What happened
On 29 January 2004, a Boeing 757-2Q8, registration D4-CBG, was taxiing for departure at Amsterdam Schiphol Airport. After receiving clearance to taxi via the south toward runway 36C, the flight crew inadvertently turned onto the active landing runway, 36R, via taxiway entrance E4. At the same time, a Boeing 7．37-306, registration PH-BDC, was on final approach to the same runway. An apron controller noticed the unauthorized runway entry and alerted the ground controller via intercom. Consequently, the landing crew of the Boeing 737 was ordered to execute a go-around to avoid a collision. The Boeing 757 was subsequently instructed to vacate the runway, and no injuries or aircraft damage were reported.
The investigation
The investigation examined the taxi routing, air traffic control (ATC) communications, and airport infrastructure. Investigators found that the flight crew had turned left at taxiway Alpha instead of right, and despite subsequent corrective instructions from the ground controller, the crew eventually entered runway 36R. The investigation also looked into the visibility conditions, noting that snow-clearing activities were underway and the runway surface was reflective due to water and sun. The role of the tower supervisor and the effectiveness of the runway lighting and stop bars were also scrutinized.
Findings
Several contributing factors led to the runway incursion:
- The flight crew experienced a loss of situational awareness, failing to recognize they had entered the active runway.
- The taxi instructions provided by the ground controller were potentially ambiguous, leading to incorrect turns.
- The intersection at entrance E4 was designed in a way that made it easy for aircraft taxiing on taxiway Bravo to enter the runway with a slight turn.
- The runway controller's view of the E4 entrance was partially obstructed by a window frame.
- The stop bar at E4 was not illuminated because low visibility procedures were not in effect at the time.
- The landing crew of the Boeint 737 could not observe the Boeing 757 until the go-around was already underway due to the reflective runway surface and the aircraft's color.
Safety action
Following the incident, the airline implemented updated pilot training and procedures to better manage taxi clearances and prevent runway incursions. Additionally, the airport infrastructure was later modified; the junction at E4 was redesigned with a bend to provide pilots with a better view of the runway and to clearly signal when they are no longer on the taxiway.