|Title:||Loss of steering on a slippery taxiway on the Easyjet Boeing B737-700, registration G-EZJM, at Amsterdam Airport Schiphol on 22 December 2003|
|Micro summary:||This Boeing 737-700 skidded on ice while taxiing and collided with a lamp post.|
|Event Time:||2003-12-22 at 2059 UTC|
|Publishing Agency:||The Dutch Safety Board|
|Publishing Country:||The Netherlands|
|Site of event:||Amsterdam Airport Schiphol|
|Departure:||Amsterdam Airport Schiphol, Amsterdam, Netherlands,|
|Destination:||London Gatwick, London, England, UK|
|Airplane Type(s):||Boeing 737-700|
|Type of flight:||Revenue|
|Executive Summary:||Flight EZY5112 of Easyjet, which was carried out with a Boeing 737-700 with registration G-EZJM, concerned a regular service from Amsterdam Airport Schiphol (AMS) to London Gatwick (LGW) on 22 December 2003. The aircraft had landed earlier that evening at AMS at 2106 hours. The scheduled departure time for the return flight was 2150 hours. There were five crewmembers on board (two pilots and three cabin crew staff members) and 98 passengers. At 2139 hours the crew received the clearance to start the engines of the aircraft. The air traffic controller of ATC indicated that ATIS information Oscar was in force. The ATIS report contained among other things the warning: "All taxiways and aprons slippery spots". At 2145 hours the crew received the instruction to taxi via taxiways A6 and B-North to runway 36L. |
After about ten minutes the crew of EZY5112 reported to ATC 'Ground West' with the message that they were located at the place of the reporting point VM (see Annex A). The air traffic controller answered: "Good evening EZY5112 continue taxiway V and V3 is available if you like". The clearance of the air traffic controller was answered by the crew with: "V for V3 is fine, thanks, EZY5112". However the crew chose not to taxi via taxiway V but to taxi via the taxiway situated next to it, taxiway VS to the intersection V3. Taxiway VS leads via the two holding points P6 and P7, where ice can be removed from aircrafts (de-icing), directly to V3. The holding points are widened parts of the taxiway and are illuminated by means of lampposts.
When making the turn to P6 the aircraft no longer responded on the nose wheel steering and taxied straight on with the aircraft skidding to the side of the apron. At the end of the holding point P6 the aircraft collided with its left wing against one of the lampposts. The collision took place at 21:59 hours. The crew switched off the engines a few seconds before the collision took place. After the collision the aircraft swerved and the aircraft came to a standstill after about 20 meters. The nose wheel stood in the grass; the main landing gear had come to a standstill on the edge of the apron against the cover plates of electricity wells6. The aircraft and the lamppost were seriously damaged. The air traffic controllers who saw the collision occur, used the alarm telephone to alert the emergency services. The airside operations manager7 (AOM) activated alarm type VOS1.8
The taxiway VS and holding point P6 turned out to be almost completely covered with a layer of ice and consequently were very slippery. In connection with the slipperiness on P6 the disembarkation of the passengers was delayed until the apron had been sprayed.9 After about half an hour the passengers could begin to disembark. At 22:48 hours all the passengers had left the aircraft and had been taken to the terminal building by buses.
The accident was caused because the pilot, because of slipperiness, was unable to control the aircraft during the taxiing, causing a collision between the left wing of the aircraft and a lamppost.
The causal factors were:
- The actions against slipperiness were not optimal.
- The slipperiness situation at VS, P6 and P7 was not in accordance with the information the crew had.
- The circumstances and the habit to leave the choice up to the aircraft crews did not exclude the use of taxiway VS.
- The AOM and the air traffic controllers were insufficiently conscious of the slipperiness situation and the potential danger it entailed.
- The taxi command given by air traffic control was not followed up by the pilot flying.
- The crew did not make sufficient use of the skills crew resource management offers.
The underlying factors were:
- The 'regeling Sneeuw –en Gladheidsbestrijding 2003-2004' is not sufficiently guaranteed in the safety management system of Amsterdam Airport-Schiphol.
- Neither the business manual nor the 'regeling Sneeuw- en Gladheidsbestrijding 2003 – 2004' provide an adequate method for measuring the braking action/friction and for fighting slipperiness on taxiways and aprons.
- Easyjet's quality system was not able to acknowledge the risk of such an accident.
- The chain of collection of information and the actions and provision of information to third parties stemming from that holds great risks of human failure.
|Learning Keywords:||Operations - Airspace - Air Traffic Control|
|Operations - Crew Resource Management|
|Operations - Ground Collision|
|Operations - Runway Excursion|
|Operations - Slippery Runway, Taxiway, Apron|
|Other - Airport Management|
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