ASN Wikibase Occurrence # 243254
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Date: | Saturday 28 May 2005 |
Time: | 23:50 |
Type: | McDonnell Douglas MD-11 |
Owner/operator: | KLM Royal Dutch Airlines |
Registration: | PH-KCK |
MSN: | 48564/612 |
Fatalities: | Fatalities: 0 / Occupants: |
Aircraft damage: | None |
Category: | Serious incident |
Location: | Amsterdam-Schiphol International Airport (AMS/EHAM) -
Netherlands
|
Phase: | Take off |
Nature: | Passenger - Scheduled |
Departure airport: | Amsterdam-Schiphol International Airport (AMS/EHAM) |
Destination airport: | Lima-Jorge Chávez International Airport (LIM/SPIM) |
Investigating agency: | Dutch Safety Board |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:In consultation with air traffic control, the driver of a bird watch vehicle had stopped at the end of runway 24 to remove the remains of an animal from the runway. At that time, an MD-11 had begun its run-up for takeoff from the beginning of runway 24, after which this aircraft flew over the vehicle.
CONCLUSION
Based on Tripod Beta, it is concluded that undesirable events occur when barriers or safety measures fail (i.e. barrier failure) or are absent (i.e. barrier missing). The descriptions of the situations or failing active barriers have been identified and are listed below:
- The verification process of the vehicle's position (and control by the controller) and the use of the flashing runway signal by the controller did not work. Reduced ability to easily see the vehicle may have been an unfavorable circumstance in the mix of lit runway and taxiway lights in the dark. This may also have contributed to the controller's assumption that the vehicle had left the runway. The fact that the bird watcher informed the air traffic controller of his intention to leave the vehicle and clean up the remains of birds may have been an additional trigger for the air traffic controller.
- Visual monitoring by the flight crew did not work. The surrounding lighting may have been an unfavorable circumstance to see a vehicle at a distance of 3,500 meters in the dark.
- Intervention by a supervisor failed. In late night operations, all traffic movements are the responsibility of one controller and no additional supervisor was present.
Accident investigation:
|
| |
Investigating agency: | Dutch Safety Board |
Report number: | |
Status: | Investigation completed |
Duration: | |
Download report: | Final report |
|
Sources:
Dutch Safety Board
Revision history:
Date/time | Contributor | Updates |
25-Sep-2020 15:40 |
ASN Update Bot |
Added |
08-Jun-2022 23:33 |
Ron Averes |
Updated [Operator] |
22-Jun-2022 03:26 |
Ron Averes |
Updated [Location] |
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