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KLM 737 @t EHAM & Aeroflot 737 @ ENGM taxiway take-off

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KLM 737 @t EHAM & Aeroflot 737 @ ENGM taxiway take-off

Old 28th May 2010, 11:37
  #201 (permalink)  
 
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Update on this case:


DRIEBERGEN - De twee piloten van KLM die eerder dit jaar opstegen vanaf een taxibaan op Schiphol, worden niet gestraft. Dat meldt BNR vrijdag (28 mei). Volgens de nieuwszender heeft na KLM en het Openbaar Ministerie ook de Inspectie Verkeer en Waterstaat besloten geen maatregelen tegen de vliegers te nemen. Wel onderzoekt KLM of de veiligheidsprocedures moeten worden aangescherpt.


Ook de Raad van de Transportveiligheid heeft de zaak nog in onderzoek. Deze instantie kan echter alleen met adviezen komen.

Het incident gebeurde na zonsondergang op 10 februari van dit jaar. Het toestel van KLM steeg op van de taxibaan naast de Zwanenburgbaan. De piloten van de 737 dachten dat ze de start op de baan zelf hadden ingezet. Het vliegtuig steeg zonder problemen op voor de vlucht naar Warschau.

Het besluit om de vliegers niet te straffen, is bij de Vereniging van Nederlandse Verkeersvliegers (VNV) goed ontvangen. De vakbond vindt dat piloten alleen moeten worden aangepakt als er sprake is van opzet.


Via google translation:

Driebergen - The two pilots of KLM earlier this year took off from a taxiway at the airport will not be punished. BNR announced that Friday (May 28). According to the news has after KLM and the Public Ministry, the CAA decided not to take action against the pilots. However KLM investigates whether safety procedures should be strengthened.

The Council of Transport Safety, the case is still under investigation. This authority can only come with advice.

The incident happened after sunset on February 10 this year. The unit of KLM rose on the taxiway next to the Zwanenburgbaan. The pilots of the 737 thought they were on the runway rather than a taxiway. The plane went without further problems to Warsaw.

The decision not to punish the pilots, is the Dutch Transport Pilots Association (VNV) well received. The union believes that pilots should only be addressed if there is intent.

==

Looks done and dusted. Turkish pilots were at mistake and this was pointed
out by IVW and VNV in a grand fashion. KLM pilots got away as if nothing ever happened ... Worrying behaviour by the Dutch. However you want to defend it, they would have been reprimanded in other countries.
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Old 28th May 2010, 13:10
  #202 (permalink)  
 
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Lightbulb

A "No Punishment"-safety culture is essential to a safe airline operation. It actually allows crews to openly report incidents - confidential or not - without the need of trying to cover the mistakes they made.

Aviation is one of the - if not the only - fields where such a philosophy exists. Try to figure out how many people die each year in the hospitals around the world because there is no possibility to learn from mistakes others made (their “mistakes” being buried in not a few cases...) and no chance to avoid systemic problems and erase them.

Taking off from a taxiway is a mistake. The only thing of interest is how to avoid such mistakes, not how to get after the guys who made it. A simple waste of time and manpower.

How many mistakes did you make while driving your car last year, some without you being at fault – and how many of them did you report to the officials to help them to cure possible accident hotspots on our streets?

None? Well, that’s the difference. Pilots report their mistakes. In good companies and mature legal systems they do this without fear. One of the reasons why it’s dangerous on the streets – an safe in the air.

Last edited by Frosch; 28th May 2010 at 16:07.
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Old 28th May 2010, 20:28
  #203 (permalink)  
 
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KLM pilots got away as if nothing ever happened ... Worrying behaviour by the Dutch. However you want to defend it, they would have been reprimanded in other countries.
They will not be criminally prosecuted, that's wat this message says. What will happen internally is up to KLM. And don't think nothing will be said/done.
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Old 28th May 2010, 22:15
  #204 (permalink)  
 
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So what did these KLM guys miss that caused this incident? Seems their heading would have been correct if it was a parallel taxiway. And if an intersection takeoff there would have been no runway markings.
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Old 28th May 2010, 23:18
  #205 (permalink)  
 
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Perhaps the yellow line in front of them instead of a white line?
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Old 29th May 2010, 17:21
  #206 (permalink)  
 
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I’m sure this idea will be received as being stupid, but chicanes (or some other curves) on parallel taxiways ought to make it patently obvious that a taxiway isn’t a runway. Chicanes would be relatively cheap to build.
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Old 3rd Jun 2010, 16:27
  #207 (permalink)  
 
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Danger

thought there was snow on the twy's 'n rwy's that day,.. night //
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Old 4th Jun 2010, 09:55
  #208 (permalink)  
 
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thought there was snow on the twy's 'n rwy's that day,.. night //
At ENGM with AFL: Winter yes, but more than 24 HRS since snowfall, and they sweep it to near "black" conditions in that time. And oh yes, it was sky clear and the sun beating down. (15:00-ish)
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Old 4th Jun 2010, 13:10
  #209 (permalink)  
 
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I quite like the idea of speed bumps or other "chikanes" on the taxiways !

would make the odd takeoff / landing on taxiways even more interesting !!

seriously: why aren't we just glad that the taxiway was straight, long enough and suitable to be used as a runway ? I am pretty sure the souls on board did...
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Old 20th Dec 2010, 15:02
  #210 (permalink)  
 
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So, the Norwegians already have a conclusion of an investigation of a simular incident.
Where is the news from the dutchies?????
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Old 5th Aug 2011, 21:48
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Takes very long....

Nearly two years on and this investigations seems to take longer than the AF crash.

Is it normal that it takes this long to investigate an incident like this?
I don't understand this unless a lack of resources and time at the Dutch investigation authority.
Looks for an outsider like they want to forget about it. I am interested to read what went on in the skipper's head.

Last edited by soullimbo; 3rd Sep 2011 at 21:51.
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Old 6th Aug 2011, 10:20
  #212 (permalink)  
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It' not unusual for the Dutch Investigation Board to take a long time before publishing the final report. Intermediate reports are only published if there is an urgency to it. Most reports take two to four years to complete, some much longer.

For example the investigation into runway incursion by a Boeing 757 on January 29, 2004, was not closed until August 11, 2010. So that was only 6.5 years for what they call a "short" investigation.

The investigation into the incident of February 10, 2010 will be a "full" investigation, let's hope that hasn't any bearing on the duration.
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Old 7th Aug 2011, 10:57
  #213 (permalink)  
 
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The only thing of interest is how to avoid such mistakes.
Thank you Frosch. Unfortunately some of our dinosaur colleagues can not understand what a "just culture" is all about and we'll have to bang it into their thick skulls time and time again.

Dinosaur speak:

KLM pilots got away as if nothing ever happened ... Worrying behaviour by the Dutch. However you want to defend it, they would have been reprimanded in other countries.
Firstly this a pretty ignorant comment. May I suggest that a lot more than 'nothing' happened. If relevant, appropriate retraining and checking would have carried out and if there was something to be learnt as an industry, that would be released by KLM in an appropriate fashion. But the deal for this to take place is that the crew say what happened and how, as far as they are able.

But let's move on. Imagine Soullimbo is party to an "interesting" incident which was NOT the result of criminal intent or negligence. Judging by the tone of his post, there would be need for the facts to be discussed, because they would not be relevant. Just because he was there he must be guilty. So after we have ripped up his licence, should we lock him up for a few years or would a fine be more appropriate?
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Old 21st Dec 2011, 08:42
  #214 (permalink)  
 
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Final report has been released today (in Dutch)

http://www.onderzoeksraad.nl/docs/ra...ief_131211.pdf
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Old 21st Dec 2011, 09:07
  #215 (permalink)  
 
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It seems like a classic runway confusion incident. The factors that were related to this incident are typically reported in such cases. Six of the causal factors out of the top eight were present in the EHAM taxi takeoff.
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Old 21st Dec 2011, 14:03
  #216 (permalink)  
 
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Surface Runway in Green, Taxiway in Red

Surface Runway in Green, Taxiway in Red, this should cut down on mistakes, and pilots can be told use RED in those cases of desperate emergency which real life can provide (rwy damage by accident and disaster airlift necessary).
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Old 21st Dec 2011, 18:11
  #217 (permalink)  
 
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How would surface colouring help under snowy conditions (as they were in Amsterdam)?
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Old 3rd Jan 2012, 00:38
  #218 (permalink)  
 
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In my book, non-punitive means coming forward with (potential) encountered dangers during the flight which without the report would not be known to anyone. This was not applicable in this case, since ATC notified them of the mishap - without a report from the crew, the incident would still be known.
What is interesting, is that - perhaps conveniently- the CVR "event" button was not pushed afterwards (contrary to regulations) ; so any cockpit conversation was not available anymore to the investigators.
Maybe the crew was not having a silent cockpit/ F/A chatting away on the flightdeck? Nobody knows. Smart game from the crew if they knew they were distracted for whatever reason..
What do we learn from this? Keep taxicharts ready, which is a standard in most airlines anyway.
Thank God nothing actually happened.
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Old 3rd Jan 2012, 07:43
  #219 (permalink)  
 
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To the best of my understanding the EVENT PB only interacts with the ACMS system and not the CVR. To keep CVR recordings the CVR must be swiched OFF, either by means of an installed switch, or by pullng the respective CB.
To imply that the crew was trying to cover their actions up by not reporting the incident to ATC is in my opinion quite speculative.
I understood from the report that ATC informed the crew quite soon. I think that the crew never having been aware of their error is a theory which lies better with me.
rgrds
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Old 3rd Jan 2012, 08:15
  #220 (permalink)  
 
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Tower controler informed crew immediately after lift off. At that point the crew still wasn't aware of their taxiway take-off. Read the report.
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