Serious incident Airbus A320-214 VP-BWM, Thursday 25 February 2010
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Date:Thursday 25 February 2010
Time:15:19
Type:Silhouette image of generic A320 model; specific model in this crash may look slightly different    
Airbus A320-214
Owner/operator:Aeroflot
Registration: VP-BWM
MSN: 2233
Year of manufacture:2004
Engine model:CFMI CFM56-5B4/P
Fatalities:Fatalities: 0 / Occupants: 67
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Oslo-Gardermoen Airport (OSL/ENGM) -   Norway
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Oslo-Gardermoen Airport (OSL/ENGM)
Destination airport:Moscow-Sheremetyevo - UUEE
Investigating agency: AIBN
Confidence Rating: Accident investigation report completed and information captured
Narrative:
On Thursday, 25 February at 1519 hours, a serious aircraft incident took place at Oslo Airport Gardermoen (ENGM). Aeroflot flight number AFL212, an Airbus A320 aircraft, made a taxiing mistake and took off from taxiway M instead of runway 01L. There were three pilots, four cabin crew members and sixty passengers onboard. After the incident, the flight continued as planned to Moscow.
The flight crew was not aware that they had taken off from the taxiway until informed of this by the air traffic controller after take-off. Under the prevailing conditions, taxiway M was by chance long enough for the aircraft to take off. The taxiway was at the time of the incident also free of other traffic and obstacles. This prevented a more serious outcome of the incident.
The investigation has uncovered several causes for AFL212's taxiing mistake and take-off from the taxiway. The factors which contributed to the events can be found with the parties involved, i.e. the airline, the control tower and the airport.
The Accident Investigation Board is of the opinion that deficient procedures and insufficient alertness in the cockpit, in combination with insufficient monitoring from the control tower and insufficient signposting in the manoeuvring area, resulted in AFL212 making a taxiing mistake and taking off from taxiway M.
On the basis of the investigation, the Accident Investigation Board has issued a safety recommendation to the airline involved, Aeroflot Russian Airlines. As the airport has already implemented measures to prevent similar incidents, and the Civil Aviation Authority has reopened an earlier safety recommendation from AIBN to Avinor, no further safety recommendations will be issued.

Accident investigation:
cover
  
Investigating agency: AIBN
Report number: 
Status: Investigation completed
Duration:
Download report: Final report

Sources:

https://www.aibn.no/Aviation/Reports/2010-18-eng?pid=SHT-Report-ReportFile&attach=1

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Revision history:

Date/timeContributorUpdates
25-Feb-2010 22:59 whiteshark Added
25-Feb-2010 23:26 RobertMB Updated [Time, Aircraft type, Registration, Cn, Departure airport, Destination airport, Source, Narrative, ]
14-Dec-2010 14:21 harro Updated [Time, Total occupants, Source, Narrative, ]

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