turned directly onto Bravo and initiated their takeoff roll. The crew did not notice their error and continued their takeoff, passing within about 300 metres of a Boeing 737-400.

It appears that the taxiway leading from taxiway Bravo to runway 36C was covered with a thin layer of snow, possibly obscuring the taxiway lights. Also, visibility of the lights of runway 36C was degraded because the lighting pattern matched that of the lights along the highway parallel to the runway.

Taxi routes of KL1369 (blue) and the preceding Boeing 747, flight CAL5420 (yellow)

More information:

Final report (in Dutch)

Report: runway confusion, poor stop bar visibility causes of serious runway incursion incident

October 15, 2010

A KLM Boeing 747-400 being towed at Amsterdam Airport (Photo: ASN)

The Dutch Safety Board released the final report of a serious runway incursion incident at Amsterdam-Schiphol Airport, the Netherlands on July 24, 2004.

Two Boeing 747-400 aircraft were being towed at Amsterdam-Schiphol Airport. PH-CKC was planning to cross runway 04-22. The other, PH-BFU was planning to cross runway 24 at the same time.

The assistant controller cleared erroneously cleared BFU to cross runway 04-22 (“BFU 04-22 crossing approved“). The tow truck driver of did not realise that the clearance was given for another runway and read back: “BFU 04-22 crossing approved.

The tow truck driver of CKC noticed the wrong clearance and readback and radioed: “You are not at 04-22 [name].”  While the assistant controller was communicating with CKC, the Tower Controller cleared a KLM Boeing 737-300 (PH-BDC) for takeoff from runway 24: “KLM1351 two four cleared for take-off.” At the same time BFU was crossing the same runway at taxiway Sierra 2, located about 1600m from the Boeing 737.

The BFU driver overheard this transmission and questioned his clearance: “BFU was at Sierra 2 24, crossing is approved, eh?” The Tower Controller then cancelled the takeoff clearance for KLM1351 which had only just commenced the takeoff roll.

The Safety Board concluded that an assumed identity and anticipated clearance are the  primary causes.  The verification process for the clearance of the tow truck driver did not work because of an  automatic subconscious “readback” of the runway id was a precondition for a possible false ‘readback’. Also, adverse conditions may have influenced  the intensity of the stop bar lights,  combined with the reflection of the sun.


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