Pilots of a KLM Boeing 737-300 were not using an airport map in darkness and snowy conditions before they turned on to, and departed from, a taxiway at Amsterdam Schiphol.
Dutch investigators, in their final report into the 10 February 2010 incident, said the crew lost positional awareness within Schiphol's "relatively complex" taxiway layout while heading for Runway 36C.
Runway 36C has two parallel taxiways, B and A, on its eastern side. While taking taxiway A, the crew accepted a ground clearance for a quicker, but less familiar, route to the runway via taxiway W8.
This short cut involved crossing taxiway B and then turning right on to the runway. However, the aircraft turned prematurely and lined up on the taxiway instead.
The Dutch Safety Board pointed out that the crew was not using an airport map because the pilots "felt sufficiently familiar" with Schiphol, KLM's home base.
But having accepted the short cut, the pilots came under increased operational pressure, making changes to the flight management system and giving themselves little time to visually confirm their position.
Air traffic control devoted "less attention" to the KLM flight than proved necessary, because it was assisting with a problem on a China Airlines Boeing 747 taxiing ahead of the 737. The KLM captain was "distracted" by the radio communication, said the inquiry board.
While the infrastructure and lighting met ICAO standards, the lighting configuration in the vicinity of taxiway W8 played a "role in the error" by the crew, particularly given the snowfall.
KLM has addressed the issues raised by developing a runway verification process, by which crews positively identify entry points before proceeding.
It has also considered installation of a runway awareness and advisory system. But while it made a decision in principle in March this year to equip its fleet, the Dutch Safety Board said, the carrier has not committed to implementation because it is "not satisfied" with the operation of the system.