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ASN Wikibase Occurrence # 226486
Last updated: 22 September 2021
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Date:03-FEB-2019
Time:19:37 LT
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different
Airbus A320-214 (WL)
Owner/operator:easyJet
Registration: G-EZWY
MSN: 6267
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Amsterdam-Schiphol International Airport (AMS/EHAM) -   Netherlands
Phase: Taxi
Nature:Passenger - Scheduled
Departure airport:London-Gatwick Airport (LGW/EGKK)
Destination airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Investigating agency: Dutch Safety Board
Narrative:
Easyjet flight U28885 (Airbus A320-214 G-EZWY) from London-Gatwick Airport, U.K., landed on runway 18R at 18:30 UTC.
It was then cleared to taxi via taxiway Z northbound to its stand at H1.
Five minutes later SAS flight SK553 (Airbus A320neo SE-DOY) from Copenhagen, Denmark, landed on runway 18C. The ground controller then cleared the aircraft to taxi southbound via taxiway B to taxiway Q for gate C10.
The controller foresaw that the two aircraft might be at the taxiway crossing between A26 and A27 at the same time. He instructed SE-DOY to give way to G-EZWY coming from the right from taxiway Z when turning to taxiway Q, and informed G-EZWY that the other aircraft would wait for them at the end of taxiway Z to pass.
Because many ground movements were taking place in his areas of responsibility, the ground controller gave the instruction in advance, around 1:30 minutes before the two aircraft would meet each other. Both crews responded affirmatively, although the crew of SE-DOY did not mention the place where they had to give way and the direction where the aircraft would come from. The incomplete read-back was not challenged by the ground controller. No other communication took place between the ground controller and both crews.
G-EZWY taxied in the direction of taxiway Q and the captain saw the other aircraft approaching them at an angle of about 45 degrees from the left. Between A26 and A27, both aircraft approached each other and the captain was of the opinion that the other aircraft was not slowing down. As a precaution, he reduced the speed to approximately 10 to 15 knots.
When it became clear that the other aircraft would not stop, the captain made an emergency stop. He saw the wing tip of the right wing of the other aircraft moving past the nose of their aircraft from left to right. He estimated the distance between the wing and the nose at 3 to 4 metres. The first officer did not look outside at that time, as he was studying the map of Schiphol. At the moment of the emergency stop, he looked up and estimated that the right wing of the other aircraft was passing 5 to 10 metres in front of the nose of their aircraft. If the easyJet captain had not braked, both aircraft would have collided.


CONCLUSION
The near miss between the two aircraft during taxi occurred, because the crew of the aircraft that had to give priority did not notice the other aircraft. The factors below played a role:
- The early instruction of the ground controller and the lack of later, additional instructions.
- The crew did not hear or did not recall where to expect the other aircraft, neither did they challenge air traffic control.
- The ground controller did not challenge the crew, when they gave an incomplete read back.
- The darkness and background lighting in combination with the complexity of the location at Amsterdam Airport Schiphol where the incident occurred and other tasks of the flight crew.
- The darkness and the distance between the control tower and both aircraft.
- The limitations of visual observation during darkness in combination with the properties of the ground radar system.

A collision between the two aircraft was prevented, because the pilot of the aircraft that had priority made a successful emergency stop.
This location has not been designated a hotspot, but many taxiways are coming together there. Despite the designation signs, flight crews must be extra alert to distinguish the different intersections. This is especially the case in darkness due to the extensive background lighting and the illumination of multiple taxiways. Also the possibilities for visual monitoring during darkness at distances by the ground controller in combination with the properties of the ground radar, are not optimal. This makes it extra important for controllers to verify that clearances have been properly heard and fully and correctly read back. In addition, it is preferable to repeat stop instructions and regularly to monitor the aircraft, until they have a clear picture of the situation thereby reducing the possibility of errors. For flight crews it is important to verify an instruction in the case it creates ambiguity.

Sources:

https://www.havkom.se/en/investigations/civil-luftfart/kollisionstillbud-pa-amsterdams-internationella-flygplats
https://www.onderzoeksraad.nl/en/page/14067/bijna-botsing-op-de-grond-airbus-a320-airbus-a320-amsterdam-airport

Accident investigation:
cover
  
Investigating agency: Dutch Safety Board
Status: Investigation completed
Duration:
Download report: Final report


Images:

Photo of G-EZWY courtesy AirHistory.net


Manchester - International (EGCC / MAN)
20 August 2021; (c) Shaun Connor


Revision history:

Date/timeContributorUpdates
22-Sep-2021 09:40 harro Updated [Time, Departure airport, Narrative, Accident report]

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