Rapport Divi Divi EN.Indd

Emergency landing at sea with Britten-Norman Islander near Bonaire on 22 October 2009 The Dutch Safety Board telephone +31(0)70 333 70 00 • e-mail [email protected] • website www.safetyboard.nl visiting address Anna van Saksenlaan 50 • 2593 HT The Hague postal address PO Box 95404 • 2509 CK The Hague • The Netherlands Emergency landing at sea with Britten-Norman Islander near Bonaire on 22 October 2009 The Hague, may 2011 (project number 2009090) The Dutch Safety Board’s reports are in the public domain. All reports are also available through the Dutch Safety Board’s website; www.onderzoeksraad.nl THE DUTCH SAFETY BOARD The Dutch Safety Board has been set up to carry out the task of investigating and determining the causes or probable causes of individual or categories of incidents in all sectors. The objective of these investigations is solely to prevent future accidents or incidents and, when the results give cause to do so, issue recommendations. The organisation consists of a Board with five permanent members and a professional bureau. The Dutch Safety Board appoints guidance committees for specific investigations. Dutch Safety Board Guidance committee Chairman: T.H.J. Joustra F.J.H. Mertens Annie Brouwer-Korf J.T. Bakker F.J.H. Mertens E.J. Burmeister J.P. Visser J. Marijnen J.A. Mulder H. Munniks de Jongh Luchsinger J.G.W. van Ruitenbeek General secretary: M. Visser Project manager: K.E. Beumkes MSHE Business address: Anna van Saksenlaan 50 Postal Postbus 95404 2593 HT Den Haag address: 2509 CK Den Haag Telephone: +31 (0)70 333 7000 Telefax: +31 (0)70 333 7077 Internet: www.safetyboard.nl This report is published in the Dutch and English languages. In the event of conflict in interpretation, the Dutch text will be deemed binding. TABLE OF CONTENTS Consideration ...................................................................................................................5 List of abbreviations ........................................................................................................ 8 1. Introduction ............................................................................................................. 11 1.1 Reason for this report ............................................................................................11 1.2 The investigation...................................................................................................11 1.3 Reader’s guide ......................................................................................................12 2. Factual information .................................................................................................. 13 2.1 Introduction .........................................................................................................13 2.2 Relevant concepts .................................................................................................13 2.3 Description of the events .......................................................................................14 2.4 Personal injury .....................................................................................................19 2.5 Damage to the aircraft ...........................................................................................20 2.6 Other damage ......................................................................................................20 2.7 Pilot information ...................................................................................................20 2.8 Aircraft information ...............................................................................................21 2.9 Meteorological data ...............................................................................................22 2.10 Navigation tools ....................................................................................................23 2.11 Communication .....................................................................................................23 2.12 Airport information ................................................................................................23 2.13 Flight recorders ....................................................................................................24 2.14 Aircraft wreckage information .................................................................................24 2.15 Medical and pathologic information ..........................................................................25 2.16 Fire .....................................................................................................................26 2.17 Survival aspects ...................................................................................................26 2.18 Tests and further investigations ..............................................................................28 2.19 Organisation and management information ..............................................................30 2.20 Additional information ............................................................................................30 3. Assessment framework ............................................................................................ 33 3.1 General................................................................................................................33 3.2 Civil aviation .........................................................................................................33 3.3 Alerting and emergency supporting services ............................................................37 3.4 Assessment framework for safety management ........................................................38 4. Involved parties and their responsibilities ............................................................... 39 4.1 Captain of flight DVR014 ........................................................................................39 4.2 Divi Divi Air ..........................................................................................................39 4.3 Ministry of Traffic and Transport (Netherlands Antilles) ..............................................39 4.4 Air traffic control on Curaçao and Bonaire ................................................................40 4.5 Britten-Norman Aircraft .........................................................................................40 4.6 Lycoming engines ..................................................................................................40 4.7 Flamingo airport ...................................................................................................41 4.8 Fire service Bonaire ...............................................................................................41 4.9 Local authorities (island council, executive board, governor) .......................................41 4.10 Bonaire police .......................................................................................................41 4.11 Bonaire hospital and healthcare and hygiene service .................................................42 4.12 Netherlands Antilles & Aruba Coastguard .................................................................42 5. Analysis .................................................................................................................... 43 5.1 Introduction .........................................................................................................43 5.2 Engine investigation ..............................................................................................43 5.3 Flight preparation ..................................................................................................43 3 5.4 Flight operation ....................................................................................................48 5.5 The maximum allowed weight .................................................................................53 5.6 Training ...............................................................................................................53 5.7 Pilot’s handling .....................................................................................................54 5.8 Divi Divi Air safety management and supervision ......................................................56 5.9 Oversight .............................................................................................................57 5.10 Timeline for radio communication ............................................................................60 5.11 Alerting and emergency supporting services ............................................................60 5.12 Measures taken after the accident ...........................................................................63 6. Conclusions .............................................................................................................. 65 7. Recommendations .................................................................................................... 67 Appendix A: Justification of investigation ......................................................................69 Appendix B: Comments parties involved ........................................................................ 73 Appendix C: Climb-Limited Take-off Weight................................................................... 74 Appendix D: Flight DVR014 load and balance sheet ....................................................... 76 Appendix E: Air traffic control transcript ......................................................................

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