On 6 September 2019, the Boeing 737-800 was scheduled for a passenger flight from Amsterdam Airport Schiphol to Chania, Greece. It taxied in the dark at Amsterdam Airport Schiphol in northerly direction on Taxiway C to Runway 18C when it received takeoff clearance for Runway 18C. The flight crew then turned left twice, lined up on Taxiway D in a southerly direction and commenced the takeoff. Air traffic control noticed that the aeroplane started to accelerate on a taxiway and instructed the crew to stop immediately. At the moment the Boeing 737 initiated the takeoff, no other aeroplanes or vehicles were present on Taxiway D. The crew rejected the takeoff and taxied back to the beginning of Runway 18C, after which the aeroplane took off uneventfully. The flight crew continued the flight to Chania and contact with the company about the occurrence was established after landing.

Investigation publication

Consequences of continuing flight after rejected takeoff

The flight crew’s decision to continue the flight after the occurrence had several consequences regarding communication and the investigation process. First, because the decision was made to depart soon after the occurrence, no contact was made with the company for consultation about the occurrence before departure; such a dialogue may increase understanding of the safety implications of the event and may provide sound options for follow-up actions. After a serious incident, the Dutch Safety Board expects the captain to consult the company for further actions, even though s/he has the final responsibility to ensure the safe execution of the flight.

Furthermore, the decision to continue the flight led to a situation in which it was not possible to secure the cockpit voice recorder data. Upon arrival at the destination airport, the recording of the cockpit voice recorder was overwritten and therefore the cockpit voice recorder data covering the event was not available for the investigation. This investigation revealed that the airline’s procedures were not effective to have flight crews timely notify the airline about the occurrence and preserve the recordings of the cockpit voice recorder.

Cockpit voice recorder data is crucial to support investigations into the decision making processes of flight crews and to reconstruct the sequence of events. In the present case, to understand why the flight crew believed they were entering the runway. Further, to understand how the decision was made to continue the flight without reporting the serious incident to the company first. Not having the cockpit voice recorder data available, hampered the Dutch Safety Board in its investigation and restricted learning from this occurrence for all parties involved.

 

 

Recommendations

Transavia

Develop new procedures, or clarify existing procedures, that guide flight crews to consult with their airline at the earliest convenient moment, about abnormal situations that have had or may have significant flight safety implications, such as an aborted takeoff from a taxiway. Communicate to flight crews what range of occurrences are meant by these situations.

All Dutch airlines

Replace or upgrade existing cockpit voice recorders currently in use to accommodate for a storage capacity of at least 25 hours on aeroplanes with a certified maximum takeoff mass of more than 27,000 kg and with a certificate of airworthiness issued after 31 December 2001, before 2028.

The International Air Transport Association

Encourage the members of IATA to replace or upgrade their existing cockpit voice recorders currently in use to accommodate for a storage capacity of at least 25 hours on aeroplanes with a certified maximum takeoff mass of more than 27,000 kg and with a certificate of airworthiness issued after 31 December 2001.

The European Union Aviation Safety Agency

Mandate that EU registered commercial air transport aeroplanes, with a certified maximum certificated takeoff mass of more than 27,000 kg, and with a certificate of airworthiness issued after 31 December 2001, to be equipped with a cockpit voice recorder capable of retaining recorded data for at least 25 hours; implement this requirement as of 1 January 2028.

The Integral Safety Management System Schiphol

Foster a work environment at Amsterdam Airport Schiphol that encourages the stakeholders of the Integral Safety Management System to challenge each other about decisions that have had or may have significant safety implications.

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Investigation data

Theme Aviation

Investigation start date

Report publication date

Type Shortened Investigation

Status Completed

Phase Publication