Transavia B738 at Amsterdam on Sep 6th 2019, rejected takeoff from taxiway

Last Update: July 5, 2020 / 17:00:31 GMT/Zulu time

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Incident Facts

Date of incident
Sep 6, 2019

Classification
Incident

Flight number
HV-1041

Destination
Chania, Greece

Aircraft Registration
PH-HSJ

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

A Transavia Boeing 737-800, registration PH-HSJ performing flight HV-1041 from Amsterdam (Netherlands) to Chania (Greece), was taxiing along taxiway C for takeoff from runway 18C at about 06:00L (04:00Z) when the crew reported ready for takeoff and was cleared for takeoff. At the end of the taxiway the aircraft turned left and immediately left again onto taxiway D (instead of runway 18C) and began to accelerate. Tower noticed the aircraft was attempting takeoff from the taxiway and instructed the aircraft to stop. The crew rejected takeoff at low speed (about 50 knots over ground), slowed safely, taxied to runway 18C again and departed about 10 minutes later.

Netherland's LVL (ATC Provider) reported the aircraft started its takeoff run from a taxiway instead of assigned runway 18C, tower instructed the crew to stop takeoff. There was no conflicting traffic on the taxiway at the time. The DSB (Dutch Safety Board) was notified.

The DSB reported: "The aeroplane taxied in northerly direction on taxiway Charlie to runway 18C when it received takeoff clearance for runway 18C. The flight crew then drove on taxiway Delta in a southerly direction and commenced the takeoff. Air traffic control noticed this and instructed the crew to stop immediately. The crew aborted the takeoff run and taxied back to the beginning of runway 18C, after which the aeroplane took off uneventfully." A shortened investigation into the occurrence has been opened.

A detail in the radio communication, while the aircraft was still following taxiway C following the takeoff clearance, permits to conclude the crew believed to be on taxiway D. The crew queried "May we take taxiway W2?", tower explained however (in Dutch) this would be a detour to the D-taxiway, it appears however this did not restore situational awareness (being on taxiway C) by the crew.

On Jul 1st 2020 Netherland's LVNL (ATC provider) released their final report concluding the probable causes of the "significant occurrence" were:

This occurrence happened due to a combination of circumstances. The infrastructure between taxiway C and taxiway D, at point C1, gave the crew of the Boeing the impression that they had turned onto runway 18C, whereas in reality they were on taxiway D. The crew received take-off clearance from the air traffic controller and were directed to the take-off runway via the outermost taxiway. After their turn at C1, they did not end up on runway 18C, but on taxiway D. At that time, the crew was preparing for a rolling take-off, which meant that they had to divide their attention between operations in the cockpit as well as navigating and manoeuvring by looking outside. The air traffic controller was focused on other work in the tower and did not initially notice the Boeing’s turn to taxiway D. Once the Boeing was on taxiway D, the deviating characteristics of the taxiway compared to the take-off runway (lines, colour of the lighting, etc.) were no longer distinctive enough to catch the crew’s attention and notify them that they were preparing to take off from a taxiway.

During the rolling take-off, the air traffic control detected that the Boeing was on the taxiway instead of on runway 18C. The air traffic controller intervened and the Boeing crew aborted the take-off.

The LVNL reported the sequence of events:

A Boeing 737 aircraft taxied towards runway 18C via taxiway C around 06.00 hours (local time). It was dark, weather and visibility were good, and there was relatively little traffic at the airport. While taxiing on taxiway C, the Boeing reported it was ready for departure. The air traffic controller gave the pilot take-off clearance to depart from runway 18C. The crew of the Boeing requested the air traffic controller if they could use an intersection, but given the position of the Boeing, it was decided in mutual consultation to take off from the beginning of the runway (W1). To get there, they had to take a turn at the end of taxiway C (at point C1) and go straight on to W1. After point C1, the Boeing continued its turn and ended up on taxiway D. After this turn, the Boeing started its rolling take-off without stopping. A colleague in the tower alerted the air traffic controller to the situation. That air traffic controller then intervened by instructing the Boeing to come to an immediate halt. The Boeing aborted its take-off and came to a standstill on taxiway D. There was no other traffic on taxiway D during the occurrence, so there was no risk of collision. The Boeing taxied back to the beginning of runway 18C and took off without any problems.

The LVNL analysed:

Infrastructure

The investigation revealed that the turn at point C1 could lead to confusion for aircraft crews regarding the taxiing direction. When taking off from runway 18C southwards, aircraft taxi to that runway via taxiway D or taxiway C. Both taxiways are equipped with centreline lighting. The lighting along taxiway C in the direction of runway 18C (point C1) is not equipped with centreline lighting, because that area is not designed for conditions that involve reduced visibility (such as fog) This creates a dark location at point C1. Moreover, the yellow centreline marking from taxiway C to runway 18C is interrupted at C1. This is to prevent potential runway incursions. As soon as the Boeing’s lights, which are used for take-off and landing, are switched on at C1 while it is dark, the yellow centreline marking will be visible, guiding the aircraft crew from taxiway C to taxiway D.

Some of the features of taxiway D differ from taxiway C, such as the width, the colour of the concrete and the taxiway edge lights, which might have given the crew the impression that taxiway D was the take-off runway.

Tower

It is unusual to use runway 18C as a take-off runway during the night. When taking off southwards at night, it is customary to use runway 24 (Kaagbaan), but that runway was under maintenance at the time of the occurrence. Aircraft usually taxi via taxiway D to the take-off point of runway 18C (W1). The reason for having the aircraft taxi via taxiway C was that taxiway D was in use for landing traffic to taxi from runway 18R (Polderbaan) to the gates.

The Boeing reported it was ready for take-off, and the air traffic controller then issued take-off clearance to the Boeing while it was taxiing on taxiway C. An air traffic controller may issue take-off clearance as soon as an aircraft reports that it is ready for take-off, is approaching the take-off runway, and there is no conflict with other traffic. Those conditions were met. On that night, eleven other aircraft taxied in the same way via taxiway C and took off from runway 18C without any problems. Air traffic control was not aware of the fact that the centreline lighting and markings on the taxiway did not provide a continuous line between taxiway C and runway 18C. In the perception of the air traffic controller, there was nothing that could go wrong while the aircraft was taxiing. After issuing take-off clearance, the air traffic controller proceeded to other work activities in the tower, with the intention of actively observing the departing Boeing again as soon as it started its take-off on runway 18C.

Cockpit

The Boeing crew had reported that they were ready for take-off, the air traffic controller’s take-off clearance had been received, and the crew were preparing for take-off during the turn from taxiway C to C1. At that moment, the attention was divided between inside and outside the cockpit. Preparations for take-off were being carried out inside the cockpit, and at the same time the crew was looking outside to navigate and manoeuvre. These preparations were carried out in a timely manner so the aircraft would be able to perform a rolling take-off. A rolling take-off means that the Boeing would turn onto the runway and start its take-off without stopping. That is the policy of the airline based on Boeing’s advice.

In most cases, the operational situation allows the air traffic controller to route an aircraft via the directly adjacent taxiway to the take-off runway, after which the crew turns onto the take-off runway with a single turn. During the occurrence, the aircraft was taxiing via the outermost taxiway C to runway 18C, which would have involved taxiing straight ahead after the first turn before turning onto the take-off runway. Partly due to the infrastructural situation at point C1, an error occurred, as a result of which the Boeing entered taxiway D in a single turn and started its rolling take-off.

Metars:
EHAM 060625Z 22014KT 9999 FEW035 13/08 Q1023 NOSIG=
EHAM 060555Z 21012KT 180V240 9999 FEW033 12/08 Q1023 NOSIG=
EHAM 060525Z 21013KT 180V240 9999 FEW031 12/08 Q1023 NOSIG=
EHAM 060455Z 21012KT 9999 FEW032 12/08 Q1023 NOSIG=
EHAM 060425Z 21011KT 9999 FEW034 12/09 Q1023 NOSIG=
EHAM 060355Z 21012KT 9999 FEW034 13/09 Q1023 NOSIG=
EHAM 060325Z 21011KT 9999 FEW034 SCT044 12/09 Q1023 NOSIG=
EHAM 060255Z 21012KT 9999 -RA FEW034 SCT044 12/08 Q1024 NOSIG=
EHAM 060225Z 21010KT 9999 FEW038 12/08 Q1024 TEMPO 7000 -SHRA SCT020TCU=
EHAM 060155Z 20008KT 9999 FEW045 11/07 Q1024 NOSIG=
EHAM 060125Z 19009KT CAVOK 11/07 Q1024 NOSIG=
Incident Facts

Date of incident
Sep 6, 2019

Classification
Incident

Flight number
HV-1041

Destination
Chania, Greece

Aircraft Registration
PH-HSJ

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

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