ASN Wikibase Occurrence # 219763
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| Date: | Sunday 10 June 2018 |
| Time: | |
| Type: |  Boeing 737-8K2 (WL) |
| Owner/operator: | KLM Royal Dutch Airlines |
| Registration: | PH-BXG |
| MSN: | 30357/605 |
| Year of manufacture: | 2000 |
| Fatalities: | Fatalities: 0 / Occupants: 189 |
| 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) |
| München-Franz Josef Strauss Airport (MUC/EDDM) | |
| Investigating agency: | Dutch Safety Board |
| Confidence Rating: |  Accident investigation report completed and information captured |
The pilots of the Boeing 737 flight KL1797 calculated their take-off speeds and the necessary engine power on the basis of the assumption that they would take off from runway 09 at Intersection N5. The take-off position was subsequently changed to Intersection N4, reducing the available take-off distance, but the data for the performance calculations were not adjusted. The Boeing 737 then took off from runway 09 at Intersection N4.
The aircraft was rotated at the calculated rotation speed and left the ground only just before the end of the runway.
Direct cause
The serious incident was caused because the aircraft accelerated too slowly to the incorrect takeoff speeds in relation to the available runway length. This was the result of using erroneous takeoff data, based on the wrong intersection.
Operational factors
The crew had planned an N5 intersection takeoff. They were not able to comply with Air Traffic Control’s request for an N4 intersection takeoff due to performance requirements.
Having heard new wind information, the crew reconsidered and determined an N4 intersection was possible which would reduce the delay. New takeoff performance calculations were completed during taxiing out just before lining up the aircraft for takeoff.
Because the initial intersection had not been changed into the actual intersection in the data necessary for the performance calculation, erroneous takeoff data were generated.
The changed data and the output of the performance calculation were neither checked nor cross checked, although this is included in the procedures. Time pressure and the division of tasks of the three-man cockpit had influence on the occurrence of the incident.
Operator’s procedures do not require the aircraft to be stopped when new takeoff performance calculations have to be made during taxiing out. Some other operators do have included this requirement in their procedures.
The erroneous takeoff performance data resulted in an effective runway length that was 1,034 metres less than the length used for the calculation. In case of an aborted takeoff at V1 the aircraft would have been unable to stop on the runway. In the event of an engine failure after V1 there would have been insufficient runway length remaining to
accelerate the aircraft to the minimum V2 speeds. This all resulted in reduced safety margins during the takeoff.
Despite some training, the crew did not recognize the need to add more thrust when the end of the runway approached and therefore did not add thrust. Not adding thrust in these situations has been identified in other earlier investigations.
Organizational factors
The process of independent performance calculation and crosschecking should be independent of crew composition as well as the timing of the calculation.
Operational pressure caused the crew to choose for an unplanned, last minute change in runway intersection. As other cases of this operator show, it was not an isolated event, nor a new phenomenon. Although the existence of operational pressure was already signalled in 2017, it still appears to exist.
The serious incident was not reported by the crew to the operator nor were the flight recorders secured.
Although mentioned in the internal report of the operator, no actions were taken to raise awareness of the importance of reporting and securing flight recorders following a serious incident.
Two other, similar, serious incidents were not reported to the Air Safety Investigation Authorities by the operator. This excluded the possibility of an independent safety investigation
Accident investigation:
 |
|
Sources:
https://www.onderzoeksraad.nl/en/media/attachment/2018/12/20/quarterly_report_aviation_3rd_quarter_2018.pdf
https://avherald.com/h?article=4f912026
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 20-Dec-2018 15:03 | harro | Added |
| 01-Jan-2022 10:34 | harro | Updated [Aircraft type, Registration, Cn, Operator, Nature, Source] |
| 19-May-2022 08:34 | harro | Updated [Total occupants, Destination airport, Narrative, Accident report] |
| 08-Jun-2022 23:43 | Ron Averes | Updated [Operator] |
| 14-Jun-2022 03:01 | Ron Averes | Updated [Location] |
| 15-Jul-2022 17:33 | Edwin | Updated [Source, Narrative] |
| 09-Oct-2022 18:34 | harro | Updated [[Source, Narrative]] |
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