Ryanair B738 at Eindhoven on Oct 11th 2012, took off from wrong intersection and without clearance

Last Update: July 11, 2013 / 22:04:27 GMT/Zulu time

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Incident Facts

Date of incident
Oct 18, 2012

Classification
Incident

Airline
Ryanair

Aircraft Registration
EI-DLD

Aircraft Type
Boeing 737-800

ICAO Type Designator
B738

The Dutch Onderzoeksraad (DSB) released their final report concluding:

The intention of ATC was for the aircraft to backtrack the runway and vacate at intersection Foxtrot.

In contrast to ICAO and European guidelines, permission for backtracking the active runway was given by Ground Control, not by Tower Control.

The Ground Controller of Eindhoven ATC made use of non-standard RT phraseology for taxi and for instructions to vacate the runway.
Limitations for airport use that are written down in the AIP were part of the pilots’ airfield brief for Eindhoven Airport, but were written in small print, and were therefore not very obvious. These limitations include the mandatory takeoff from the beginning of the runway by jet aircraft, and the restriction on 180 degree turns on runways and taxiways. During the investigation the airfield brief for Eindhoven Airport was changed by the company, making the restrictions more obvious.

The crew were aware of work in progress at the airfield, they were not aware of the content of the memo sent by Eindhoven Airport Authorities to all operators with the details about interim taxi procedures.

Because the crew taxied in under tower control after landing, and were given clearance to backtrack the active runway, the crew were subconsciously under the impression they were under tower control.

The use of non standard phraseology by ATC during taxi, led to some ambiguity, and was misinterpreted by the crew. The crew wrongly interpreted given clearances as having takeoff clearance received.
Despite some uncertainty expressed, the crew did not ask for confirmation from ATC.

The taxiway at Eindhoven Airport is situated parallel and at the far side of the runway, coming from the apron. Taxiing traffic should, according to the rules, switch from ground control to tower control and back when crossing the runway. This causes extra workload and radio traffic for the crew and ATC. It is therefore understandable that traffic crossing the active runway when taxiing stay on Ground Control frequency. However, Dutch Safety Board finds that traffic taxiing over the main runway (backtrack), should be under control of Tower Control, according to procedures.

The DSB reported following startup the crew contacted ground control and was instructed to backtrack runway 04 and turn right at (taxiway) Foxtrott with the intention to have the aircraft taxi to the holding point runway 04 via taxiways F,B and G. About halfway down the runway the crew received enroute clearance. When the aircraft reached the intersection with taxiway F, ground control instructed the crew "this one to the right, and for departure contact tower, 131,10, good flight". The crew performed a 180 to the right and departed without contacting tower and without takeoff clearance. There was no danger.

The crew comprised of a captain (58, ATPL, 19,650 hours total, 5,400 hours on type) and a first officer (45, ATPL, 9,500 hours total, 4,000 hours on type), both crew were well rested.

The DSB analysed: "In the first clearance from Eindhoven Ground Control where EI-DLD was instructed to leave the runway at intersection Foxtrot, Eindhoven Ground Control did not use the term ‘vacate’. Instead the phrase ‘intersection Foxtrot to the right’ was used. The intention of the ground controller was that EI-DLD would leave the runway, taxi to ‘Golf’ according to interim taxi procedures, and then enter the runway again at ‘Golf’ and perform the takeoff from there. Later, when EI-DLD was in the vicinity of intersection ‘Foxtrot’, Eindhoven Ground Control states “this one to the right, and for departure contact tower 131.0, good flight, bye bye”. Despite the fact that non-standard phraseology is used, no permission was given for the actual takeoff, and the crew had to switch to tower frequency to obtain takeoff clearance from the Tower Control Officer. In the mind of the crew however, they were already on tower frequency, due to the fact that they were taxiing on an active runway. The fact that Ground Control wished them a good flight strengthened their belief."

The DSB continued: "Data on the CVR reveals that the last clearance from Eindhoven Ground Control to leave the runway and contact tower for departure, was falsely interpreted by the crew as a clearance for takeoff. The notion of getting a ‘good flight bye bye’ greeting from the controller may have give the crew the wrong impression. When the captain challenged the first officer in an attempt to confirm the alleged takeoff clearance, the first officer confirmed the takeoff clearance was given. His exact wording, with some hesitation, were: ‘we are cleared takeoff, yeah, it’s after airborne contact tower in the air, I think that was it’. Despite the words ‘I think that was it’, there was no trigger to ask Eindhoven Ground Control or Eindhoven Tower for confirmation of the alleged clearance given."
Aircraft Registration Data
Registration mark
EI-DLD
Country of Registration
Ireland
Date of Registration
Kq j cfhjgfb Af Subscribe to unlock
Manufacturer
THE BOEING COMPANY
Aircraft Model / Type
BOEING 737-8AS
ICAO Aircraft Type
B738
Year of Manufacture
Njfc Subscribe to unlock
Serial Number
FAjpi Subscribe to unlock
Maximum Take off Mass (MTOM) [kg]
pejb Subscribe to unlock
Engine Count
C Subscribe to unlock
Engine
Lln jmhnbnfkdimbjgfegkhfgh Subscribe to unlock
Main Owner
Kp hnp j bichmj cfllmkdemekqjnAqnmfejlfhdfhhfpebngcljgAfjcndlgbbh Subscribe to unlock
Incident Facts

Date of incident
Oct 18, 2012

Classification
Incident

Airline
Ryanair

Aircraft Registration
EI-DLD

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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