Report: misinterpreted taxiway markings factor in attempted takeoff from taxiway, Amsterdam

Home Aircraft Accidents Report: misinterpreted taxiway markings factor in attempted takeoff from taxiway, Amsterdam
Report: misinterpreted taxiway markings factor in attempted takeoff from taxiway, Amsterdam

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Date: 06-SEP-2019
Time: 06:10 LT
Type: Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8K2 (WL)
Owner/operator: Transavia
Registration: PH-HSJ
MSN: 42150/4810
Fatalities: Fatalities: 0 / Occupants:
Other fatalities: 0
Aircraft damage: None
Category: Serious incident
Location: Amsterdam-Schiphol Airport (AMS) –
  Netherlands

Phase: Take off
Nature: Passenger – Scheduled
Departure airport: Amsterdam-Schiphol International Airport (AMS/EHAM)
Destination airport: Chania-Soúda Airport (CHQ/LGSA)
Investigating agency:  Dutch Safety Board
Confidence Rating: Accident investigation report completed and information captured

Narrative:
Transavia flight HV1041, a Boeing 737-800, aborted the takeoff from a taxiway at Amsterdam-Schiphol Airport, Netherlands.
The flight crew, consisting of two pilots, was scheduled to fly from Schiphol Airport to Chania International Airport (LGSA) in Greece. During flight preparation, the flight crew planned and discussed the taxi route to and the takeoff from runway 18C. They made a performance calculation for a takeoff from Intersection W3. The first officer was the pilot flying.
At 06:03 hours, the ground controller issued the taxi clearance via Taxiways B and C to the holding point of runway 18C. The captain read back the clearance.
When the Boeing 737-800 entered taxiway C, there were no other aircraft in front of it.
At 06:08 hours the aircraft taxied north on taxiway C abeam W4, as the captain informed ground control they were approaching runway 18C and ready for departure.
The ground controller instructed the crew to contact the tower (runway controller). Because it was busy on the tower frequency, the captain could not immediately contact the runway controller and request the intersection takeoff from W3, which they had planned. The captain contacted the runway controller when the aircraft was near C2 at 06:09 hours and reported ready for departure.
The runway controller cleared the aircraft to line up at runway 18C and to take off. The captain read back the clearance and then asked if they could depart via W2, to which the runway controller replied that: ‘it is a long detour’. The captain apologised and reported that he meant W1. The aircraft continued north on taxiway C. When approaching C1, the pilots selected the departure chart on their Electronic Flight Bags.
The first officer turned left on C1, where the landing lights of the aircraft were switched on, and then made a second left turn, steering the aircraft onto taxiway D. The captain described the situation towards the runway as a ‘black hole’ without a stop bar and ‘wig-wag’ lights visible. He also stated that the runway identifier signs were not lit. After the aircraft had lined up on taxiway D, the first officer applied full throttle, engaged the autothrottle and began a rolling takeoff. At 06:10 hours, the captain made the 80 knots call, which was confirmed by the first officer.
The ground controller noticed the takeoff roll from the taxiway when he looked on his ground radar to see what the position was of another aircraft that was taxiing via taxiway C towards runway 18C for departure. He immediately informed the runway controller about it. The runway controller then looked at his ground radar straightaway and instructed the flight: takeoff: “Transavia one zero four one stop immediately, stop immediately, hold position.”
The aircraft’s position was then between W2 and W3. The captain took over the controls and initiated the procedure for a rejected takeoff. The aircraft came to a stop on the taxiway just south of W5.
Only after the runway controller had informed the pilots that they started their takeoff roll from the taxiway, the pilots realised what they had done. They were both completely astounded by what had just happened. The flight crew informed the cabin crew and passengers that they had rejected the takeoff due to a warning in the cockpit.
The pilots discussed what just had happened and judged that they were able to continue the flight despite the rejected takeoff.
The aircraft subsequently departed normally from runway 18C.

Safety Board Conclusions
In the morning darkness the flight crew interpreted Taxiway D as the designated Runway 18C and started the takeoff roll. They initiated the takeoff roll from a taxiway, because they had misinterpreted taxiway markings and environmental cues.
As Taxiway D was used for incoming traffic, air traffic control used parallel Taxiway C for the aeroplane to taxi to the holding point of Runway 18C. While taxiing on Taxiway C, the crew was not fully aware of the exact position of the aeroplane. The taxiway centre line markings did not provide continuous guidance; the yellow taxi line at C1 was uninterrupted towards Taxiway D and interrupted towards Runway 18C. The line became clearly visible when the crew switched on the landing lights. Following the only taxiway guidance that was clearly visible to the crew, i.e. the yellow line from C1, the aircraft ended up on Taxiway D. Cues such as the yellow, thin and continuous centre line marking and green centre line lights, were not recognised by the flight crew as cues of being on a taxiway. Environmental cues, such as signs indicating Runway 18C, enhanced the perception of the crew that they were lined up on Runway 18C, instead of on Taxiway D.

Several factors contributed to this serious incident:
• The use of outer Taxiway C in combination with an early issuance of the takeoff clearance, introduced a risk of taxiing incorrectly.
• The runway controller issued the takeoff clearance when prompted by the crew with a ready for departure notification. Thereafter he shifted his attention to other traffic and did not observe the line-up of the aeroplane on Taxiway D. Based upon the operational situation and his expert judgement, the runway controller did not perceive his reduced focus on the Boeing 737-800 as a risk, especially because it concerned a home based carrier.
• When taxiing from Taxiway C towards the holding position of Runway 18C, the taxiway centre line markings did not provide continuous guidance, as the design of these markings was focused on preventing runway incursions during low visibility operations.

Sources:

https://www.lvnl.nl/veiligheid/overzicht-voorvallen/dossiers/20190909-voorval-tijdens-start-schiphol
https://www.onderzoeksraad.nl/nl/page/15141/start-vanaf-taxibaan-boeing-737-amsterdam-airport-schiphol-6
https://www.liveatc.net/
https://www.flightradar24.com/2019-09-06/04:16/12x/TRA1041/21fd4fc6

Accident investigation:

   
Investigating agency:  Dutch Safety Board
Status: Investigation completed
Duration: 2 years and 8 months
Download report: Final report

Location

Images:

Photo of PH-HSJ courtesy AirHistory.net


Amsterdam – Schiphol (EHAM / AMS)
28 June 2021; (c) Fred Willemsen


Taxi route of HV1041 from Flightradar24

Revision history:

Date/time Contributor Updates
13-Sep-2019 18:33 harro Added
17-Sep-2019 14:06 harro Updated [Aircraft type, Source, Narrative]
17-Sep-2019 14:44 harro Updated [Time, Aircraft type, Registration, Cn, Operator, Nature, Destination airport, Source, Narrative]
17-Sep-2019 15:01 harro Updated [Narrative, Photo]
17-Sep-2019 17:51 Anon Updated [Narrative]
25-May-2022 08:33 harro Updated [Narrative, Category, Accident report]
25-May-2022 09:47 harro Updated [Narrative]
25-May-2022 10:02 harro Updated [Photo]

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