What happened
On July 27, 2018, a high-risk situation developed at Amsterdam Airport Schiple involving an Embraer ERJ 190-100 STD, registered PH-EXV, and a Boeing 737-800, registered PH-BXI. The Embraer was stationary at the start of runway 18C when it was cleared for takeoff. Simultaneously, the Boeing 737 was granted clearance to line up for an intersection takeoff using high-speed exit W4 on the same runway.
Upon hearing the clearance, the Boeing 737 crew stopped past the hold-short line and notified the tower they were on the runway. Despite this, the runway controller issued the takeoff clearance to the Boeing 737. The Embraer crew began its takeoff roll but aborted the maneuver after realizing the Boeing 737 had also been cleared to depart. The aircraft passed within approximately 19 meters of each other at a speed of roughly 85 knots. The Runway Incursion Alerting System (RIASS) only triggered an alarm after the Embraer had already begun to decelerate.
The investigation
The investigation examined the operational complexities of runway 18C, which features non-standard exits and names. It looked into the controller's workload, noting that the controller was managing three different runways simultaneously. The investigation also reviewed recent incidents involving the same controller, including two separate occurrences earlier in the same shift that may have impacted mental resilience.
Findings
- The use of intersection starts, particularly via non-right-angled high-speed exits, increases the risk of incursions because crews have difficulty seeing approaching traffic from the runway start.
- The controller increased operational complexity by authorizing an intersection start rather than instructing the Boeing 737 to line up behind the Embraer.
- The RIASS failed to act as an effective safety barrier, as the alarm only sounded after the potential collision was already in progress.
- The controller's workload was high due to managing multiple runways and recent stressful incidents involving other aircraft.