Narrative:Flight EZY5112 concerned a regular service from Amsterdam Airport Schiphol (AMS) to London Gatwick (LGW). At 21:39 hours the crew received the clearance to start the engines of the aircraft. The ATIS report contained among other things the warning: "All taxiways and aprons slippery spots". At 21:45 hours the crew received the instruction to taxi via taxiways A6 and B-North to runway 36L. After about ten minutes the crew of EZY5112 reported to ATC 'Ground West' with the message that they were located at the place of the reporting point VM. The air traffic controller answered: "Good evening EZY5112 continue taxiway V and V3 is available if you like". The crew replied: "V for V3 is fine, thanks, EZY5112". However the crew chose not to taxi via taxiway V but to taxi via the taxiway situated next to it, taxiway VS to the intersection V3. Taxiway VS leads via the two holding points P6 and P7, where ice can be removed from aircraft, directly to V3. When making the turn to P6 the aircraft no longer responded on the nose wheel steering and taxied straight on with the aircraft skidding to the side of the apron. At the end of the holding point P6 the aircraft collided with its left wing against one of the lampposts. The crew switched off the engines a few seconds before the collision took place. After the collision the aircraft swerved and the aircraft came to a standstill after about 20 meters. The nose wheel stood in the grass; the main landing gear had come to a standstill on the edge of the apron against the cover plates of electricity wells. The aircraft and the lamppost were seriously damaged.
|Date:||Monday 22 December 2003|
|C/n / msn:|| 30248/1118|
|First flight:|| 2002-04-09 (1 year 9 months)|
|Total airframe hrs:||5816|
|Engines:|| 2 CFMI CFM56-7B20|
|Crew:||Fatalities: 0 / Occupants: 5|
|Passengers:||Fatalities: 0 / Occupants: 98|
|Total:||Fatalities: 0 / Occupants: 103 |
|Airplane damage:|| Substantial|
|Airplane fate:|| Repaired|
|Location:||Amsterdam-Schiphol Airport (AMS) ( Netherlands)
|Phase:|| Taxi (TXI)|
|Nature:||International Scheduled Passenger|
|Departure airport:||Amsterdam-Schiphol International Airport (AMS/EHAM), Netherlands|
|Destination airport:||London-Gatwick Airport (LGW/EGKK), United Kingdom|
The accident was caused because the pilot, because of slipperiness, was unable to control the aircraft during the taxiing, causing a collision between the left wing of the aircraft and a lamppost.
The causal factors were:
- The actions against slipperiness were not optimal.
- The slipperiness situation at VS, P6 and P7 was not in accordance with the information the crew had.
- The circumstances and the habit to leave the choice up to the aircraft crews did not exclude the use of taxiway VS.
- The AOM and the air traffic controllers were insufficiently conscious of the slipperiness situation and the potential danger it entailed.
- The taxi command given by air traffic control was not followed up by the pilot flying.
- The crew did not make sufficient use of the skills crew resource management offers.
The underlying factors were:
- The 'regeling Sneeuw en Gladheidsbestrijding 2003-2004' is not sufficiently guaranteed in the safety management system of Amsterdam Airport-Schiphol.
- Neither the business manual nor the 'regeling Sneeuw- en Gladheidsbestrijding 2003 2004' provide an adequate method for measuring the braking Action/friction and for fighting slipperiness on taxiways and aprons.
- Easyjet's quality system was not able to acknowledge the risk of such an accident.
- The chain of collection of information and the actions and provision of information to third parties stemming from that holds great risks of human failure.
Official accident investigation report
Follow-up / safety actions
The following recommendations were issued:
1. All parties at Amsterdam Airport Schiphol, who are responsible for the system of provision of information to airmen, should give a more adequate substance to their (joint) responsibility as regards diminishing the risks involved in the reporting of information. In this respect, the use of the non-ICAO term 'slippery spots' needs to be assessed.
2. It is recommended to Amsterdam Airport Schiphol to assess the functioning of the business manual and the underlying regulations, such as the 'snow and iciness control measures 2003-2004' and remedies the flaws therein.
3. It is recommended to Air Traffic Control the Netherlands to give more adequate substance to the task of air traffic controllers in special circumstances, such as in the event of slipperiness.
4. It is recommended to Easyjet to include the flaws pertaining to the crew resource management in its training courses and to take appropriate action to prevent this in future.
5. It is recommended to the Minister of Transport, Public Works and Water Management to encourage further rules to be set, both at national and international level, as regards the operational state of taxiways and aprons at airports.
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from Amsterdam-Schiphol International Airport to London-Gatwick Airport as the crow flies is 362 km (226 miles).