What happened
On 18 April 2012, an Airbus A3t30, registration N815NW, landed at Amsterdam Airport Schiphol after a long-haul flight from Detroit. While taxiing toward gate E17, the flight crew received instructions from the ground controller to cross the airfield at point Z2. However, instead of following the prescribed route, the aircraft turned left at intersection W11 and crossed runway 18C. At the time of the incursion, another aircraft was on final approach for the same runway, approximately 3 nautical miles away. While the incident caused a runway incursion, there was no immediate risk of collision, and the approaching aircraft landed safely.
The investigation
The Dutch Safety Board examined the cockpit communications, the crew's use of aeronautical charts, and the airport's infrastructure. The investigation focused on why the crew deviated from the instructed path and why the intersection W11 was not identified as a hazard during the turn. Investigators also reviewed the radiotelephony used by the ground controller and the visibility of airport markings and stop bars at the time of the event.
Findings
Several contributing factors led to the incursion. The investigation established that the crew failed to notice a "hot spot" warning on their Jeppesen charts, which highlighted the high-risk nature of the W11 and W12 intersections. On the flight deck, the two first officers were preoccupied with discussing the route and locating Alpha North on the chart, which diverted their attention from the external taxiway markings.
Crucially, the use of the word "cross" in the controller's instruction led the captain to believe he had permission to cross the active runway 18C itself, rather than crossing the taxiway at Z2. This misunderstanding was compounded by the captain's fatigue following a trans-Atlantic flight and his relatively recent transition to the Airbus A330 type. Additionally, the stop bar at intersection W11 was not illuminated, providing no visual warning of the runway boundary.