What happened
During a recent flight operation involving a Transavia aircraft, a rejected takeoff occurred on a taxiway. Following the aborted takeoff, the flight crew proceeded with the remainder of the flight without notifying the airline of the incident. This decision meant that the safety implications of the event were not discussed with company operators, and the incident was not properly addressed in real-time.
The investigation
The investigation into the event was significantly hindered by the loss of critical audio data. Because the flight continued after the occurrence, the cockpit voice recorder data from the period of the rejected takeoff was overwritten and could not be recovered. This lack of recordings prevented investigators from fully analyzing the flight crew's decision-making process, specifically regarding why the crew believed they were entering a runway and how they decided to continue the flight after the aborted takeoff.
Findings
Key findings from the investigation include the following:
- The airline's existing procedures were ineffective in ensuring that flight crews provided timely notifications to the company regarding safety-related occurrences.
- The failure to report the event prevented the preservation of the cockpit voice recorder data.
- A lack of a culture of challenge within the safety management system at Amsterdam Airport Schiphol was identified as a factor in how decisions are handled.
Safety action
To prevent similar data loss and improve safety oversight, the Dutch Safety Board has issued several recommendations:
- Transavia must develop or clarify procedures to ensure crews consult with the airline regarding abnormal situations that impact flight safety, such as aborted takeoffs on taxiways.
- All Dutch airlines are advised to upgrade cockpit voice recorders to support at least 25 hours of storage for aircraft with a maximum takeoff mass exceeding 27,000 kg.
- The International Air Transport Association (IATA) is encouraged to promote similar storage upgrades among its members.
- The European Union Aviation Safety Agency (EASA) is urged to mandate that EU-registered commercial aircraft with a takeoff mass over 27,000 kg be equipped with recorders capable of 25-hour retention by 2028.
- Stakeholders at Amsterdam Airport Schiphol should foster an environment that encourages challenging decisions with significant safety implications.