KLM Cityhopper E190 at Amsterdam on Feb 28th 2016, runway incursion by tow truck, balked landing

Last Update: December 29, 2018 / 21:17:30 GMT/Zulu time

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Incident Facts

Date of incident
Feb 28, 2016

Classification
Incident

Cause
Runway incursion

Airline
KLM Cityhopper

Flight number
KL-1884

Departure
Nuremberg, Germany

Destination
Amsterdam, Netherlands

Aircraft Registration
PH-EXF

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

A KLM Cityhopper Embraer ERJ-190, registration PH-EXF performing flight KL-1884 from Nuremberg (Germany) to Amsterdam (Netherlands), was on final approach to Amsterdam's runway 36R cleared to land on the runway when tower instructed the aircraft to go around. The aircraft, just about to touch down, rejected landing and went around. Tower subsequently apologized for the late go-around due to a tow truck having been cleared to cross the runway unknown to tower. The Embraer positioned for another approach to runway 36R and landed safely 11 minutes later.

On Mar 2nd 2016 the Dutch Onderzoeksraad Voor Veiligheid/Safety Board (DSB) announced that an investigation has been opened into the occurrence. A tow truck towing an aircraft was crossing the active runway and had been cleared to do so, while an aircraft was on final approach cleared to land. Tower instructed the landing aircraft to go around.

On Oct 17th 2018 the DSB released their final short summary report without a formal conclusion (editorial note: the link was updated on Dec 29th 2018 due to reorganisation of the DSB website, the PDF remained unchanged). The DSB however wrote:

The crossing of active runway 18L-36R via intersection E3 by a tug combination

Towing crews are not informed of runway use prior to a towing movement. This means they cannot anticipate when they should contact LVNL and when contact with Apron Control is sufficient. Not having been transferred and having received clearance from Apron Control gave the tug driver the impression that the runway was not active.

Because the tug combination had to make a turn just before crossing the runway and drove onto the runway at a ‘coasting’ speed, there was little time to properly assess the situation, carefully check for other (aircraft) traffic and pay attention to the warning signals (runway guard lights and stop bar). This reduced the safety margins.

The stop bar may have been illuminated at an intensity of 10% (night setting). When combined with the clear weather and sunshine, this may have created the illusion that the stop bar was not illuminated.

In a training situation, the tug crew was unclear about the distribution of roles and responsibilities. The KLM Ground Services documentation does not set this out either.

The avoidance of a collision between the approaching aircraft and the tug combination

The situational awareness of the runway controller, assistant 2 and the aircraft crew was what prevented a collision. The Runway Incursion Alerting System Schiphol worked, and a warning signal was issued in good time.

As a result of separate locations in the air traffic control towers and the use of different frequencies, towing processes for which LVNL is responsible cannot be followed by the air traffic controllers. Nor were they able to intervene to prevent the runway incursion in this incident.

Just Culture

The AOM’s decision to hold the tug driver solely responsible for the runway incursion immediately after the incident, to classify the incident as a contravention and to revoke his Schiphol pass was not even-handed.

The decision to hold the tug driver solely responsible was not in line with the term ‘just culture’ and could have effects on future safety investigations and safety management by AAS. Reporting unsafe situations and being able to speak freely about one’s own actions and errors during an incident is one of the most important conditions that a ‘just culture’ must satisfy.

The DSB reported that the tug driver was in contact with apron control, apron control erroneously cleared the tug to cross runway 36R, although the runway was active and was under sole jurisdiction by tower (LVNL), an aircraft was on short final.

The DSB described the following events:

The tug driver and his instructor, who was sitting in the aircraft, did not notice the illuminated warning lights, orange flashing runway guard lights and red stop bar lights, at the intersection. Neither of them realised that the runway was currently being used by landing aircraft. The tug combination drove onto the landing runway to cross it. Air traffic control ordered an aircraft that was approaching for a landing on the runway to abort its approach and to initiate a go-around.

After the incident, the instructor and the tug driver had a discussion with the Airside Operations Manager (AOM). The AOM considered that the tug driver had caused the runway incursion and therefore temporarily revoked his Schiphol Pass.

The DSB analysed:

The apron controller was able to grant an incorrect clearance due to a combination of factors. Because he was completing administrative work, he was not focussed on his primary task of supervising the towing traffic. In addition, the runway status (active/not active) changes regularly, and the failure of the apron controller to check the status of the runways on the runway panel contributed to this incorrect clearance.

Because the status of the runways is shown on a separate runway panel and is not integrated into the primary radar screen, the apron controller was unable to see at a glance that the runway for which he had granted clearance was an active runway. The runway panel is located diagonally behind the radar screen, and not within the apron controller’s direct line of sight.
Aircraft Registration Data
Registration mark
PH-EXF
Country of Registration
Netherlands
Date of Registration
Cmddffmqmkjbkdmgn Subscribe to unlock
Airworthyness Category
Pjigdfj Subscribe to unlock
Legal Basis
Lbig Subscribe to unlock
Manufacturer
EMBRAER S/A - Empresa Brasileira de Aeronautica
Aircraft Model / Type
ERJ 190-100 STD
ICAO Aircraft Type
E190
Year of Manufacture
EAfg Subscribe to unlock
Serial Number
Qjln hpA Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
MnqAjk Subscribe to unlock
Maximum Take off Mass (MTOM) [kg]
BqAqk Subscribe to unlock
Engine Count
G Subscribe to unlock
Engine
JAjgpkb fkglicedmqdncAkq njpeefmhbmjmqdpjen p Subscribe to unlock
Engine Type
AnhhklAql Subscribe to unlock
Incident Facts

Date of incident
Feb 28, 2016

Classification
Incident

Cause
Runway incursion

Airline
KLM Cityhopper

Flight number
KL-1884

Departure
Nuremberg, Germany

Destination
Amsterdam, Netherlands

Aircraft Registration
PH-EXF

Aircraft Type
Embraer ERJ-190

ICAO Type Designator
E190

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