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ASN Wikibase Occurrence # 237019
Last updated: 1 July 2020
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Date:27-JUL-2018
Time:16:57 LT
Type:Silhouette image of generic E190 model; specific model in this crash may look slightly different
Embraer ERJ-190STD (ERJ-190-100)
Owner/operator:KLM Cityhopper
Registration: PH-EXV
C/n / msn: 19000750
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Amsterdam-Schiphol Airport (AMS) -   Netherlands
Phase: Take off
Nature:International Scheduled Passenger
Departure airport:Amsterdam-Schiphol International Airport (AMS/EHAM)
Destination airport:Edinburgh-Turnhouse Airport (EDI/EGPH)
Narrative:
KLM flight KL1289, an Embraer ERJ-190 registered PH-EXV, was involved in a serious runway incursion incident on takeoff from Amsterdam-Schiphol Airport, the Netherlands.
KL1289 had lined up on runway 18C and was given take-off clearance while KLM flight KL1783, a Boeing 737-800 registered PH-BXI, had also been given clearance to line up for an intersection take-off on the same runway, via high speed exit W4. After hearing the take-off clearance issued to the ERJ-190, the crew of the B737 stopped past the hold short line and reported via the radio that they were located 'on the runway'. The runway controller then also issued a take-off clearance to the B737. The crew of the ERJ-190 had started the take-off roll when they saw that the B737 was clear of the runway, but broke off their take-off when they heard that the B737 had also been given clearance to take off. Shortly afterwards, the Runway Incursion Alerting System Schiphol (RIASS) sounded a warning in the air traffic control tower and the runway controller withdrew the clearance to the ERJ-190. The ERJ-190 passed the B737 at a speed of approximately 85 knots and a separation of approximately 19 metres.
The take-off clearance to the ERJ-190 resulted in a potential (collision) hazardous situation because both aircraft due to their different start positions were simultaneously given authorized access to the same section of the runway. In this situation, the RIASS was revealed to not be an effective safety barrier; the system in fact only generated an alarm after the ERJ-190 had already started to decelerate, on its own initiative. The fact that both crews involved were communicating on the same radio frequency, and were able to see each other were effective safety barriers.

Use of intersection starts
Previous investigations have shown that the use of intersection starts can increase risks. These risks are further increased by using a (non-rightangled) high speed exit as an access to the runway, a situation which is advised against, internationally. As a consequence, once they have passed the hold short line approaching the runway, the aircraft crew experience difficulty in seeing other approaching traffic taking off from the start of the runway.

Workload runway controller
At the moment of the occurrence, the runway controller was supervising three runways: runways 18C and 09 which were in use for aircraft taking off, and runway 22 in use for aircraft both taking off and landing. Runway 18C is less often used for departing traffic, features non-standard exit and entrance numbers and also employs non-standard names for standard departure routes. The ISMS report2 concluded that the use of runway 18C as a runway for departing traffic, in combination with simultaneous use of other runways, can be referred to as an operation with increased complexity. The runway controller also increased his own workload by allowing the ground controller to offer the B737 an intersection start, rather than instructing the B737 to line up behind the ERJ-190.
Earlier in his shift, the runway controller had been involved in two other occurrences. Approximately 23 minutes before the occurrence, a light aircraft crossing the airport in the direction of the coast failed to follow his instructions. As a consequence, for some time, there was a risk to traffic taking off from runway 18C. The runway controller said that he had been shocked by this occurrence but after consulting with his supervisor stated he was able to continue his shift. Approximately 4 minutes before the occurrence, the runway controller also authorized an aircraft to taxi onto runway 18C via intersection W4, despite the fact that 15 seconds previously, he had issued clearance to another aircraft to take off on the same runway. Immediately after the aircraft crew read back the clearance to taxi, the runway controller withdrew the takeoff clearance.
Air Traffic Control the Netherlands has no written rules on whether or not to permit the continuation of work following incidents. The possibility cannot be excluded that these events did have some effect on the mental resilience of the runway controller at the moment of the investigated incident.

Conclusion
In the past, the Dutch Safety Board has concluded that safety risks can arise at Schiphol as a result of choices that result in complex handling of air traffic.
An example of such a choice is the offering of intersection takeoffs at Schiphol, as in this case. The Safety Board has expressed appreciation for the extensive report drawn up by the sector within the ISMS system into this occurrence and broadly supports the conclusions of that report. In line with the conclusions of the ISMS report, the Safety Board believes that attention for previous incidents involving air traffic controllers during their shift and continuing work following such occurrences is appropriate. Moreover, the Safety Board calls for attention for the relationship between this occurrence and the issuing in practice of intersection takeoffs to air traffic at Schiphol.

Sources:

https://www.onderzoeksraad.nl/en/media/inline/2020/6/15/quarterly_aviation_report_q1_2020.pdf


Images:

Photo of PH-EXV courtesy AirHistory.net


Amsterdam - Schiphol (EHAM / AMS)
19 November 2019; (c) Gerard Helmer


Graphic: OVV

Revision history:

Date/timeContributorUpdates
16-Jun-2020 14:18 harro Added

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