Date: | Monday 22 December 2003 |
Time: | 21:59 |
Type: | Boeing 737-73V |
Owner/operator: | easyJet |
Registration: | G-EZJM |
MSN: | 30248/1118 |
Year of manufacture: | 2002 |
Total airframe hrs: | 5816 hours |
Cycles: | 4246 flights |
Engine model: | CFMI CFM56-7B20 |
Fatalities: | Fatalities: 0 / Occupants: 103 |
Aircraft damage: | Substantial, repaired |
Category: | Accident |
Location: | Amsterdam-Schiphol Airport (AMS) -
Netherlands
|
Phase: | Taxi |
Nature: | Passenger - Scheduled |
Departure airport: | Amsterdam-Schiphol International Airport (AMS/EHAM) |
Destination airport: | London-Gatwick Airport (LGW/EGKK) |
Investigating agency: | Dutch Safety Board |
Confidence Rating: | Accident investigation report completed and information captured |
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.
CAUSES:
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.
Accident investigation:
|
| |
Investigating agency: | Dutch Safety Board |
Report number: | 2003133 |
Status: | Investigation completed |
Duration: | 2 years and 2 months |
Download report: | Final report |
|
Sources:
SKYbrary
History of this aircraft
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Location
Images:
photo (c) Chris Ufkes; Amsterdam-Schiphol International Airport (AMS/EHAM); 23 December 2003
photo (c) Chris Ufkes; Amsterdam-Schiphol International Airport (AMS/EHAM); 23 December 2003
Revision history:
Date/time | Contributor | Updates |