What happened
On the evening of February 10, 2010, a KLM Boeing 737, registration PH-BDP, departed from a taxiway at Amsterdam Airport Schiphol rather than the intended runway. The aircraft, operated by a two-person crew, had recently completed de-icing procedures and was taxiing toward runway 36C. During the taxi, air traffic control suggested a shorter route via entry W8. While following this new instruction, the crew mistakenly turned onto a taxiway, believing it to be the runway. The aircraft subsequently accelerated and performed a takeoff from the taxiway. Although the incident created a high-risk situation, there were no injuries and no damage to the aircraft.
The investigation
The Dutch Safety Board examined the sequence of events, the cockpit crew's actions, and the air traffic control environment. The investigation focused on the complex taxiway infrastructure at Schiphol, the crew's navigation methods, and the communication between the cockpit and the tower. Investigators also reviewed the lighting conditions at the time of the incident, which included darkness and light snowfall, and analyzed the workload of both the flight crew and the air traffic controllers.
Findings
Several contributing factors led to the incorrect runway identification. The flight crew was experiencing increased workload due to the need to update the flight computer with the new route, which reduced their ability to visually monitor their position. Furthermore, the crew did not utilize a taxi chart, relying instead on their familiarity with Schiphol. The captain was also distracted by radio communications regarding another Boeing 747 that was taxiing in the wrong direction.
On the air traffic control side, the controller's attention was diverted to monitoring the other aircraft, and they assumed the crew would follow the instructions correctly. The controller did not continue to monitor the PH-BDP after the takeoff clearance was issued, which prevented the timely detection of the error. Additionally, the lack of green centerline lighting on entry W8 and the presence of snow contributed to the crew's confusion regarding the path.
Safety action
The investigation highlighted that the complexity of Schiphol's taxiway system necessitates strict adherence to taxi charts. The report noted that while the infrastructure meets international standards, additional measures, such as improved lighting or enhanced monitoring of aircraft following non-standard routes, could prevent similar incursions.