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Rapport Divi Divi NL.Indd Noodlanding op zee met Britten-Norman Islander nabij Bonaire, 22 oktober 2009 Onderzoeksraad voor Veiligheid (070) 333 70 00 • [email protected] • www.onderzoeksraad.nl Anna van Saksenlaan 50 • 2593 HT Den Haag • Postbus 95404 • 2509 CK Den Haag Noodlanding op zee met Britten-Norman Islander nabij Bonaire, 22 oktober 2009 Den Haag, mei 2011 (projectnummer 2009090) De rapporten van de Onderzoeksraad voor Veiligheid zijn openbaar. Alle rapporten zijn bovendien beschikbaar via de website van de Onderzoeksraad www.onderzoeksraad.nl DE ONDERZOEKSRAAD VOOR VEILIGHEID De Onderzoeksraad voor Veiligheid is ingesteld met als taak te onderzoeken en vast te stellen wat de oorzaken of vermoedelijke oorzaken zijn van individuele of categorieën voorvallen in alle sectoren. Het doel van een dergelijk onderzoek is uitsluitend toekomstige ongevallen of incidenten te voorkomen en indien de uitkomsten daartoe aanleiding geven, daaraan aanbevelingen te verbinden. De organisatie bestaat uit een raad met vijf vaste leden en een professioneel bureau. Voor specifieke onderzoeken worden begeleidingscommissies in het leven geroepen. Onderzoeksraad Begeleidingscommissie Voorzitter: mr. Tjibbe Joustra prof. dr. ing. F.J.H. Mertens mr. Annie Brouwer-Korf J.T. Bakker prof. dr. ing. Ferdinand Mertens E.J. Burmeister dr. ir. Koos Visser J. Marijnen prof. dr. ir. J.A. Mulder mr. H. Munniks de Jongh Luchsinger ir. J.G.W. van Ruitenbeek Algemeen mr. M. Visser secretaris: Project- ing. K.E. Beumkes MSHE leider: Bezoek - Anna van Saksenlaan 50 Post adres: Postbus 95404 adres: 2593 HT Den Haag 2509 CK Den Haag Telefoon: +31 (0)70 333 7000 Telefax: +31 (0)70 333 7077 Internet: www.onderzoeksraad.nl Dit rapport is in de Nederlandse en Engelse taal gepubliceerd. Bij verschil in interpretatie dient de Nederlandse tekst als bindend te worden beschouwd. INHOUD Beschouwing .................................................................................................................... 5 Lijst van afkortingen en begrippen .................................................................................. 9 1. Inleiding ................................................................................................................... 11 1.1 Aanleiding ............................................................................................................11 1.2 Het onderzoek ......................................................................................................11 1.3 Leeswijzer ............................................................................................................12 2. Feitelijke informatie ................................................................................................. 13 2.1 Inleiding ..............................................................................................................13 2.2 Relevante begrippen ..............................................................................................13 2.3 Beschrijving van de gebeurtenissen ........................................................................14 2.4 Persoonlijk letsel ...................................................................................................20 2.5 Schade aan het luchtvaartuig .................................................................................21 2.6 Overige schade .....................................................................................................21 2.7 Gegevens van de piloot ..........................................................................................21 2.8 Gegevens van het vliegtuig ....................................................................................21 2.9 Meteorologische gegevens .....................................................................................23 2.10 Navigatiehulpmiddelen ...........................................................................................24 2.11 Communicatie ......................................................................................................24 2.12 Gegevens luchthavens ...........................................................................................25 2.13 Vluchtregistratie apparatuur ...................................................................................25 2.14 Gegevens inzake het vliegtuigwrak ..........................................................................25 2.15 Medische en pathologische informatie ......................................................................26 2.16 Brand ..................................................................................................................27 2.17 Overlevingsaspecten .............................................................................................27 2.18 Tests en nadere onderzoeken .................................................................................28 2.19 Organisatie- en managementinformatie ...................................................................31 2.20 Aanvullende informatie ..........................................................................................31 3. Beoordelingskader .................................................................................................... 33 3.1 Algemeen.............................................................................................................33 3.2 Luchtvaart ...........................................................................................................33 3.3 Alarmering en hulpverlening ...................................................................................37 3.4 Beoordelingskader voor veiligheidsmanagement .......................................................38 4. Betrokken partijen en hun verantwoordelijkheden .................................................. 39 4.1 Gezagvoerder vlucht DVR014 ..................................................................................39 4.2 Divi Divi Air ..........................................................................................................39 4.3 Ministerie van Verkeer en Vervoer (Nederlandse Antillen) ...........................................39 4.4 Luchtverkeersleiding op Curaçao en Bonaire .............................................................40 4.5 Britten-Norman Aircraft .........................................................................................40 4.6 Lycoming engines ..................................................................................................41 4.7 Luchthaven Flamingo .............................................................................................41 4.8 Brandweer van Bonaire ..........................................................................................41 4.9 Lokale autoriteiten (eilandsraad, bestuurscollege, gezaghebber) .................................41 4.10 Politie Bonaire ......................................................................................................42 4.11 Ziekenhuis Bonaire en Dienst Gezondheidszorg & Hygiëne .........................................42 4.12 Kustwacht Nederlandse Antillen en Aruba ................................................................42 5. Analyse ..................................................................................................................... 43 5.1 Inleiding ..............................................................................................................43 5.2 Motoronderzoek ....................................................................................................43 5.3 Vluchtvoorbereiding ............................................................................................. 44 3 5.4 Vluchtuitvoering ...................................................................................................48 5.5 Het maximaal toegestane gewicht ...........................................................................54 5.6 Training ...............................................................................................................54 5.7 Het handelen van de piloot .....................................................................................56 5.8 Intern toezicht en veiligheidsmanagement Divi Divi Air ..............................................57 5.9 Extern toezicht .....................................................................................................59 5.10 Tijdlijn radiocommunicatie ......................................................................................61 5.11 Alarmering en hulpverlening ...................................................................................62 5.12 Acties en maatregelen genomen na het ongeval .......................................................65 6. Conclusies ................................................................................................................ 67 7. Aanbevelingen .......................................................................................................... 69 Bijlage A: Onderzoeksverantwoording ........................................................................... 70 Bijlage B: Commentaar betrokken partijen .................................................................... 74 Bijlage C: Klimgelimiteerde startgewicht ....................................................................... 75 Bijlage D: Load and balance formulier vlucht DVR014.................................................... 77 Bijlage E: Transcript luchtverkeersleiding .....................................................................
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