What happened
On 5 March 2007, at Amsterdam Schiphol Airport, an Airbus A319, registration G-EZIP, initiated its take-off run-up on runway 24 under the mistaken belief that departure clearance had been granted. During the roll, the crew observed a Boeing 747 crossing the active runway at intersection S2. The pilots immediately aborted the take-off, and air traffic controllers subsequently instructed the aircraft to stop. The aircraft came to a halt at intersection S4, avoiding a collision with the crossing heavy jet.
The investigation
The investigation examined the communication protocols and operational procedures in place at the Schip and the actions of both the flight crew and air traffic controllers. It was established that the Boeing 747 was being managed by the ground controller rather than the runway controller. To reduce workload and provide a service to pilots, the standard procedure—which requires crossing traffic to switch to the runway controller's frequency—was bypassed. This meant the Airbus A319 crew had no direct radio indication that the runway was occupied.
Furthermore, the investigation found that the crew of the G-EZIP had erroneously read back a take-off clearance that was actually intended for an Airbus A330 operating on runway 18L. Because the frequencies for the two departure runways were linked, the Airbus A319 crew could hear the clearance for the other aircraft and mistakenly applied it to their own departure. The controllers did not immediately notice the incorrect read-back, partly due to high noise levels in the tower and the fact that a shift change was occurring.
Findings
Several contributing factors led to the near-miss:
- The decision to allow the Boeing 747 to cross the runway without transferring to the runway controller's frequency meant the Airbus A319 crew lacked situational awareness regarding crossing traffic.
- The Airbus A319 crew failed to properly verify their departure clearance, with the pilot monitoring incorrectly confirming a clearance intended for another aircraft.
- A failure to follow standard crossing procedures by air traffic control prevented the pilots from being informed of the runway occupancy.
- High ambient noise in the control tower and the simultaneous transition of controllers between shifts hindered the ability of staff to detect the erroneous read-back.
Safety action
Following the incident, the airline involved reviewed and updated its standard operating procedures. The 'before take-off checklist' was amended to require the pilot flying to explicitly verify that take-off permission has been obtained.