Quarterly Aviation Report
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Quarterly Aviation Report page 4 Investigations Within the Aviation sector, the Dutch Safety Board is required by law to investigate occurrences involving aircraft on or above Dutch territory. In addition, the Board has a statutory duty to January - March 2017 investigate occurrences involving page 14 Dutch aircraft over open sea. Its investigations are conducted in The review of the investigated occurrences in this quarterly report focuses on accordance with the Safety Board general aviation last year. Three types of occurrences were most frequently Kingdom Act and Regulation (EU) reported: the loss of control, emergency landings following engine failure and no. 996/2010 of the European hard landings. Factors contributing to these investigated occurrences will be Parliament and of the Council of explored in this quarterly report. 20 October 2010 on the investiga- tion and prevention of accidents Thirteen serious incidents and twenty accidents have been reported to the Dutch and incidents in civil aviation. Safety Board in the course of 2016. General aviation aircraft were involved in 28 of If a description of the events is the 33 serious incidents and accidents reported. Five occurrences involving airliners took place. enough to learn lessons, the Board does not conduct any The Dutch Safety Board launched investigations into two occurrences involving page 15 further investigation. airliners in the first quarter of 2017. These concern a cargo aircraft that hit the runway threshold lightning during its landing and a passenger aircraft of which its The Board’s activities are mainly landing gear collapsed during landing. At 6 april the Dutch Safety Board published aimed at preventing occurrences the final report of the investigation into air traffic safety at Amsterdam Airport in future or limiting their conse- Schiphol. The Dutch Safety Board notes that further growth of Schiphol will require more than marginal adjustments to the existing policy. The risks to air traffic at quences. If any structural safety and around the airport must be addressed structurally. shortcomings are revealed, the Board may formulate recommen- Tjibbe Joustra, dations to remove these. The Chairman, Dutch Safety Board Board’s investigations explicitly exclude any culpability or liability aspects. Identified trends Review of occurrences investigated in 2016 In the past year 13 serious incidents and 20 accidents which military aeroplanes were involved. This resulted in a were reported to the Dutch Safety Board, which has slightly injured casualty. investigated these occurrences; some of the occurrences are still under investigation. The Dutch Safety Board has Reported occurrences concerning general aviation also assisted foreign investigating authorities with The focus in this review is on the occurrences reported 30 investigations into occurrences with Dutch involvement regarding general aviation in the Netherlands because that took place abroad in 2016. this is where the vast majority of the reported occurrences originate. In the accidents investigated by the Dutch Safety Board in 2016 there were two fatalities and seven people that Over the last three years a slightly rising trend is visible in sustained serious injuries. One person died during a flight the number of serious incidents and accidents reported in under visual flight rules that ended up in instrument general aviation in the Netherlands. meteorological conditions and there was one fatality in an accident with a paramotor. Of the general aviation occurrences that were investigated by the Dutch Safety Board in 2016 roughly half took place In 28 of the 33 serious incidents and accidents reported in the final phases of the flight, during approach and general aviation aircraft were involved. Five serious landing. Of the occurrences that took place during the incidents and accidents took place with commercial approach, three took place during the execution of the aeroplanes. In addition to the above occurrences in which traffic pattern. There were two near misses in the traffic civil aircraft were involved, there was one accident in pattern area. ErnstigSerious incidentincident OngevalAccident 40 36 32 28 24 20 Aantal Number 16 12 8 4 0 2010 2011 2012 2013 2014 2015 2016 Year 2 - Dutch Safety Board A risk of collision occurred on one occasion because a during a go-around. The causes of the loss of control Emergency landing following engine failure pilot wanted to land in the wrong runway direction. varied. Contributory factors to the loss of control of the In 2016 four emergency landings were reported that Another risk of collision occurred because of a mutual aeroplane in the investigated occurrences were: were the result of an engine failure. Twice the engine difference in speed and the failure to notice another • VFR flights in instrument meteorological conditions. failure occurred while climbing, once during cruise and aeroplane in the traffic pattern. On one occasion a loss of • Little experience with the aircraft type concerned. once during final approach. Three times the result of control took place while flying in the traffic pattern. • Little recent experience in instrument flying. the emergency landing was damage to the aircraft. The • Incorrect steering movements during a go-around in following factors played a part in the three emergency Three occurrences took place while executing special strong wind conditions. landings that resulted in damage to the aircraft: manoeuvres, two of which when executing aerobatic • Limited experience in recognising a spin. • Landing with tailwind (in two cases). manoeuvres and one during a low pass of a glider. • Possible icing on the wings. • Mistakenly flying with the choke activated, which led • Loss of consciousness due to high G-forces. to the fuel mixture being too rich on final approach. In 2016 three types of occurrences were most frequently • Continuing a final approach after ending up too high reported. These were loss of control, emergency landing on the final approach leg. Hard landing following engine failure and hard landings. All other types Four times damage to an aircraft occurred because of a of occurrences took place fewer than four times and are The American safety investigation authority National hard landing. Twice a glider was involved and twice an not discussed separately in this report for this reason. Transportation Safety Board (NTSB) found that loss of aeroplane. Factors contributing to these hard landings control of the aircraft was the cause of 48% of the fatal were: Loss of control accidents in general aviation in the United States1 in the • Landing flare initiated too high. Loss of control of the aircraft in general aviation was period 2008 to 2014. The NTSB therefore gives priority • Air brakes of a glider opened mistakenly during the reported seven times in 2016. It is therefore the type to preventing such accidents and has drawn up learning loss of winch power at low altitude. of occurrence most frequently reported in 2016. Loss points to achieve this. • Landing with tailwind. of control occurred in different phases of the flight: • Too much height on the final approach leg for an off- shortly after take-off, while climbing, while cruising, airfield landing with a glider. during special manoeuvres, during the approach and The three most reported types of occurrences in general aviation in the Netherlands in 2016. 3 8 Special manoeuvres Take-off 6 5 Climbing 11 The phases of Cruising 4 flight in which Number Approach occurrences took (traffic pattern) place in general aviation in 2016. 2 Landing 2 No serious incidents or accidents occurred during 3 taxiing or descent. 0 4 Loss of Emergency landing Hard control following engine failure landing 1 https://www.ntsb.gov/safety/mwl/Documents/2017-18/2017MWL-FctSht-LossControl-A.pdf Quarterly Aviation Report 1st quarter 2017 - 3 Runway lighting struck during landing, Landing gear collapsed during landing, Occurrences into Boeing 747-8F, VQ-BLR, Amsterdam Bombardier DHC-8-402-Q, G-JECP, Airport Schiphol, 13 January 2017 Amsterdam Airport Schiphol, which an 23 February 2017 The cargo aeroplane struck some of the threshold lighting lamps on the runway threshold shortly before landing on The right main landing gear of the Bombardier Q400 investigation has runway 36R. The aeroplane sustained damage as a result. collapsed during landing on runway 22. The aeroplane came to a stop on the runway on its right wing and in the process sustained damage to the right wing, the right been initiated Classification: Serious incident propeller, the landing gear and the fuselage. Nobody on Reference: 20170 02 the aeroplane was injured. Classification: Accident Reference: 2017016 The three threshold lamps (after replacement) struck by VQ-BLR. (Photo: AAS) G-JECP with the collapsed landing gear 4 - Dutch Safety Board Bush struck on final approach, Schleicher Emergency descent following loss of ASK-21, PH-1290, Langeveld glider cabin pressure, Boeing 767-36N, airfield, 12 March 2017 G-POWD, 35 NM to the southwest of Amsterdam Airport Schiphol, The glider, with an instructor and a student on board, 19 March 2017 made a crosswind landing during a check flight at the start of the gliding season. On final approach the left wing struck a bush at low altitude, as a result of which the glider The Boeing 767 was making a passenger flight from rotated approximately 270 degrees about its top axis in London Stansted Airport in the UK to Rzeszów Jasionka the air and then came to a stop on the ground. Neither Airport in Poland. While cruising at an altitude of FL370, occupant was harmed. The glider sustained, among other approximately 35 nautical miles to the southwest of things, damage to its left wing tip. Schiphol Airport, a cabin altitude warning was generated on the flight deck. As a result of this the oxygen masks were automatically deployed in the cabin. The crew made Classification: Serious incident an emergency call, carried out a descent and decided to Reference: 2017018 divert to Schiphol Airport in response to the warning, where a safe landing was made.