racedo
17th Nov 2010, 11:13
Report: Easyjet A319 at Amsterdam on Mar 5th 2007, began takeoff without clearance (http://www.avherald.com/h?article=43382d26&opt=0)
The Dutch Onderzoeksraad (Dutch Safety Board DSB) released their final report in Dutch (http://www.onderzoeksraad.nl/docs/rapporten/2007015_G-EZIP.pdf) concluding the probable cause was:
The crew of the Airbus A319 read the takeoff clearance from runway 18L transmitted to an Airbus A330 mistakenly back and began their takeoff roll from runway 24. The wrong read back was not heard by the tower controller.
In the past rules permitted a deviation from the rule, that only the tower controller could issue clearance to enter/cross active runways as long as safety was assured, so that ground controllers could issue a clearance to cross an active runway. Today this is no longer permitted, ground controllers can only issue clearances to cross an inactive runway.
Contributing factors were:
- the crossing traffic was not transferred to the tower due to different load on ground and tower frequencies, a service oriented attitude towards flight crew, a difference in understanding and implementing procedures by individual controllers and issues in the team resource management.
- the A319 crew failed to properly monitor the takeoff clearances, the possibility of a call sign confusion due to similiarity and the expectation to receive takeoff clearance were unfavourable conditions as was the non-verification of the runway by the pilot flying. The use of two departure runways on the same frequency can contribute to confusion.
- The tower controller failed to hear the read back and failed to intervene. The controller was affected by unusual noise levels during current change of shift.
- The A330 crew failed to intervene.
- The A319 crew was not informed about the crossing traffic due to non-compliance with the procedures for crossing traffic
- Only two remaining safe guards did not fail: The assistant controller warned about the crossing traffic and the A319 crew saw the 747, both factors led to the takeoff being rejected
---
Quite a serious incident and shades of TFN - Pan Am / KLM relating to confusion over who had clearance. Good on someone who though not fully accredited saw something wrong and called it, also on U2 flight crew for acting correctly when realised error.
Thankfully its better to write a report over a potential incident rather than try and pick up the real pieces after it.
The Dutch Onderzoeksraad (Dutch Safety Board DSB) released their final report in Dutch (http://www.onderzoeksraad.nl/docs/rapporten/2007015_G-EZIP.pdf) concluding the probable cause was:
The crew of the Airbus A319 read the takeoff clearance from runway 18L transmitted to an Airbus A330 mistakenly back and began their takeoff roll from runway 24. The wrong read back was not heard by the tower controller.
In the past rules permitted a deviation from the rule, that only the tower controller could issue clearance to enter/cross active runways as long as safety was assured, so that ground controllers could issue a clearance to cross an active runway. Today this is no longer permitted, ground controllers can only issue clearances to cross an inactive runway.
Contributing factors were:
- the crossing traffic was not transferred to the tower due to different load on ground and tower frequencies, a service oriented attitude towards flight crew, a difference in understanding and implementing procedures by individual controllers and issues in the team resource management.
- the A319 crew failed to properly monitor the takeoff clearances, the possibility of a call sign confusion due to similiarity and the expectation to receive takeoff clearance were unfavourable conditions as was the non-verification of the runway by the pilot flying. The use of two departure runways on the same frequency can contribute to confusion.
- The tower controller failed to hear the read back and failed to intervene. The controller was affected by unusual noise levels during current change of shift.
- The A330 crew failed to intervene.
- The A319 crew was not informed about the crossing traffic due to non-compliance with the procedures for crossing traffic
- Only two remaining safe guards did not fail: The assistant controller warned about the crossing traffic and the A319 crew saw the 747, both factors led to the takeoff being rejected
---
Quite a serious incident and shades of TFN - Pan Am / KLM relating to confusion over who had clearance. Good on someone who though not fully accredited saw something wrong and called it, also on U2 flight crew for acting correctly when realised error.
Thankfully its better to write a report over a potential incident rather than try and pick up the real pieces after it.