ASN Wikibase Occurrence # 243253
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| Date: | Friday 23 September 2005 |
| Time: | 11:24 |
| Type: |  McDonnell Douglas MD-11 |
| Owner/operator: | KLM Royal Dutch Airlines |
| Registration: | PH-KCG |
| MSN: | 48561/585 |
| Year of manufacture: | 1995 |
| 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) |
| Bonaire-Flamingo International Airport (BON/TNCB) | |
| Investigating agency: | Dutch Safety Board |
| Confidence Rating: |  Accident investigation report completed and information captured |
An MD-11 was given permission to depart from runway 24. During the takeoff run, a bird watch vehicle received permission to cross Runway 24. Both the MD-11 and the vehicle continued on their way without incident.
CONCLUSION
Based on Tripod Beta it is concluded that unwanted events occur when barriers or safety measures fail (i.e., failed barrier) or are not in place (i.e., missing barrier). The descriptions of the situations or failed active barriers have been identified and listed below:
• The option by the driver of the vehicle to follow a route without runway crossings did not work.
It is unclear what precondition was or might have been in effect.
• The positive identification and unambiguous clearance by the assistant 2 did not work. The identified (possible) unfavorable preconditions were the workload of the assistant 2 and his perception of the possibility that the vehicle might be behind buildings feeding its assumed position. Other preconditions might be the assistant’s expanded range of duties and repetitive checks and clearances during duty affecting his attention. Also no specific procedures for positive identification for vehicles in the maneuvering area are laid down in the VDV2.
• The read back and clearance check by the driver of the vehicle did not work. Radio load and quality, names of taxiways and positions, routine violations and expected clearances have been identified as (possible) preconditions.
• The checks of runway 24 and supervision for crossing failed.
• The stop bar functionality failed. The followed route by the driver of the vehicle was such that it will not encounter a stop bar before crossing the runway.
• The check of the runway by the flight crew failed. Unfavorable preconditions might have been that at the moment the take-off clearance was issued the vehicle was not on the runway and during the take-off roll the crew was not aware that a vehicle was going to cross the runway
Accident investigation:
 |
|
Sources:
Dutch Safety Board
History of this aircraft
Other occurrences involving this aircraft
| 10 April 2004 | PH-KCG | KLM Royal Dutch Airlines | 0 | Amsterdam-Schiphol International Airport (AMS/EHAM) | |
non |
| 2 December 2008 | PH-KCG | KLM Royal Dutch Airlines | 0 | Amsterdam-Schiphol International Airport (AMS/EHAM) | |
min |
| Collision with other aircraft on apron | ||||||
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 25-Sep-2020 15:40 | ASN Update Bot | Added |
| 08-Jun-2022 23:34 | Ron Averes | Updated [Operator] |
| 22-Jun-2022 03:27 | Ron Averes | Updated [Location] |
Corrections or additions? ... Edit this accident description
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