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Report: airline, airport and controller were factors in A320 taxiway takeoff at Oslo-Gardermoen
14 December 2010

Oslo-Gardermoen. The orange line indicates where the aircraft took off northbound on taxiway M, instead of on runway 01L, west of taxiway M. (photo: AIBN)

An investigation report by the Accident Investigation Board Norway (AIBN) concluded that the airline, airport and controller were all factors in a serious incident at Oslo-Gardermoen Airport when an Aeroflot Airbus A320 took off from a taxiway.

The serious incident occurred on 25 February 2010. Aeroflot flight number AFL212, an Airbus A320 aircraft, made a taxiing mistake and took off from taxiway M instead of runway 01L. There were three pilots, four cabin crew members and sixty passengers onboard. After the incident, the flight continued as planned to Moscow.

The flight crew was not aware that they had taken off from the taxiway until informed of this by the air traffic controller after take-off. Under the prevailing conditions, taxiway M was by chance long enough for the aircraft to take off. The taxiway was at the time of the incident also free of other traffic and obstacles. This prevented a more serious outcome of the incident.

The investigation has uncovered several causes for AFL212’s taxiing mistake and take-off from the taxiway. The factors which contributed to the events can be found with the parties involved, i.e. the airline, the control tower and the airport.

The Accident Investigation Board is of the opinion that deficient procedures and insufficient alertness in the cockpit, in combination with insufficient monitoring from the control tower and insufficient signposting in the manoeuvring area, resulted in AFL212 making a taxiing mistake and taking off from taxiway M.

On the basis of the investigation, the Accident Investigation Board has issued a safety recommendation to the airline involved, Aeroflot Russian Airlines. As the airport has already implemented measures to prevent similar incidents, and the Civil Aviation Authority has reopened an earlier safety recommendation from AIBN to Avinor, no further safety recommendations were issued.