What happened
On the afternoon of Saturday, December 18, 2010, a runway incursion occurred on runway 24 at Amsterdam Airport Schiphol. The incident began when the airport's bird control unit requested permission to drive a vehicle onto the active runway to inspect for bird, snow, and ice debris. The runway controller, assisted by a tower assistant, granted this permission. Simultaneously, the runway controller authorized a Boeing 747 to cross the runway from the cargo apron. While the assistant controller warned the bird control team about the crossing heavy aircraft, a Boeing 737 was positioned on the same runway, prepared for departure.
Once the Boeing 747 had cleared the runway, the runway controller issued takeoff clearance to the Boeing 737. However, the controller failed to notice that the bird control vehicle was still traversing the runway. Consequently, the Boeing 737 took off and flew directly over the vehicle still in motion on the runway.
The investigation
The Dutch Safety Board (OVV) investigated the sequence of events and the underlying systemic failures. The investigation examined the technical and procedural tools available to the runway controller to signal runway occupancy. It also reviewed the communication protocols between the ground controller and the runway controller, specifically regarding the transfer of aircraft and vehicles between different controller frequencies.
Findings
- The direct cause of the incident was the runway controller's failure to observe the bird control vehicle remaining on the runway.
- Technical and procedural safeguards were insufficient, as the available warning systems did not indicate the specific number of vehicles or aircraft occupying the runway.
- A breakdown in communication occurred because the crossing traffic was not transferred from the ground controller to the runway controller's frequency. This resulted in a fragmented operational environment where two aircraft and one vehicle were being managed across three different frequencies by three different controllers.
- Internal regulations lacked a clear definition of what constitutes an "active" runway, leading to ambiguity in when aircraft must be transferred to the runway controller's frequency.
Safety action
The investigation highlighted that the safety management systems of the airport and air traffic control provider were not sufficiently integrated for shared operational areas. The OVV noted that the lack of coordinated oversight contributed to the persistence of such incidents and recommended that the organizations align their safety management processes and review vehicle operations against international ICAO standards.