KLM B737 and Transavia B738 at Amsterdam on Mar 29th 2018, late go around on 18C and conflicting takeoff on 24

Last Update: September 24, 2020 / 18:05:22 GMT/Zulu time

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Incident Facts

Date of incident
Mar 29, 2018

Classification
Incident

Airline
KLM

Flight number
KL-1080

Departure
Manchester, United Kingdom

Destination
Amsterdam, Netherlands

Aircraft Registration
PH-BGK

Aircraft Type
Boeing 737-700

ICAO Type Designator
B737

A KLM Boeing 737-700, registration PH-BGK performing flight KL-1080 from Manchester,EN (UK) to Amsterdam (Netherlands), was on final approach to runway 18C and had been advised there was traffic departing from runway 24.

A Transavia Boeing 737-800, registration PH-HXF performing flight HV-5193 from Amsterdam (Netherlands) to Paris Orly (France), was cleared for takeoff from runway 24 and was accelerating for takeoff, when KL-1080 initiated a go around from low height due to an early flare. Tower instructed KL-1080 to turn right immediately to a heading 270 and HV-5193 to immediately turn left to a heading of 180.

KL-1080 positioned for another approach and landed safely on runway 18C about 11 minutes after the go-around.

HV-5193 continued to Paris for a safe landing.

The Dutch Onderzoeksraad (Dutch Safety Board DSB) opened an investigation into the occurrence rated a loss of separation between the two aircraft. The DSB argued: "Because the extensions of both runways intersected, the aircraft came close together."

Dutch LVNL (ATC provider) confirmed the occurrence stating they are going to investigate the occurrence themselves and report the result. LVNL stated: "From the tower the air traffic is visually separated, the air traffic controller gives instructions to pilots based on what he or she sees. There are no minimum requirements for the distance between two aircraft (separation standards) for the area where traffic control is given from the tower."

A similiar occurrence had happened earlier in the day, see Incident: KLM 772 and KLM B773 at Amsterdam on Mar 29th 2018, late instruction for go around on 18C and conflicting clearance for takeoff on 24 with similiar separation left. The LVNL had told The Aviation Herald with respect to that event: "Landing aircraft are warned about take-offs in progress 24. Consequently, separation norms do not apply. A 'loss of separation' cannot be claimed." The LVNL confirmed, this later occurrence involving the Boeing 737s of KLM and Transavia is the one being investigated by the DSB.

On Jul 12th 2018 the DSB reported the occurrence was rated a serious incident involving the loss of separation that led to a potentially dangerous situation. Following the information of the go around tower immediately instructed the aircraft going around to turn right to 270 degrees and the departing aircraft to turn left to 180 degrees. Both crews had visual contact with each other. The investigation is ongoing.

On Sep 24th 2020 the DSB released their final report reporting the separation between the two aircraft reduced to 300 feet vertically and 0.5nm horizontally and concluding the probabe causes of the incident were:

- The runway controller observed the aircraft taking off from runway 24, and was confronted with a potential conflict when the crew of the landing aircraft on runway 18C announced their go-around. Runway 24 and 18C are converging runways. Attempts to cause the aircraft to abort its takeoff failed, resulting in a potential hazardous situation. Thanks to the almost simultaneous intervention by the runway controller and the response from the two crews, no actual collision hazard occurred.

- Allowing reduced separation during the use of dependent takeoff and landing runways is a procedure which can result in the occurrence of undesirable and potentially hazardous situations. Aside from the uncertainty about the legitimacy of this procedure, the question is whether the advantage gained – namely increased capacity – outweighs the potential hazard that can arise. With that in mind, LVNL should maintain the basic rule that takeoff clearance will only be issued after the landing on the dependent runway has actually been confirmed by the runway controller or if the landing aircraft is still at least 2 NM from the runway threshold.

The DSB reported:

Shortly before landing on runway 18C, the crew of the Boeing 737-700 reported their intention to perform a go-around. At that time, the runway controller had already issued clearance to the Boeing 737-800 to start its takeoff procedure from runway 24. The runway controller wanted to instruct this aircraft to abort its takeoff, but because the wrong flight number was used in the instruction to abort the takeoff, the crew did not respond to the instruction and the aircraft took off. The runway controller recognized the potential conflict and issued instructions to both the Boeing 737-700 and the Boeing 737-800 to perform divergent turns in order to establish a greater separation between the two aircraft. The crews of both aircraft immediately complied with these instructions, also because they had themselves recognized the potentially hazardous situation. The smallest separation between the two aircraft was around 960 metres (0.5 NM horizontal and 300 feet vertical).

This occurrence took place because the procedures in the Operations Manual of Air Traffic Control the Netherlands (LVNL) allows the possibility of the simultaneous use of two converging runways for aircraft landing and taking off. Although the basic rule is that clearance to take off is only issued after the landing on the dependent runway has actually been confirmed by the runway controller, there is an exception to this basic rule.

The Operations Manual offers the possibility, under certain conditions, of permitting reduced separation, so that it is possible that takeoff clearance is given before it has been confirmed that the landing aircraft has actually landed. In the event of a go-around by the landing aircraft, if immediate measures are not taken, the two aircraft can find themselves undesirably close together. This situation has arisen twice in the past.

The procedure for reduced separation has not been explicitly approved by the Human Environment and Transport Inspectorate (ILT). The procedure was already present in the former manual of LVNL at the time when the manual was converted into the current Operations Manual. This Operations Manual in its entirety was approved by the ILT, such that the above procedure was implicitly permitted. The ILT was however unable to trace back the actual way in which the former manual was converted into the Operations Manual. The procedure for reduced separation was not considered during subsequent amendments to the Operations Manual, which were approved by the ILT.
Aircraft Registration Data
Registration mark
PH-BGK
Country of Registration
Netherlands
Date of Registration
Qbhbcckmfcm Subscribe to unlock
Airworthyness Category
Emkhpbc Subscribe to unlock
Legal Basis
Jddd Subscribe to unlock
Manufacturer
The Boeing Company
Aircraft Model / Type
737-700
ICAO Aircraft Type
B737
Year of Manufacture
MljA Subscribe to unlock
Serial Number
Qg pg Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
Fkjgkl Subscribe to unlock
Maximum Take off Mass (MTOM) [kg]
Cl qd Subscribe to unlock
Engine Count
H Subscribe to unlock
Engine
BdmmqnAflgp ebcmcdpncelkiAkbjfegpc Subscribe to unlock
Engine Type
Beklepbb Subscribe to unlock
Incident Facts

Date of incident
Mar 29, 2018

Classification
Incident

Airline
KLM

Flight number
KL-1080

Departure
Manchester, United Kingdom

Destination
Amsterdam, Netherlands

Aircraft Registration
PH-BGK

Aircraft Type
Boeing 737-700

ICAO Type Designator
B737

This article is published under license from Avherald.com. © of text by Avherald.com.
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