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ASN Wikibase Occurrence # 72581
Last updated: 10 August 2020
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Date:10-FEB-2010
Time:20:36
Type:Silhouette image of generic B733 model; specific model in this crash may look slightly different
Boeing 737-306
Owner/operator:KLM
Registration: PH-BDP
C/n / msn: 24404 / 1681
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:Frederick Chopin International (WAW/EPWA )
Investigating agency: Dutch Safety Board
Narrative:
On February 10, 2010 KLM flight KL1369 was cleared for takeoff on runway 36C at Amsterdam-Schiphol International Airport (AMS/EHAM). Instead, the crew took off from the parallel taxiway B.

At the time of the incident, about 20:30, it was dark and it was snowing. The airplane had just been de-iced and was instructed to taxy down taxiway Alpha towards runway 36C. This meant that the crew had to use taxiway Alpha in the opposite direction, contrary to published procedures. Air traffic control is allowed to use this taxiway in the opposite direction if deemed necessary. This is sometimes the case when an aircraft leaves the Juliet platform after de-icing, just like KL1369.

The crew were very familiar with the airport and did not use a taxiway map although they were supposed one. The air traffic controller then offered the flight to enter the runway through intersection W-8. At that time a preceding Boeing 747 had taxied the wrong way and was blocking the taxiway. The KLM flight crew accepted the offer because this also meant an opportunity for an expedited takeoff.

At that point the crew started losing positional awareness. The workload increased because the an entry in the FMS now had to be changed because the crew had anticipated using intersection W-9. Meanwhile the captain was distracted by radio communications between the air traffic controller and the pilot of the Boeing 747. The crew had to cross parallel taxiway Bravo to enter runway 36C. However, they turned directly onto Bravo and initiated their takeoff roll. The crew did not notice their error and continued their takeoff, passing within about 300 metres of a Boeing 737-400.

It appears that the taxiway leading from taxiway Bravo to runway 36C was covered with a thin layer of snow, possibly obscuring the taxiway lights. Also, visibility of the lights of runway 36C was degraded because the lighting pattern matched that of the lights along the highway parallel to the runway.

Sources:

https://www.onderzoeksraad.nl:443/index.php/onderzoeken/opgestegen-vanaf-taxibaan-2010011/

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


Images:

Photo of PH-BDP courtesy AirHistory.net


Helsinki - Vantaa (EFHK / HEL)
29 July 2008; (c) Juhani Sipilš

Revision history:

Date/timeContributorUpdates
11-Feb-2010 13:04 harro Added
12-Feb-2010 01:47 harro Updated [Narrative]
12-Feb-2010 05:37 jpiddink Updated [Time, Registration, Cn, Destination airport, Source, Narrative]
12-Feb-2010 14:36 RobertMB Updated [Time, Aircraft type, Destination airport, Source, Narrative]
18-Jul-2010 10:42 harro Updated [Source]
21-Dec-2011 13:41 harro Updated [Total fatalities, Source, Narrative]

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