History of the Flight
On 13 February 2019 at approximately 09:51 local time, a Boeing 747-400 (registration PH-BFV) collided during pushback with a Boeing 787-9 (registration PH-BHA) that was standing on taxiway A16 at Amsterdam Airport Schiphol. The B787 had initially been parked at gate F08. Due to a boarding delay, the pushback clearance was received about 15 minutes after its scheduled departure time. Ground Control amended the clearance, instructing the B787 flight crew to make the push long enough to allow an arriving aircraft to dock at gate F08. The flight crew relayed this instruction to the pushback truck driver, as truck drivers at Schiphol have no direct communication with Ground Control. The driver positioned the B787 approximately 20 meters beyond the pushback limit line on taxiway A16.
Ground Control Actions
Shortly after the B787's long pushback, a B747 received clearance to commence pushback. The ground controller then realized that the B747's pushback would bring it close to the B787 and issued a cautionary message to the B747 flight crew. However, the transmission was partially blocked by another transmission. The B747 flight crew did not provide a readback of the message, and the ground controller did not follow up on the missing readback. Consequently, the caution was not relayed to the B747 pushback truck driver. The driver of the B747 was unaware of the B787's extended position and could not see it due to obstruction by the B747's engines.
Procedures and Communication
The long pushback clearance issued to the B787 was an undocumented procedure. It was not an assessed or aligned procedure within the sector parties at Schiphol. The deviation from standard pushback procedures introduced risks as separation margins were no longer ensured. The ground controller's mitigation measure, the cautionary message, proved ineffective due to the blocked transmission. Ground control is responsible for assessing taxiway conditions and issuing conflict-free pushback clearances. The report noted that deviating from standard procedures was not uncommon for air traffic controllers at Schiphol, as also observed in previous safety board investigations.
Damage and Injuries
The collision resulted in minor damage to the B747 and substantial damage to the B787. There were no injuries. The occurrence happened in daylight conditions.
Cockpit Voice Recorder
The investigation found that the operator's procedures were not effective in preserving the Cockpit Voice Recorder (CVR) recordings of one of the aircraft involved, which is required in case of an accident or serious incident for safety investigation purposes. The need for extended CVR recording duration has been recognized by aviation regulators.
Safety Actions
Following the accident, sector parties conducted a joint investigation under the Integral Safety Management System (ISMS). The working practice for long pushbacks was amended: Air Traffic Control the Netherlands (LVNL) now issues clearances with a specific end position. However, this practice, where separation margins may still not be guaranteed, continues to be used. Additional safety measures have been identified but require further study or technological development.