Incident Boeing 737 MAX 8 A6-FMC,
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ASN Wikibase Occurrence # 302595
 
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Date:Thursday 11 November 2021
Time:21:06 UTC
Type:Silhouette image of generic B38M model; specific model in this crash may look slightly different    
Boeing 737 MAX 8
Owner/operator:Flydubai
Registration: A6-FMC
MSN: 60969/6630
Year of manufacture:2017
Fatalities:Fatalities: 0 / Occupants: 160
Aircraft damage: None
Category:Incident
Location:Warszawa-Frédéric Chopin Airport (WAW/EPWA) -   Poland
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Warszawa-Frédéric Chopin Airport (WAW/EPWA)
Destination airport:Dubai Airport (DXB/OMDB)
Investigating agency: SCAAI
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Flydubai flight FZ1830, a Boeing 737 MAX 8, was involved in a runway incursion incident at Warszawa-Frédéric Chopin Airport (WAW), Poland

At 21:03:18 UTC the crew of the FZ1830 reported readiness to taxi. Warsaw TWR instructed the crew to
taxi to the left via taxiway L to the holding point short of runway 29.
At 21:03:41 hrs the crew of LOT flight LO268, a Boeing 737-800 (SP-LWF) was on final approach to runway 33 and reported to the TWR. LO268 was cleared to land.
Before FZ1830 reached the holding point, the TWR controller issued an instruction to its crew to line up runway 29 and wait. The crew read back the instruction correctly. At 21:05:36 hrs, during taxiing on runway 29, FZ1830 asked for confirmation whether they should establish communication on the 128.805 frequency after departure. The TWR controller confirmed the frequency. At that time, the Warsaw APP staff asked the TWR controller whether the FZ1830 was taking-off. The TWR controller replied that it was not taking off due to landing of another aircraft.
Meanwhile another plane was approaching the holding point short of runway 29. The TWR controller issued its crew a conditional instruction to line up runway 29 behind FZ1830. During that time, at 21:06:12 hrs, the crew of the FZ1830 started the take-off run. At 22:06:23 hrs TWR ordered the FZ1830 crew to stop immediately. The FZ1830 crew acknowledged the instruction. The take-off was aborted at the speed of 89 kt. The plane stopped at runway 29 approximately 250 m from the intersection with runway 33.
LO268 confirmed the validity of the clearance for landing with the TWR controller and continued the approach.
The TWR controller instructed FZ1830 to enter runway 29 and wait. FZ1830 read back their clearance to line up runway 29 and take off. The TWR controller thanked the crew for stopping the plane. Then the FZ1830 crew, following the instructions of the TWR controller, started taxiing to the holding point short of runway 29. The take-off of the FZ1830 took place at 22:16 hrs.

Causes of the incident
The most likely cause of the take-off initiated without clearance was the crew’s partial loss of situational awareness.
Contributing factors
"Confirmation bias" phenomenon affecting the crew.

Accident investigation:
cover
  
Investigating agency: SCAAI
Report number: 
Status: Investigation completed
Duration: 1 year 1 month
Download report: Final report

Sources:

SCAAI

Revision history:

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