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

Last Update: May 25, 2022 / 16:48:59 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

Airport ICAO Code
EHAM

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.

On May 25th 2022 the Dutch Onderzoeksraad (Dutch Safety Board DSB) released their final report concluding the probable causes of the serious incident were:

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.

In addition to the above main conclusion, the Dutch Safety Board draws the following conclusions.

A takeoff from a taxiway is a hazardous situation, since a taxiway is not intended for takeoffs. In this case, a safety barrier worked as the flight crew was instructed by the runway controller to stop. Furthermore at the moment the Boeing 737-800 initiated the takeoff from Taxiway D, no other aeroplanes or vehicles were present on that taxiway, so that the consequences of the serious incident were limited in time.

After an abnormal situation, that affects safety, the Dutch Safety Board expects from flight crew members to consult the company for further actions. The flight crew’s decision to immediately continue the flight resulted in a missed opportunity to confer the situation with the company. Also, this decision led to the circumstance that it was not possible to secure the cockpit voice recorder data. Due to this, the Dutch Safety Board lacked information and because of this all parties involved were not able to learn optimally from this occurrence.

The airline’s procedures were not effective to have flight crews timely notify the airline about the occurrence and preserve the cockpit voice recorder recordings. Cockpit voice recorder data is crucial to support the investigation into the decision making process of the flight crew. In this case, to understand why the flight crew believed they were entering the runway and, thereafter, how the decision was made to depart without reporting the serious incident to the company first.

The broken centre line marking from C1 towards the beginning of Runway 18C did not comply with CS ADR-DSN.L.555, but it was included in the Deviation Acceptance and Action Document and therefore accepted by the Human Environment and Transport Inspectorate.

Due to restrictions of the logging system, it cannot be confirmed that a part of the taxiway centre line lights was not illuminated.

The actions taken by Air Traffic Control the Netherlands and Amsterdam Airport Schiphol in response to the recommendations of the Dutch Safety Board regarding the investigation into the takeoff from a taxiway in 2010 did not prevent reoccurrence.

The DSB analysed that taxi route and taxi instructions were standard. The DSB analysed:

The captain had operated from Schiphol since 2000 and the first officer for about three years. They were both familiar with the infrastructure of the airport. Nevertheless, the assigned taxi route was unusual for the crew. The first officer stated that he had never taken off from Runway 18C before. The captain had previously taken off a few times from this runway.

Both pilots stated that they had not been distracted while taxiing. There was a relaxed atmosphere in the cockpit; visibility was good, even though it was dark. Both pilots stated they felt no reason to be extra alert when taxiing.

Although the crew had performed a takeoff performance calculation for W3, they did not ask to use this intersection to line up on the runway. The fact that the captain asked if they could depart via W2, while the aeroplane was near C2, suggests that he was unaware of their precise location at the time. This would have required the aeroplane to turn left at C2, the position where it already was. The first officer stated that he knew they were on Taxiway C but was unaware that they were on an outer parallel taxi track. While taxiing on Taxiway C, the crew was not fully aware of their exact position.

When pilots taxi and take off during daylight conditions, they normally have a wide range of visual cues by which they can navigate and verify their location. At night however, the amount of visual information available is markedly reduced. Pilots rely more on the taxiway and runway lighting patterns and what can be seen in the field of the aeroplane’s taxi and landing lights.45 So, at times of darkness and low visibility, flight crew members must take additional care to ensure accuracy in navigation on the ground.

Both pilots experienced the taxiway lighting near C1 as confusing. At the junction between Taxiway C and intersection C1, the green centre line lights continue north. The green lights the crew had been following on taxiways B and C did not continue towards the holding point of Runway 18C. In contrast, green centre line lights do continue south from the holding point (W1) towards taxiway D.

This might have given the pilots the impression that W1 was a western entry to Runway 18C. However, there is no such entry on the west side of the runway threshold. This impression was reinforced by the fact that both the centre line and edge lighting of Runway 18C are not clearly visible from the side. The runway edge lights of Runway 18C that were visible from C1, form visual patterns with the lights in the background and therefore these edge lights cannot be clearly distinguished. The stop bar at W1 was not lit at the moment the aeroplane taxied at C1. The pilots described the way to the runway, seen from C1, as a ‘black hole’ due to the lack of green centre line lights. The captain stated that the runway identifier signs were not lit.

When approaching C1, the flight crew, according to procedure, started their preparations and checks for the takeoff. Since takeoff clearance had been received when the aeroplane was taxiing near C2, around C1 the crew was not solely focusing on taxiing, but was also preparing for takeoff. The pilots selected the departure chart on their Electronic Flight Bags. The takeoff checklist requires the crew to verify that they are about to enter the correct runway and have clearance to do so. In the perception of the crew, this was the case. They noticed signs indicating Runway 18C, which to them was confirmation that they were entering the runway they were cleared to.

The airline’s company procedure was to perform a rolling takeoff where possible.46 To achieve this, takeoff preparations need to be completed when entering the runway, as this moment is immediately followed by the takeoff roll. The airline policy for a rolling takeoff requires the crew to perform multiple tasks (landing lights on, engine checks, switches etc.) simultaneously, thereby shifting their attention between inside and outside the cockpit during the line-up phase, instead of solely focusing on taxiing. This may have resulted in the crew missing visual clues in the ‘black hole’ of C1 that they were not entering a runway (like signs and markings designating the actual runway entry) and paying less attention to the verification of the correct runway.

Another point that the pilots had noticed, concerns the absence of a straight continuous yellow centre line from C1 towards the holding point of Runway 18C. When turning from Taxiway C to C1 there is an interruption of the yellow centre line marking. In contrast, the yellow line continues in a U-turn towards Taxiway D. This yellow taxi line, uninterrupted towards Taxiway D and interrupted towards Runway 18C (see Figure 5), became clearly visible at C1 when the crew switched on the landing lights.47 So following the only taxiway guidance that was clearly visible to them, i.e. the yellow line from C1, the crew were led onto Taxiway D. This was a significant contributing factor in initiating the takeoff from the taxiway. Noted, a taxiway has green centre line lights and a runway has white centre line lights. The reconstruction of the occurrence showed that the bright beam of an aeroplane’s taxi or landing lights can make it difficult to distinguish these colours under dark circumstances. The crew stated that they did not notice any difference in colours of the lighting.

The width of C1 is approximately 40 meters, which resembles the width of a runway (45 meters), while a taxiway normally is 23 meters wide. This might also have been a cue of entering the beginning of a runway.
The design of taxiway centre line markings at Schiphol was focused on preventing runway incursions during low visibility circumstances. The lining on taxiways at some points of the aerodrome therefore lead to another taxiway instead of a runway.

After the aeroplane was lined up on Taxiway D and the landing lights were turned on, the first officer applied full thrust, selected the auto throttle and made a rolling takeoff. The ‘runway’ was clear from other traffic. Everything looked normal for both pilots. The captain stated he saw W2 to the right and a waiting aeroplane (at W5) during the takeoff roll. According to him, the situation was correct until the runway controller instructed them to stop immediately and hold position.

Environmental cues enhanced the perception of the crew that they were lined up on Runway 18C, instead of on Taxiway D. It likely attributed to a confirmation bias. 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.

No changing environmental conditions took place in the period from 05.22 hours that might have contributed to the occurrence. Seven aeroplanes took off from Runway 18C from that time until the serious incident occurred, all using Taxiway C, without any problems. METAR data indicates that the visibility was more than 10 kilometres and did not change in this time period.

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=
Aircraft Registration Data
Registration mark
PH-HSJ
Country of Registration
Netherlands
Date of Registration
Gpelkilhhckg Subscribe to unlock
Airworthyness Category
Legal Basis
Manufacturer
The Boeing Company
Aircraft Model / Type
737-800
ICAO Aircraft Type
B738
Year of Manufacture
Serial Number
Aircraft Address / Mode S Code (HEX)
Maximum Take off Mass (MTOM) [kg]
Engine Count
Engine
MnlA fjqlngcnplmnkq ggffgnminmdcdAi Subscribe to unlock
Engine Type
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

Airport ICAO Code
EHAM

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