Investigation Background
The Dutch Safety Board conducted an investigation into an occurrence where a flight crew executed an aborted takeoff from a taxiway. After the rejected takeoff, the crew continued the flight without notifying their airline about the event.
Findings
The investigation revealed that the airline’s procedures were not effective in ensuring that flight crews timely notify the airline about such occurrences. As a result, the crew continued the flight without discussing the safety implications of the occurrence and the follow-up actions with the airline. Continuing the flight also prevented the preservation of the cockpit voice recorder (CVR) recordings.
The lack of CVR data hampered the investigation into the decision-making process of the flight crew, particularly to understand why the crew believed they were entering the runway and how the decision was made to continue the flight after the rejected takeoff.
The Dutch Safety Board noted that it has conducted other investigations where CVR recordings were not available, and it emphasizes the importance of CVR data to determine facts as part of an air safety investigation.
Regulatory Context
European regulations regarding the duration of CVR recordings have been amended to require that CVRs be capable of recording the preceding 25 hours, instead of 2 hours. This requirement applies only to aeroplanes with a certificate of airworthiness issued on or after 1 January 2022.
Recommendations
The Dutch Safety Board issued the following recommendations:
- To Transavia: Develop new procedures, or clarify existing ones, that guide flight crews to consult with their airline at the earliest convenient moment about abnormal situations that have had or may have significant flight safety implications, such as an aborted takeoff from a taxiway. Communicate to flight crews what range of occurrences are meant by these situations.
- To All Dutch Airlines: Replace or upgrade existing CVRs to accommodate a storage capacity of at least 25 hours on aeroplanes with a certified maximum takeoff mass of more than 27,000 kg and with a certificate of airworthiness issued after 31 December 2001, before 2028.
- To the International Air Transport Association (IATA): Encourage IATA members to replace or upgrade their existing CVRs to accommodate a storage capacity of at least 25 hours on aeroplanes with a certified maximum takeoff mass of more than 27,000 kg and with a certificate of airworthiness issued after 31 December 2001.
- To the European Union Aviation Safety Agency (EASA): Mandate that EU-registered commercial air transport aeroplanes with a certified maximum takeoff mass of more than 27,000 kg and with a certificate of airworthiness issued after 31 December 2001 be equipped with a CVR capable of retaining recorded data for at least 25 hours, implementing this requirement as of 1 January 2028.
- To the Integral Safety Management System Schiphol: Foster a work environment at Amsterdam Airport Schiphol that encourages stakeholders to challenge each other about decisions that have had or may have significant safety implications.