Quarterly Aviation Report

DUTCH SAFETY BOARD

page 12 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 investigate occurrences involving Dutch aircraft over July - September 2018 open sea. Its investigations are conducted in accordance with the Safety Board Kingdom Act This past quarter, an incident involving a passenger aircraft occurred at and Regulation (EU) no. 996/2010 Zakynthos International Airport in Greece. During take-off, the aircraft only of the European Parliament and left the runway on the final section. This was due to wrong values having of the Council of 20 October been used in the performance calculations for take-off. Because of these 2010 on the investigation and wrong values, the engine thrust was insufficient. A similar incident occurred prevention of accidents and at Amsterdam Airport Schiphol this quarter. incidents in civil aviation. If a page 15 description of the events is The Dutch Safety Board has investigated several similar incidents in the past, sufficient to learn lessons, the which continue to occur regularly. A system that warns pilots in the event of Board does not conduct any insufficient thrust can prevent such incidents. further investigation. In March 2018, the Safety Board issued a recommendation to the EASA The Board’s activities are to immediately start developing a warning system. According to the EASA, mainly aimed at preventing the feasibility of such systems has yet to be proven. The industry continues occurrences in the future or to search for technical solutions. Up until now, the specifications for such limiting their consequences. If warning systems could not be established. any structural safety short- comings are revealed, the Board may formulate recommendations The Safety Board considers it of the greatest importance that safety in to remove these. The Board’s this area will be increased and therefore continues to seek international investigations explicitly exclude attention for this (safety) issue. any culpability or liability aspects. Tjibbe Joustra Chair of the Dutch Safety Board page 18 V1 V2

DIENSTWEG KOP 18R

SCHIPHOLWEG

18 R

V3 V4

SCHIPHOLWEG

R81 GEWTSNEID EKJILETSEW GEWTSNEID R81

HOOFDVAART

OOSTELIJKE DIENSTWEG 18R

HOOFDWEG WESTZIJDE V6 IJWEG

V5 V6

R81 GEWTSNEID EKJILETSEW GEWTSNEID R81

36L-18R V6

36L-18R

VIJFHUIZERTOCHT

IJWEG

OOSTELIJKE DIENSTWEG 18R VIJFHUIZERWEG HOOFDWEG OOSTZIJDE V BRANDWEER NIEUWERKERKERTOCHT POST VIJFHUIZEN C4 V2 HOOFDWEG WESTZIJDE

36L-18R

V16 36L-18R C6 V7 V10 V14 18C-36C DIENSTWEG KOP 18C C4 HOOFDVAART Y2 RHP Y1 RHP

36C-18C

18C-36C Y2 Y1 SCHIPHOLWEG

36C-18C NOORDELIJKE DIENSTWEG TWEEDUIZEND EL V3

36L-18R RIJBAAN VICTOR SOTA T2 C3 C2

36L-18R V18 Y AMSTERDAM OUDE HAAGSEWEG V 18 SLOTERWEG AIRPORT HOTEL VS C

V9 V12 P34 1 8 C W1 C1 VN P35 V18

1 8 C TAR WEST V4 ZUIDELIJKE DIENSTWEGVS VE C8 C9 T1 T4 C81-C63

V19 KAGERTOCHT 3 6 L V15 V17 V W2

P36 C81-C63 3 6 L VS V20 HOOFDWEG OOSTZIJDE Y T6

OOSTELIJKE DIENSTWEG RIJBAANY RIJBAAN VICTOR OPSTELPLAATSEN D C 1 36 UGS-C C2 V21 V23 KOEKOEKSLAAN L C81-C63 Insufficient thrust during take-off, Emergency landing, Beechcraft A36 V11 P22 V13 Boeing 737-800, Amsterdam Airport Bonanza, Vlagtwedde, 25 July 2018 Occurences 18 NIEUWERKERKERTOCHT ROLHEK W3 R 60 Schiphol, 10 June 2018

IJWEG TOEGANG TOT UGS-C EKJILETSEW GEWTSNEID NAABJIR Y C2 NIEUWE VIJFHUIZERTOCHT C81-C63 DIENSTWEG CU2 The single-engine plane registered in Germany with two KOP 36L 10 NOORDELIJKE DIENSTWEG RIJBAAN VICTOR into which an The pilots of the Boeing 737 calculated their take-off people on board was en route from Norderney, a German VIJFHUIZERWEG R 61 speeds and the necessary engine power on the basis of island in the East Frisian Islands, to Nordhorn-Lingen 3 T8 C81-C63 the assumption that they would take off from Runway 09 Airport in Germany. In the vicinity of Bourtange (in the investigation has at Intersection N5. The take-off position was Province of Groningen), at an altitude of approximately 9 17 2 4 V25 V22 subsequently changed to Intersection N4, reducing the 2,000 feet, the engine started to make a strange noise HOOFDVAART W4 R 62 available take-off distance, but the data for the and lost full power shortly afterwards according to the 11 beenC81-C63 launched performance calculations were not adjusted. The Boeing pilot’s statement. After performing a number of standard 737 then took off from Runway 09 at Intersection N4. operations, which failed to increase the engine power, the LOEVESTEINSE RANDWEG

WESTELIJKE DIENSTWEG 18C R 63 The aircraft was rotated at the calculated rotation speed pilot decided to perform an emergency landing. The pilot OPSTELandPLAATS left the ground only just before the end of the chose a potato field for this manoeuvre and performed DIENSTWEG HOOFDWEG WESTZIJDE RANDWEG P44 UGS-Drunway. the emergency landing with the landing gear retractedP40STRAAT KOP 18L T1 and withoutLOEVESTEINSE putting the flaps into the landing position. HOLIDAY CATERINGWEG AccordingAVENUE to the pilot, this procedure was intended to 12 16 15 14 5 V Classification: Serious incident prevent the aircraft from flipping over. The aircraft came GEWDIURKENNOZReference: 2018095 to a standstill on its belly and sustained minor damage. T10 P23 C2 SLOTERWEG C8 The passengers were unhurt. H2 T3 18 TESLA 13 OOSTELIJKE DIENSTWEG 18C DUIZENDBLADWEG OPLAADPLAATS VM The shortened investigation by the Dutch Safety Board is L SCHIPHOLWEG V27 focussing on the causes of the engine failure; the C81-C63 C63-C81 CU4 performance of the emergency landing procedure is not SPOTTERSPLAATS CATERINGWEG W5 being investigated. H1 8 6 W5 C3 1 8 L KOETSIERSTRAAT

Z2 C81-C63

C63-C81 VERLENGDE SLOTERWEG NOORDELIJKE DIENSTWEG 27 GEWMEOLBNEROK 1 8 L Classification: Accident S3

Reference: 2018074

27-09 S1

E6 27-09 NOORDELIJKE DIENSTWEG 27 Z 27-09

GEWREZIUHFJIV L81-R63

LOEVESTEINSE RANDWEG EWUEIN KJIDREEM

DIENSTWEG 18L DIENSTWEG Z1 T5 T12 HS1 HS2 OOSTELIJKE BRANDWEER 7 P24 C2 POST SLOTEN BUIS 2 R63-L81 S5 SNEEUWVLOOTWEG S7 BUIS 1 NOORDELIJKE DIENSTWEG 27 27 RIJKSWATERSTAAT S7 C1 VERMEER NIEUWE VIJFHUIZERTOCHT S13 S11 S9

90 POK GEWTSNEID POK 90 2 7 2 7 KAGERTOCHT D C 09 N1

L81-R63 09 N3 N9 S6 N2 HS3 S2

R63-L81 HS4 W6 N4 09-27 09-27 DIENSTWEG S8 09-27 KOP 22 S12 S10 09-27 S6 E5 09-27 09-27 E5 N5 L81-R63 09-27 P24 S14 09-27 S10 HOOFDVAART B P13 0 9 0 9 R63-L81 P16 P15 P14 A13 A16 A15 A14 36 Runway 09 with Intersections N4 and N5. (Source: StandardB Map of Amsterdam Airport Schiphol) P18 P17 The Beechcraft A36 after the emergency landing. A1 P20 A18 A17 36 ZUIDELIJKE DIENSTWEG 27 A19 P19 A H5 H6 E5 N1 WESTELIJKE DIENSTWEG 22 P21 A20 R17 36

P25 A21 36 L81-R63 A2 R19 A14 69 Z3 T7 T14 A R20 A17 A16 R18 36 A22 OPSLAG A13 E4 S2 WALAARDT SACRÉSTRAAT

DE-ICING 22

R21 NIVO H 22 A2 A19 2 A B E4 J1 NIVO R14 E4 J2 L81-R63 2 2 SCHIPHOLWEG SCHIPHOL WEG OM DE NOORD 2 R63-L81 H8 G1 THERMIEKSTRAAT 2 - Dutch Safety BoardP10 A20 P12 G BASCULEBRUG

J3 J4 NIVO HET EILAND 2 BUS ARR A10 22-04 BUS ARR A11 A12 2 2 THERMIEKSTRAAT A9

GEWREZIUHFJIV J5 J6 A12 A13 H7 G3

P11 E3 A11 22-04 GD L81-R63

P12 P11 3-L81 R6 A4 CANADAWEG 526 G2 Z C81-C63 B A E3 G W7 P26 RINSE HOFSTRAWEG R13 OOSTGAT 61 A11 L3 OOSTGATSTEEG SCHIPHOL P13 KLM A19N RINSE HOFSTRAWEG R15 BUS ARR A12 04-22 G2 ON DRAAIBRUG BUS ARR A09 A19S BUS ARR A14 NIELPSNOITA P14 HN DEP G11-16 L2 A3 31 T SLEEPDIENST Terminal 3 P10 H9 H10 A13 WESTELIJKE DIENSTWEG RIJBAAN Z WESTELIJKE DIENSTWEG 18C 10 BUS ARR A15 A10 R40 P27 EXCELLENCE A10 L1 04-22 COLLISTRAAT P15 PARKING R63-L81 R41

C81-C63 31 GL GEPLAND TS LOEVESTEINSE RANDWEG

NIR A13 A10 E2 S G VERTREKPASSAGE HAVENSTR. P16 WESTELIJKE DIENSTWEG 32 GEWREIZELP NAJ GEWREIZELP OH E A6 Terminal 2 NIVO 52 F BUS DEP D42 2 525 AANKOMSTPASSAGE BUS ARR A08 R42 HANGAR 14 TRAVERSE R12 P9 BUS DEP D06 A24 VIADUCT RINSE HOFSTRAWEG NOORD TRANSPORT WARTS STRAAT A-B-C-E-F-G-H-K-L CEINTUURBAAN NOORD JAN POORTSTRAAT

DELLAERT GE NIELP 04-22 DE GOEDE REE Z5 Z6 T9 T16 P28 P22 NAVIGATOR STRAAT STATION SPLEIN EGASSAPKERTREVTerminal 1 G3 GEWDNAR EKJILETSEW GEWDNAR SCHIPHOLDIJK BUS ARR A04 A9C R43 .R A9 RANDWEG T KRAAYVELD STRAAT SCHIPHOL BOULEVARD S.EPXE

INSP. PASSAGE 04-22 G4 A5 SCRIBENSTRAATKOKS MAAT P8 WEG UITKEER BEHOUDENVAARTWEGKAJUITSTRAAT E INKEER R11 STATIONSPLEIN ZW N I E U W A8 HENK VEENENDAAL OPSTELPLAATS WEG COCKPITPLEIN H11 BINNENWEG HALIM P.K.STRAAT BRUGSTRAAT C81-C63 SKIHUT A UGS-B 36 UITBREIDING B W8 CEINTUURBAAN ZUID HAVENMEESTERWEG A5

C SCHIPHOL A8 BOULEVARDWEGENERGIESTRAAT BUS ARR A03 22-04 BUS DEP C DAKOTAWEG

C21-C22-C23-C24 A8 A25 BUITENWEG RINSE HOFSTRAWEG R10 4 2 TRIPORT P7 BOSRAND C81-C63 PIET GUILLONARDWEG R A8

IND

EBREH

R8 22-04 G INN B BRUG

A25 A6 4 2 S

A7 TULIP R T18 24-06 P29 GIERSTR. E1 G4 KEMAJORANSTRAAT A N P6 PLATFORM IN D EDAKSLEDNAH W C81-C63 A5 M1

A15 ONTWIKKELING E 24-06 M3 24 GEWAIVATAB G BUS ARR A01 BUSBAAN

KOKSPASSAGE

GEBOUW A6 S7E VOLT WEG C63-C81 EVERT VD BEEKSTRAAT 523 24-06 04-22 BUS DEP P5 G4 R44 B1-B8(NIVO 0) DOORLAATPOST

R23 S6 S7W AMSTERDAM TOEGANG TOT UGS-B W12 W9 A26 A5 24-06 M5 VRACHTVAARDERSPLEIN A GEW

C81-C63 18C-36C WESTEINDE WESTZIJDEWEST OOST A7 04-22 NAMLE P30 G E W D N A R EKJILETSE W A4E P4 L81-R63 VIJFHUIZERWEG S5 OP

60 GEWTSNEID EKJILEDIUZ GEWTSNEID 60 G5 NE EVERTWESTEINDE VD BEEKSTRAAT A4W A27 DREEW P31 EDAKSLEDNAH A4 B 3 6 C R45 WESTELIJKE DIENSTWEG 22 TAARTSOTAHN A V L81-R63 C 6 3 R46

BALLON PLATFORM IN P33 T11 T20 R7 24-06 ONTWIKKELING M79 ZANDERIJSTRAAT 3 6 C A10

S8 M77

VIADUCT RINSE HOFSTRAWEG ZUID SITUATIE 24-06 M74

R24 NADARSTRAAT PAKHUISSTRAAT 20-10-17 TOT M7 P3 4 0 M75 SCHIPHOLDIJK W10 30-11-18 A3 HM SOUTHERN W11 Z A75 CROSSTRAAT MR.JAC.TAKKADE M70 M73 C 6 3 A65 FOKKERWEG

R25 A74 R6 M.VAN MEELWEG 4 0 M71 P32 VD-E A56 A64 S4 06-24 36 A73 A3 06-24 H12 G5 E.L.T.A.STRAAT A55 R5 M66 M69 R RINSE HOFSTRAWEG A63 A46 A72 M67 Z 26 A54 A62 C A45 A71 R4 P2 A9 M65 T13 T22 PELIKAANWEG A53 M62 GRENS LUCHTHAVENGEBIED A61 A2 BRANDWEER 0 4

A44 S G5 M63 WESTERKIMWEG 36C-18C POST RIJK Z1 RHP VD-D R27 A35 A52 R3 WEG POSTDUIFWEG A43 M61 SNIPWEG A2 M9 RIJKWEG 0 4 MANASSEN 18C-36C A34 A51 G JOHANNA AMSTERDAM BATAVIAWEG A42 A1C RIVISIESTRAAT STRAAT GRENS AIRSIDE (BEDRIJVENTERREIN SCHIPHOL-OOST) ZUIDELIJKE DIENSTWEG 06 RIJKWEG R46

Z2 RHP A33 R2

36C-18C A41 04 Z1 TENDER M2 Q PLEIN 24-06 UIVERWEG A32 A1B R47

BADHOEVEDORP Z5 VD-C A31 A 24-06 GRENS BEDRIJVENTERREIN SCHIPHOL-OOST 18C-36C A1A GEWTSNEID POK 40 R47 Z2 P1 WESTERKIMWEG HAARLEM R1 N41 TURBINESTRAAT T A A RTSELTTIH W K N A RF RIS BEVERWIJK Z7 DOORLAATPOST S3 VD-B TOEGANG TOT UGS-A B M4 WERKINGSGEBIED CBP - S / CPAAS ALKMAAR H13 H14 A12 N42 DIENSTWEG RIJKERSTREEK ZUIDELIJKE DIENSTWEG 06 KOP 36C R87 R48 PHILIP M4 POPELWEG VD-A

R28 SECURITY GRENS SCHIPHOL-OOST P21 24-06 PELIKAANWEG P20 M11 ZUIDEINDE

RIJNLANDERWEG R83 OUDE R49 24-06 VIJFHUIZERWEG ABDIJ EKJILETSEW GEWTSNEID R63 HORI PERIFERIEHEK / HEKNUMMER R82 G ZON TUNNEL S PAD KRONENBURG WESTERKIMWEG R81 OPSTELPLAATS S2 KOM STRAAT UGS-A ZUIDEINDE PAS PAD AMSTERDAM BATAVIAWEG R80 DOORLAATPOST R50 JUMBOWEG 29 KJIDLOHPIHCS TOEKANWEG INSTRUMENTENWEG R77 R M6 OMKOPPELPOST R74 S2 RIJNLANDERWEG R72 R73 NOORDELIJKE DIENSTWEG 06 06-24 ONDERWEG ANCHORAGELAAN ULD-POST OP ACHTERGEVEL R71 MARABOEWEG M13 06-24 G RIJKERSTREEK M8 H16 R

R29 24-06 51 ULD-POST MET TOEZICHT ACHTERTERREIN

VALKWEG R29 24-06 M8

HOEKSTEEN OUDE VIJFHUIZERWEG PERSONEN- EN VOERTUIGENDOORLAATPOST FLAMINGOWEG S1 GANDERWEG FOKKERWEG ANCHORAGELAAN H15 ULD-POST IN PERIFERIEHEK ZUIDELIJKE DIENSTWEG 06 PRESTWICKWEG H ONDERWEG 18 SHANNONWEG H17 TRUCK TEN POL PARKING 1 OMKOPPELPOST / ULD-POST MET TOEZICHT RIJNLANDERWEG P30 STRAAT M15 ANCHORAGELAAN TEN POL ACHTERTERREIN LEISTEEN REYKJAVIKWEG KRUISWEG 36

R63 GEWTSNEID EKJILETSOO GEWTSNEID R63 NOODUITGANG NS-TUNNEL VUURSTEEN R

M10 TRUCK FOKKERWEG RINSE HOFSTRAWEG ZUID PARKING 2 LAAN

TAURUSAVENUE HOOFDDORPDREEF N 196 FOLKSTONEWEG BREGUET

LAAN DIENSTWEG KOP 06 H18

BREGUETLAAN BREGUET 06 N 201 CARGO ENTRANCE

RANGOONWEG DIENSTWEG KOP 36R

FOKKERWEG H19 H20 TRUCK FOKKERWEG VD-A HOOFDDORPDREEF PARKING 3 NOODUITGANG ABDIJ TUNNEL

RIJKERDREEF

FOKKERWEG UITGANGSSTELLING SCHIPHOL KOOLHOVENLAAN KOOLHOVENLAAN FOKKERWEG PONTWEG A2 BAANSTATION AALSMEERDERWEG

CESSNALAAN KRUISWEG DOUGLASSINGEL P10 REMOTE DE-ICING SPOTS (WINTER) BEECHAVENUE FOKKERWEGKOOL AALSMEERDERDIJK CESSNALAAN

CAPRONILAAN GRENS SENSITIVE AREA TIJDENS BZO SIKORSKYLAAN KOOLHOVENLAAN HOV OOSTTAK NAALNEVOH WATERWOLF TUNNEL G G7 RIJBAANNUMMER

TUPOLEVLAAN TUPOLEVLAAN RIJKERDREEF 04-22 RUNWAY HOLDING POSITION TUPOLEVLAAN BELLSINGEL FOKKERWEG N 196 N 201 MAX. SPANWIJDTE KOOLHOVENLAAN MOLENWEG R44 VELDNUMMER BOEING AVENUE MOLENWEG STOPBAR PERMANENT BRANDEND MOLENWEG

ROZENBURGDREEF KRUISWEG STOPBAR SCHAKELBAAR FOKKERWEG

HERMADIX MOLENWEG

BOEING AVENUE STOPBAR BZO SCHAKELBAAR

KRUISWEG STOPBAR BZO NIET SCHAKELBAAR NARITAWEG MOLENWEG WINDZAK

MOLENWEG PUDONGWEG LICHTMAST H3 VERZAMELPLAATS PROEFDRAAIPLAATS INCHEONWEG A-GEBIED PUDONGWEG © AAS / OPS / SRA • VERSIE: 07 11 17

N 196 N 201 V1 V2

DIENSTWEG KOP 18R

SCHIPHOLWEG

18 R

V3 V4

SCHIPHOLWEG

R81 GEWTSNEID EKJILETSEW GEWTSNEID R81

HOOFDVAART

OOSTELIJKE DIENSTWEG 18R

HOOFDWEG WESTZIJDE V6 IJWEG

V5 V6

R81 GEWTSNEID EKJILETSEW GEWTSNEID R81

36L-18R V6

36L-18R

VIJFHUIZERTOCHT

IJWEG

OOSTELIJKE DIENSTWEG 18R VIJFHUIZERWEG HOOFDWEG OOSTZIJDE V BRANDWEER NIEUWERKERKERTOCHT POST VIJFHUIZEN C4 V2 HOOFDWEG WESTZIJDE

36L-18R

V16 36L-18R C6 V7 V10 V14 18C-36C DIENSTWEG KOP 18C C4 HOOFDVAART Y2 RHP Y1 RHP

36C-18C

18C-36C Y2 Y1 SCHIPHOLWEG

36C-18C NOORDELIJKE DIENSTWEG TWEEDUIZEND EL V3

36L-18R RIJBAAN VICTOR Runway incursion, Boeing 737-800 and SOTA Embraer 190, Amsterdam Airport T2 C3 C2

36L-18R V18 Y Schiphol, 27 July 2018 AMSTERDAM OUDE HAAGSEWEG V 18 SLOTERWEG AIRPORT HOTEL VS An Embraer E190 was lined up on Schiphol Runway 18C, C

V9 V12 P34 at the start of the runway near Intersection W1, ready for 1 8 C take-off. A Boeing 737-800 was near Intersection W4 on W1 C1 VN the same runway, ready to taxi onto the runway. The P35 V18 runway controller gave the Boeing 737 permission to line

1 8 C TAR WEST up on Runway 18C. Shortly afterwards, the runway V4 ZUIDELIJKE DIENSTWEGVS VE controller gave the Embraer permission to take off,C8 while C9 T1 T4 C81-C63 it was at the start of the runway. As the crew of the Boeing V19 KAGERTOCHT 3 6 L V15 V17 V 737 were taxiing towards the runway along Intersection W2

P36 W4, they heard the take-off clearance for the Embraer. C81-C63

3 6 L The crew stopped the Boeing 737 immediately; the plane HOOFDWEG OOSTZIJDE T6 VS V20 came to a standstill shortly before the runway. The crewY of

OOSTELIJKE DIENSTWEG RIJBAANY RIJBAAN VICTOR the Embraer aborted the take-off. OPSTELPLAATSEN D C 1 36 UGS-C C2 V21 V23 KOEKOEKSLAAN L C81-C63 V11 V13 Classification: Serious incident P22 Reference: 2018077 18 NIEUWERKERKERTOCHT ROLHEK W3 R 60

IJWEG TOEGANG TOT UGS-C EKJILETSEW GEWTSNEID NAABJIR Y C2 NIEUWE VIJFHUIZERTOCHT C81-C63 DIENSTWEG CU2 KOP 36L 10 NOORDELIJKE DIENSTWEG RIJBAAN VICTOR VIJFHUIZERWEG R 61 3 Runway 18C with Intersections W1 and W4. (Source: Standard Map of T8 Amsterdam Airport Schiphol) C81-C63 9 17 2 4 V22 HOOFDVAART V25 W4 R 62 11

C81-C63

LOEVESTEINSE RANDWEG

WESTELIJKE DIENSTWEG 18C R 63 OPSTELPLAATS DIENSTWEG HOOFDWEG WESTZIJDE RANDWEG P44 UGS-D P40STRAAT KOP 18L T1 LOEVESTEINSE

HOLIDAY CATERINGWEG V AVENUE 12 16 15 14 5

GEWDIURKENNOZ T10 P23 C2 SLOTERWEG C8 H2 T3 18 TESLA 13 OOSTELIJKE DIENSTWEG 18C DUIZENDBLADWEG OPLAADPLAATS VM L SCHIPHOLWEG V27 C81-C C63-C81 CU4 SPOTTERSPLAATS CATERINGWEG W5 63 H1 8 6 W5 C3 1 8 L KOETSIERSTRAAT

Z2 C81-C63 C63-C81 VERLENGDE SLOTERWEG NOORDELIJKE DIENSTWEG 27

GEWMEOLBNEROK 1 8 L S3

27-09 S1

E6 27-09 NOORDELIJKE DIENSTWEG 27 Z 27-09

GEWREZIUHFJIV

L81-R63

LOEVESTEINSE RANDWEG EWUEIN KJIDREEM

DIENSTWEG 18L DIENSTWEG Z1 T5 T12 HS1 HS2 OOSTELIJKE BRANDWEER 7 P24 C2 POST SLOTEN BUIS 2 R63-L81 S5 SNEEUWVLOOTWEG S7 BUIS 1 NOORDELIJKE DIENSTWEG 27 rd 27 Quarterly Aviation Report 3 quarter 2018 - 3 RIJKSWATERSTAAT S7 C1 VERMEER NIEUWE VIJFHUIZERTOCHT S13 S11 S9

90 POK GEWTSNEID POK 90 2 7 2 7 KAGERTOCHT D C 09 N1

L81-R63 09 N3 N9 S6 N2 HS3 S2

R63-L81 HS4 W6 N4 09-27 09-27 DIENSTWEG S8 09-27 KOP 22 S12 S10 09-27 S6 E5 09-27 09-27 E5 N5 L81-R63 09-27 P24 S14 09-27 S10 HOOFDVAART B P13 0 9 0 9 R63-L81 P16 P15 P14 A13 A16 A15 A14 36 B P18 P17 A1 P20 A18 A17 36 ZUIDELIJKE DIENSTWEG 27 A19 P19 A H5 H6 E5 N1 WESTELIJKE DIENSTWEG 22 P21 A20 R17 36

P25 A21 36 L81-R63 A2 R19 A14 69 Z3 T7 T14 A R20 A17 A16 R18 36 A22 OPSLAG A13 E4 S2 WALAARDT SACRÉSTRAAT

DE-ICING 22

R21 NIVO H 22 A2 A19 2 A B E4 J1 NIVO R14 E4 J2 L81-R63 2 2 SCHIPHOLWEG SCHIPHOL 2 R63-L81 G1 THERMIEKSTRAAT WEG OM DE NOORD P10 A20 P12 H8 G BASCULEBRUG

J3 J4 NIVO HET EILAND 2 BUS ARR A10 22-04 BUS ARR A11 A12 2 2 THERMIEKSTRAAT A9

GEWREZIUHFJIV J5 J6 A12 A13 H7 G3

P11 E3 A11 22-04 GD L81-R63

C81-C63 31 GL GEPLAND TS LOEVESTEINSE RANDWEG

C SCHIPHOL A8 BOULEVARDWEGENERGIESTRAAT BUS ARR A03 22-04 BUS DEP C DAKOTAWEG

C21-C22-C23-C24 A8 A25 BUITENWEG RINSE HOFSTRAWEG R10 4 2 TRIPORT P7 BOSRAND C81-C63 PIET GUILLONARDWEG R A8

IND

EBREH

R8 22-04 G INN B BRUG

A25 A6 4 2 S

A7 TULIP R T18 24-06 P29 GIERSTR. E1 G4 KEMAJORANSTRAAT A N P6 PLATFORM IN D EDAKSLEDNAH W C81-C63 A5 M1

A15 ONTWIKKELING E 24-06 M3 24 GEWAIVATAB G BUS ARR A01 BUSBAAN

KOKSPASSAGE

GEBOUW A6 S7E VOLT WEG C63-C81 EVERT VD BEEKSTRAAT 523 24-06 04-22 BUS DEP P5 G4 R44 B1-B8(NIVO 0) DOORLAATPOST

R23 S6 S7W AMSTERDAM TOEGANG TOT UGS-B W12 W9 A26 A5 24-06 M5 VRACHTVAARDERSPLEIN A GEW

C81-C63 18C-36C WESTEINDE WESTZIJDEWEST OOST A7 04-22 NAMLE P30 G E W D N A R EKJILETSE W A4E P4 L81-R63 VIJFHUIZERWEG S5 OP

60 GEWTSNEID EKJILEDIUZ GEWTSNEID 60 G5 NE EVERTWESTEINDE VD BEEKSTRAAT A4W A27 DREEW P31 EDAKSLEDNAH A4 B 3 6 C R45 WESTELIJKE DIENSTWEG 22 TAARTSOTAHN A V L81-R63 C 6 3 R46

BALLON PLATFORM IN P33 T11 T20 R7 24-06 ONTWIKKELING M79 ZANDERIJSTRAAT 3 6 C A10

S8 M77

VIADUCT RINSE HOFSTRAWEG ZUID SITUATIE 24-06 M74

R24 NADARSTRAAT PAKHUISSTRAAT 20-10-17 TOT M7 P3 4 0 M75 SCHIPHOLDIJK W10 30-11-18 A3 HM SOUTHERN W11 Z A75 CROSSTRAAT MR.JAC.TAKKADE M70 M73 C 6 3 A65 FOKKERWEG

R25 A74 R6 M.VAN MEELWEG 4 0 M71 P32 VD-E A56 A64 S4 06-24 36 A73 A3 06-24 H12 G5 E.L.T.A.STRAAT A55 R5 M66 M69 R RINSE HOFSTRAWEG A63 A46 A72 M67 Z 26 A54 A62 C A45 A71 R4 P2 T13 T22 A9 M62 M65 GRENS LUCHTHAVENGEBIED PELIKAANWEG A53 A61 BRANDWEER 0 4 A44 A2 S G5 WESTERKIMWEG

POST RIJK M63 Z1 RHP 36C-18C VD-D R27 A35 A52 R3 WEG POSTDUIFWEG A43 M61 SNIPWEG A2 M9 RIJKWEG 0 4 MANASSEN 18C-36C A34 A51 G JOHANNA AMSTERDAM BATAVIAWEG A42 A1C RIVISIESTRAAT STRAAT GRENS AIRSIDE (BEDRIJVENTERREIN SCHIPHOL-OOST) ZUIDELIJKE DIENSTWEG 06 RIJKWEG R46

Z2 RHP A33 R2

36C-18C A41 04 Z1 TENDER M2 Q PLEIN 24-06 UIVERWEG A32 A1B R47

R28 SECURITY GRENS SCHIPHOL-OOST P21 24-06 PELIKAANWEG P20 M11 ZUIDEINDE

R29 24-06 51 ULD-POST MET TOEZICHT ACHTERTERREIN

VALKWEG R29 24-06 M8

R63 GEWTSNEID EKJILETSOO GEWTSNEID R63 NOODUITGANG NS-TUNNEL VUURSTEEN R

M10 TRUCK FOKKERWEG RINSE HOFSTRAWEG ZUID PARKING 2 LAAN

TAURUSAVENUE HOOFDDORPDREEF N 196 FOLKSTONEWEG BREGUET

LAAN DIENSTWEG KOP 06 H18

BREGUETLAAN BREGUET 06 N 201 CARGO ENTRANCE

RANGOONWEG DIENSTWEG KOP 36R

FOKKERWEG H19 H20 TRUCK FOKKERWEG VD-A HOOFDDORPDREEF PARKING 3 NOODUITGANG ABDIJ TUNNEL

RIJKERDREEF

FOKKERWEG UITGANGSSTELLING SCHIPHOL KOOLHOVENLAAN KOOLHOVENLAAN FOKKERWEG PONTWEG A2 BAANSTATION AALSMEERDERWEG

CESSNALAAN KRUISWEG DOUGLASSINGEL P10 REMOTE DE-ICING SPOTS (WINTER) BEECHAVENUE FOKKERWEGKOOL AALSMEERDERDIJK CESSNALAAN

CAPRONILAAN GRENS SENSITIVE AREA TIJDENS BZO SIKORSKYLAAN KOOLHOVENLAAN HOV OOSTTAK NAALNEVOH WATERWOLF TUNNEL G G7 RIJBAANNUMMER

ROZENBURGDREEF KRUISWEG STOPBAR SCHAKELBAAR FOKKERWEG

HERMADIX MOLENWEG

BOEING AVENUE STOPBAR BZO SCHAKELBAAR

KRUISWEG STOPBAR BZO NIET SCHAKELBAAR NARITAWEG MOLENWEG WINDZAK

MOLENWEG PUDONGWEG LICHTMAST H3 VERZAMELPLAATS PROEFDRAAIPLAATS INCHEONWEG A-GEBIED PUDONGWEG © AAS / OPS / SRA • VERSIE: 07 11 17

N 196 N 201 Broken aileron control rod, Britten- Damage to wheel rim, Boeing 787-8, Norman BN-2B-21 Islander, Robert L. Cancún International Airport (Mexico), Occurences abroad Bradshaw Airport (Federation of Saint 7 July 2018 Kitts and Nevis), 4 July 2018 with Dutch After a flight from Juan Gualberto Gómez Airport in Cuba The Britten-Norman Islander took off from Sint Eustatius to Cancun International Airport in Mexico, a deflated tyre (in the Netherlands Antilles) in the Caribbean for a flight and damage to a wheel rim were observed in the main involvement into to neighbouring Saint Kitts and Nevis, part of the British landing gear of a Dutch-registered Boeing 787. Commonwealth. During the approach to Robert L. Bradshaw Airport, the crew experienced issues with The Mexican Dirección General de Aeronáutica Civil which an control of the ailerons. An inspection after landing (DGAC) has started an investigation into this occurrence, revealed that the control rod for one of the ailerons was for which the Dutch Safety Board has offered its broken. assistance.

investigation was The British Air Accidents Investigation Branch (AAIB) informed the Dutch Safety Board of the occurrence Classification: Serious incident because it was unclear in which phase of the flight the Reference: 2018094 launched by a control rod had broken and the aircraft had taken off from the Netherlands Antilles. The AAIB has started an foreign authority investigation into this occurrence. Classification: Serious incident Reference: 2018066

The flat tyre. (Source: Mexican DGAC)

Britten-Norman BN-2B-21 Islander. (Source: J. Allen)

4 - Dutch Safety Board Crash, Convair 340/440, near Mid-air collision, Schleicher ASW 20 and Wonderboom Airport (South Africa), Reims F172, Borken (Germany), 10 July 2018 18 July 2018

The aircraft took off from Runway 29 at Wonderboom The Dutch-registered Reims F172 was on a cross-country Airport in South Africa. On board were three crew flight to Stadtlohn in Germany. The Schleicher ASW 20, a members and sixteen passengers. Three of the glider, was making a local flight. The aircraft collided with passengers were of Dutch nationality. On 12 July 2018, each other, then landed at Borken Airport with substantial the plane was to be flown to the Aviodrome at Lelystad damage. The occupants were unhurt. Airport in the Netherlands. The German Bundesstelle für Flugunfalluntersuchung Smoke was detected after take-off, coming from the left (BFU) has started an investigation into this occurrence, for engine. The plane crashed shortly afterwards. One of the which the Dutch Safety Board has offered its assistance. people on board died and the other eighteen suffered injuries ranging from minor to major. Eight people on the ground were injured. The aircraft was completely Classification: Accident destroyed. Reference: 2018071

The South African Accident and Incident Investigation Division (AIID) has started an investigation into this occurrence, for which the Dutch Safety Board has offered its assistance.

Classification: Accident Reference: 2018068

The Reims F172 and Schleicher ASW 20 after the collision. (Source: BFU)

Archive photo of Convair. (Source: South African AIID)

Quarterly Aviation Report 3rd quarter 2018 - 5 Crash, Schempp-Hirth Janus B, Wrong flap position selected, Fokker F28 Occurences abroad Curienne (Savoie, France), 26 July 2018 Mark 0100, near Kalgoorlie-Boulder with Dutch Aerodrome (Australia), 1 August 2018 The Dutch-registered glider took off from Challes-les- involvement into Eaux in France with a pilot and an instructor on board. The Fokker 100 was conducting a flight from Perth to While executing a turn, the glider came too close to the Kalgoorlie in Australia. During the approach, the pilot in mountainside. The instructor then took over control and command accidentally made a call for ‘flaps 42’ instead of which an set a course for the valley. Given the height of the terrain a ‘flaps 25’ landing configuration. The first officer asked in the locality, this action was taken too late. As a result, the pilot in command a question about this call, which the investigation was the glider hit the treetops horizontally with its wings and latter interpreted incorrectly. The first officer selected lost speed. This circumstance caused the glider to crash. ‘flaps 42’; the pilot in command detected this fact and launched by a The pilot broke his lower leg, the instructor was uninjured. aborted the approach. The glider was totally destroyed. foreign authority The Australian Transport Safety Bureau (ATSB) has started The French Bureau d’Enquêtes et d’Analyses pour la an investigation into this occurrence, for which the Dutch Sécurité de l’Aviation civile (BEA) has started an Safety Board has offered its assistance. investigation into this occurrence, for which the Dutch Safety Board has offered its assistance. Classification: Incident Reference: 2018096 Classification: Accident Near-collision, ASK 21 and Embraer Reference: 2018075 190/195, Meschede (Germany), 18 July 2018

The Dutch-registered ASK 21 was flying at an altitude of approximately 1,200 metres in uncontrolled airspace, Class E, to the south of Bestwig in Germany. While executing a left turn, the pilot suddenly saw an Embraer straight ahead of the glider, flying from left to right and climbing. The glider pilot did not change his flight path because the left turn that the glider was making increased the distance between the two aircraft. The crew of the Embraer had seen the glider and executed a climbing left turn as an evasive manoeuvre.

The German Bundesstelle für Flugunfalluntersuchung (BFU) has started an investigation into this occurrence, for which the Dutch Safety Board has offered its assistance. Fokker 100 pedestal. (Source: simFlight)

Classification: Serious incident The Janus B after the accident. (Source: BEA) Reference: 2018073

6 - Dutch Safety Board Insufficient thrust during take-off, Crash, Beechcraft G58 Baron, Boeing 737-800, Zakynthos Airport Münster-Osnabrück Airport (Germany), (Greece), 8 August 2018 9 August 2018

During take-off, the crew noticed that the aircraft was The Dutch-registered aircraft with two people on board sluggish in its rotation and in its response to rudder took off from Lelystad Airport for a training flight. The deflections. A review of the take-off performance plane crashed at Münster-Osnabrück Airport and came to calculations showed that the take-off mass (TOM) of the a halt upside down. Both occupants were killed. aircraft used in the calculations was too low. The reason was that the zero fuel mass (ZFM) had been used by The German Bundesstelle für Flugunfalluntersuchung mistake rather than the TOM. The selected engine thrust, (BFU) has started an investigation into this occurrence, for which is partially dependent on the TOM, was therefore which the Dutch Safety Board has offered its assistance. insufficient for take-off. Preliminary information shows that the aircraft lifted off the ground on the last section of the runway. Classification: Accident Reference: 2018083 The Hellenic Air Accident Investigation and Aviation Safety Board (AAIASB) has started an investigation into this occurrence, in which the Dutch Safety Board and the operator are participating.

Classification: Serious incident Reference: 2018087

Archive photo of the Beechcraft G58 Baron. (Source: E. Stam)

Quarterly Aviation Report 3rd quarter 2018 - 7 Aircraft turned back during the flight, Damage incurred following emergency Occurences abroad Fokker 27 Mk050, Ovoot Airport landing, Lancair 320, Thezac (France), with Dutch (Mongolia), 18 August 2018 19 August 2018 involvement into The Fokker 50, with five crewmembers and fourteen During a flight from Marmande to Fumel in France, the passengers on board, was flying from Ovoot Airport to aircraft experienced engine problems, which led the pilot Chinggis Khaan International Airport in Mongolia. During to execute an emergency landing in a field. The aircraft which an the climb away from Ovoot Airport, engine torque in the was severely damaged. Neither occupant was harmed. right-hand engine decreased. The crew decided to switch investigation was off this engine and return to the airport. The landing was The French Bureau d’Enquêtes et d’Analyses pour la completed without further problems. Sécurité de l’Aviation civile (BEA) has not started an launched by a investigation into this occurrence, because the aircraft The Mongolian Air Accident Investigation Bureau has type concerned is listed in Annex II to European foreign authority started an investigation into this occurrence, for which the Regulation 216/2008. Dutch Safety Board has offered its assistance.

Classification: Accident Classification: Serious incident Reference: 2018090 Reference: 2018092

Archive photo of a Lancair 320. (Source: Texel International Airport)

The Fokker 50 after landing. (Source: Mongolian AAIB)

8 - Dutch Safety Board Runway excursion, Société Dyn’Aéro - MCR-01 (MLA), Rotenburg (Germany), 2 September 2018

After a flight from Fassberg to Rotenburg in Germany, the aircraft veered off the runway during landing and suffered damage. The pilot and passenger were unharmed.

The German Bundesstelle für Flugunfalluntersuchung (BFU) has started an investigation into this occurrence, for which the Dutch Safety Board has offered its assistance.

Classification: Serious incident Reference: 2018200

The plane after the runway excursion. (Source: BFU)

Quarterly Aviation Report 3rd quarter 2018 - 9 “See-and-avoid” is a key principle for VFR flights in order The Dutch Safety Board also made a recommendation to to keep clear of other air traffic and obstacles. The the European Aviation Safety Agency (EASA) that – for the Published investigation by the Dutch Safety Board revealed that this sake of commercial air transport – it should give priority to principle did not adequately work due to unfavourable the introduction of requirements for aircraft to be circumstances, namely: equipped with devices that can issue warnings of reports impending collisions with other aircraft. Such devices are • the constant position of the aircraft in relation to each already mandatory for aircraft with a maximum take-off other for a long period (there was no movement within mass of more than 5,700 kg or a maximum operational the pilots’ field of vision); passenger seating configuration of more than 19 seats. • the comparatively high relative velocity; The Do-228-100 does not currently meet these • the limited to nil visibility of the anti-collision lights due thresholds. to the fine, sunny weather; • the lack of an electronic warning system for potential The Dutch Safety Board published the English-language collisions. report and a Dutch summary on 18 September 2018 on its website. In addition, the following factors may have contributed to the near-collision:

• Because they were communicating on different radio frequencies, the pilots of the two aircraft did not know from which direction they could expect other traffic to be approaching. • The route of the turboprop aircraft ran close to the compulsory reporting point for Grass Runway 05, resulting in an increased chance that the planes could come in contact with each other. Near mid-air collision, Dornier Do-228-100 - D-IROL and In addition to the above causes and factors, the Board Tecnam P92 Echo Super - PH-4D3, investigated the effectiveness of the straight-in approach procedure that applied to the turboprop aircraft. In near Lelystad Airport, 1 August 2015 particular, it appeared that the pilots of the turboprop aircraft had applied a different interpretation of this A twin-engine turboprop aircraft coming from Texel approach procedure, based on their specific context. As a Archive photo of D-IROL. (Source: A. Oferta) experienced a near-collision in the vicinity of Lelystad result, they approached the landing runway from a Airport with a light, single-engine aircraft (microlight direction to which traffic in the standard circuit does not aircraft, MLA) that was making a local flight. A total of 20 normally pay attention. This situation resulted in an people were on board the two aircraft. Both flights were increased risk of collision within the ATZ. being conducted under Visual Flight Rules (VFR) in Class G airspace, just outside the Aerodrome Traffic Zone (ATZ) To improve the clarity of the straight-in procedure, and of Lelystad Airport. The turboprop aircraft heading to thus the effectiveness of the approach procedure, the Lelystad Airport was supposed to land on Paved Runway Dutch Safety Board recommended to the Human 05 and the MLA was supposed to land on Grass Runway Environment and Transport Inspectorate (ILT) that all VFR 05. The pilot of the MLA only noticed the other plane at a approach procedures (flight paths) should be visualised late stage, but he was able to execute an evasive (marked out) on the VFR approach charts of uncontrolled manoeuvre. The crew of the turboprop aircraft had not airfields in the Netherlands. seen the MLA.a

10 - Dutch Safety Board Damage to left wing spar, SZD-51-1 The Dutch Safety Board published the English-language “Junior” - PH-1006, Larserveld, report and a Dutch summary on 16 August 2018 on its 15 July 2016 website.

After a flight of over an hour, the pilot decided to perform a number of loops. At that moment, the glider was at an altitude of approximately 700 metres. The pilot stated that he increased speed to 180 km/h and started the loops gradually. The first loop proceeded without incident. The pilot then began a second loop in the same manner. At the end of the second loop, when the glider was flying horizontally again, the pilot heard a loud bang behind him. The pilot still had complete control over the glider and flew an alternative circuit before landing safely.

An inspection after the flight showed that the underside of the trailing edge of the left wing was cracked, close to the end of the glass-fibre reinforced plastic (GFRP) spar. Further investigation showed that the crack was already present before the incident. The aluminium insert in the Crack in the left wing spar. (Source: NLR) wing spar had become detached from the GFRP material, which led to a certain degree of play that in turn caused severe, localised stresses in the spar. It is likely that the spar finally gave way due to the high stress at the end of the loop. The reason why the aluminium insert had come loose was impossible to establish with certainty.

The Dutch Safety Board informed the Polish civil aviation authority on the day after the incident. In collaboration with this authority, Allstar PZL Glider (as the holder of the type certificate) is currently working on a supplement to the Technical Maintenance Manual in which inspections are conducted to check the adhesion of the aluminium insert in the wing spar(s). Work is also being done on a Service Bulletin, which will indicate that the same inspections must be conducted on all gliders that have been involved in hard landings and/or ground skids. Neither the supplement nor the Service Bulletin had been completed at the time of publication of this report.

Quarterly Aviation Report 3rd quarter 2018 - 11 During a normal landing, the runway threshold would be Following the incident, the airline concerned took the Voorvallen die passed at an altitude of around 50 feet (15 metres)2 and necessary measures to prevent incidents such as hard and Published the actual landing would take place in the touchdown short landings. The measures underscore the importance niet uitgebreid zone at a distance of at least 300 metres from the start of of internationally accepted guidelines on the criteria for a reports the runway. Landings that take place before the aiming stable approach and the execution of a go-around if the zijn onderzocht point are called short landings. A possible consequence approach becomes unstable. of short landings is that the wheels of the aircraft may touch the ground before the runway threshold. Beyond The Dutch Safety Board published the report on its the edges of the landing runway, the ground is not website on 19 July 2018. suitable to bear the weight of an aircraft. If the wheels come into contact with the soft ground beyond the edges of the landing runway, there is a chance of substantial damage to the landing gear, resulting in possible control issues. The possible consequences in such a situation could be serious, which makes short landings potentially dangerous. In this incident, the margin between the landing before the threshold of Runway 36R and the place where the actual landing took place was minimal. Threshold lighting damaged during landing, Boeing 747-8F - VQ-BLR, The hard landing was the consequence of a high rate of Amsterdam Airport Schiphol, descent. The landing flare did not reduce this rate or did not do so sufficiently. 13 January 2017 The fact that the plane made contact with the runway Archive photo of a Boeing 747-8F. (Source: AirBridgeCargo Airlines) A Boeing 747-8F executed a landing on Landing Runway threshold was a combination of systematically flying 36R at Amsterdam Airport Schiphol. During this landing, below the desired glide slope, from the moment that the the wheels of the right main landing gear came into crew deactivated the autopilot at 700 feet and the pilot in contact with the runway lighting marking the start of command assumed control, and the high rate of descent Runway 36R. This runway lighting was at the runway shortly before landing. The plane was making a stable threshold and 300 metres in front of the aiming point approach until right before the landing. marking located within the touchdown zone.1 Three runway lights shattered under the weight of the wheels. Immediately before the landing, the GPWS generated two The plane also suffered damage; multiple dents and warnings (‘glideslope’ and ‘sink rate’) and the criteria for a scratches were visible on the fuselage and wings. The stable approach were exceeded. This situation damage to the plane was observed by the technical constituted grounds for executing a go-around. However, service after the flight. The cockpit crew was aware of the a go-around was not performed by the pilot in command, fact that they had made a hard landing but had not although it was required by the procedures. The pilot in encountered any problems in controlling the plane or command stated that despite these signals, it would not slowing down to a safe taxi speed. It was only when they have been possible to react by initiating a go-around received the message from the technical service that the procedure, because the landing occurred almost crew realised that they had hit something during the immediately thereafter. landing.

1 T he touchdown zone markings start a considerable distance before the aiming point marking. 2 Source: 747 Flight Crew Training Manual, Boeing.

12 - Dutch Safety Board Crash during approach, Dyn’Aéro MCR Near-collision, Fokker 50 - OO-VLF and The Swiss Transportation Investigation Safety Board (STSB) 45-2002 - PH-VGH, Água Longa (Santo Piper PA-28RT-201T - OK-ELL, 10 NM published the report on 2 October 2018. The report can Tirso, Portugal), 26 May 2015 north-east of Friedrichshafen Airport be downloaded from the STSB website. (Germany), 21 April 2016 The single-engine homebuilt aircraft carrying two people had taken off from Vilar de Luz Airport in Portugal. After The Fokker 50 and Piper PA-28RT both had performing several circuits, the aircraft rolled while Friedrichshafen Airport as their destination and were turning left into the final approach to Runway 34, after flying on converging courses in Class E airspace. The which it crashed killing both occupants and completely Fokker 50, which was flying under Instrument Flight Rules, destroying the aircraft. was in contact with Approach Control. The Piper, which was flying under Visual Flight Rules, was in contact with The pilot lost control of the aircraft as a result of local Air Traffic Control in the tower. asymmetrically extended flaps. This situation was caused by the failure of the flap operating system, which in turn At a certain moment, the short-term conflict alert system was caused by a worn bronze nut in the actuator. An at Air Traffic Control generated a warning for both planes, Airworthiness Directive applies to this nut, which states at which point the approach controller informed the crew that the nut must be replaced; however, this replacement of the Fokker 50 about the presence of unknown VFR was not done. traffic. The crew of the Fokker 50 saw the traffic flying at the same altitude on the screen of their Traffic Alert and The Portuguese Gabinete de Prevenção e Investigação de Collision Avoidance System (TCAS). The pilot in command Acidentes com Aeronaves (GPIAA) published the report decided to execute an evasive manoeuvre by turning 90 on 9 July 2018. The report can be downloaded from the degrees to the right. At approximately the same moment, GPIAA website. the pilot of the Piper reported that he had seen the Archive photo of OK-ELL. (Source: J. Beran) Fokker 50. During the evasive manoeuvre, the flight level of both planes was around 4,000 feet AMSL. The Classification: Accident minimum distance between the two aircraft was 0.5 NM Reference: 2015033 horizontally with a vertical distance of 100 feet. Both aircraft continued their approach without further incident.

Wreckage of PH-VGH. (Source: GPIAA)

Quarterly Aviation Report 3rd quarter 2018 - 13 Wire strike during night flying, Due to the vision system used on board, visibility is Apache AH-64D - Q-29, Zoelmond, limited in darkness. The image on the pilots’ displays Defence 13 November 2017 gives poor visibility of small or thin objects such as high- voltage power lines.

On 13 November 2017, a night flying exercise took place During part of the exercise, a simulated attack on a with an Apache-type helicopter (AH-64D) from Defence practice target, the helicopter itself was attacked by Helicopter Command (DHC) in the vicinity of Zoelmond. ground units. The initial response of the crew to the attack During an evasive manoeuvre, the helicopter made by hostile forces was to swerve. When the practice enemy contact with the top wire of a high-voltage power line, the attacked, the threat was from the left. As a result, the earth wire, which caused a short circuit in the power grid. response entailed moving the helicopter swiftly to the This situation led to a power cut in the vicinity of the right and dropping down out of sight of the practice incident, in which approximately 25,000 households were enemy. without power for several hours. The helicopter landed in a meadow immediately to the north of the location of the At that moment, the back-seater was not aware of the wire strike. helicopter’s location in relation to the high-voltage power lines because his attention was on the simulated combat DHC helicopter pilots regularly conduct flight exercises at situation. low altitudes in darkness. The training flights are performed under the most realistic conditions possible. When the training area was selected, the presence of Because of the darkness, limited visibility and low high-voltage power lines was not explicitly taken into altitudes at which the helicopters are operating, these consideration, because low-flying helicopters do have to training flights involve increased risk. However, the flights deal with obstacles in the form of power lines and pylons are necessary to maintain the operational status of the during actual deployment. These obstacles were helicopter crews. The flight that caused the accident was appropriate for creating a realistic exercise in order to part of an exercise designed to ensure the operational ensure crews are well prepared for actual deployment. readiness of the helicopter crews. To mitigate the risk of collisions with obstacles and power The crew of an Apache helicopter consists of two pilots, a lines, Defence took a range of measures including front-seater and a back-seater, named for their positions reconnaissance flights along the route prior to the night- in the cockpit. The front-seater is the pilot in command time flight, the composition of the crews, the use of charts and as such is responsible for the performance of the on which high-voltage power lines and obstacles were mission as a whole. The back-seater is mainly responsible projected and shaded, and set procedures for flying past for the actual flying of the helicopter. cables. These measures were indeed followed during the exercise. An additional measure could consist of placing an active warning system in the helicopter.

14 - Dutch Safety Board Given his experience, the set of tasks to be performed by the back-seater was substantial: he had to fly the helicopter, monitor the surrounding area using the limited tools at his disposal and heed the command of the front- seater to bring the helicopter into the right position in order to fire missiles at the practice target within the context of the simulated attack. At the same time, he had to execute an evasive manoeuvre after the attack by the practice enemy. This task load may have contributed to the incident.

The Dutch Safety Board made three recommendations to the minister of Defence for options to avoid wire strikes, the availability of flight hours and the use of flight charts.

The Dutch Safety Board published the report on 6 September 2018 on its website.

Apache AH-64D.

Quarterly Aviation Report 3rd quarter 2018 - 15 V1 V2

DIENSTWEG KOP 18R

SCHIPHOLWEG

18 R

V3 V4

SCHIPHOLWEG

R81 GEWTSNEID EKJILETSEW GEWTSNEID R81

HOOFDVAART

OOSTELIJKE DIENSTWEG 18R

HOOFDWEG WESTZIJDE V6 IJWEG

V5 V6

R81 GEWTSNEID EKJILETSEW GEWTSNEID R81

36L-18R V6

36L-18R

VIJFHUIZERTOCHT

IJWEG

OOSTELIJKE DIENSTWEG 18R VIJFHUIZERWEG HOOFDWEG OOSTZIJDE V BRANDWEER NIEUWERKERKERTOCHT POST VIJFHUIZEN C4 V2 HOOFDWEG WESTZIJDE

36L-18R

V16 36L-18R C6 V7 V10 V14 18C-36C DIENSTWEG KOP 18C C4 HOOFDVAART Y2 RHP Y1 RHP

36C-18C

18C-36C Y2 Y1 SCHIPHOLWEG

36C-18C NOORDELIJKE DIENSTWEG TWEEDUIZEND EL V3

36L-18R RIJBAAN VICTOR SOTA T2 C3 C2

36L-18R V18 Y AMSTERDAM OUDE HAAGSEWEG V 18 SLOTERWEG AIRPORT HOTEL VS C

V9 V12 P34 1 8 C W1 C1 VN P35 V18

1 8 C TAR WEST V4 ZUIDELIJKE DIENSTWEGVS VE C8 C9 T1 T4 C81-C63

V19 KAGERTOCHT 3 6 L V15 V17 V W2

P36 C81-C63 3 6 L VS V20 HOOFDWEG OOSTZIJDE Y T6

OOSTELIJKE DIENSTWEG RIJBAANY RIJBAAN VICTOR OPSTELPLAATSEN D C 1 36 UGS-C C2 V21 V23 KOEKOEKSLAAN L C81-C63 V11 V13 P22

18 NIEUWERKERKERTOCHT ROLHEK W3 R 60

IJWEG TOEGANG TOT UGS-C EKJILETSEW GEWTSNEID NAABJIR Y C2 NIEUWE VIJFHUIZERTOCHT C81-C63 DIENSTWEG CU2 KOP 36L 10 NOORDELIJKE DIENSTWEG RIJBAAN VICTOR VIJFHUIZERWEG R 61 3 T8 C81-C63

9 17 2 4 V22 HOOFDVAART V25 W4 R 62 11

C81-C63

LOEVESTEINSE RANDWEG

WESTELIJKE DIENSTWEG 18C R 63 OPSTELPLAATS DIENSTWEG HOOFDWEG WESTZIJDE RANDWEG P44 UGS-D P40STRAAT KOP 18L T1 LOEVESTEINSE

HOLIDAY CATERINGWEG V AVENUE 12 16 15 14 5

GEWDIURKENNOZ T10 P23 C2 SLOTERWEG C8 H2 T3 18 TESLA 13 OOSTELIJKE DIENSTWEG 18C DUIZENDBLADWEG OPLAADPLAATS VM L SCHIPHOLWEG V27 C81-C63 C63-C81 CU4 SPOTTERSPLAATS CATERINGWEG W5 H1 8 6 W5 C3 1 8 L KOETSIERSTRAAT

Z2 C81-C63 C63-C81 VERLENGDE SLOTERWEG NOORDELIJKE DIENSTWEG 27

GEWMEOLBNEROK 1 8 L S3

27-09 S1

E6 27-09 NOORDELIJKE DIENSTWEG 27 Z 27-09

GEWREZIUHFJIV

L81-R63

LOEVESTEINSE RANDWEG EWUEIN KJIDREEM

90 POK GEWTSNEID POK 90 2 7 2 7 KAGERTOCHT D C 09 N1

L81-R63 09 N3 N9 S6 N2 HS3 S2

P25 A21 36 L81-R63 A2 R19 A14 69 Z3 T7 T14 A R20 A17 A16 R18 36 A22 OPSLAG A13 E4 S2 WALAARDT SACRÉSTRAAT

DE-ICING 22

R21 NIVO H 22 A2 A19 2 A B E4 J1 NIVO R14 E4 J2 L81-R63 2 2 SCHIPHOLWEG SCHIPHOL 2 R63-L81 G1 THERMIEKSTRAAT WEG OM DE NOORD P10 A20 P12 H8 G BASCULEBRUG

J3 J4 NIVO HET EILAND 2 BUS ARR A10 22-04 BUS ARR A11 A12 2 2 THERMIEKSTRAAT A9

GEWREZIUHFJIV J5 J6 A12 A13 H7 G3

P11 E3 A11 22-04 GD L81-R63

P12 P11 3-L81 R6 A4 CANADAWEG 526 G2 Z C81-C63 B A E3 G W7 P26 RINSE HOFSTRAWEG R13 OOSTGAT 61 A11 L3 OOSTGATSTEEG SCHIPHOL P13 KLM A19N RINSE HOFSTRAWEG R15 BUS ARR A12 04-22 G2 ON DRAAIBRUG A Boeing 737 aircraft landed on Runway 18R and taxiedBUS ARR A09 A19S BUS ARR A14 NIELPSNOITA P14 HN DEP G11-16 L2 A3 31 T SLEEPDIENST towards Parking SpaceTerminal D54. 3 Because Runway 18C was P10 H9 H10 A13 WESTELIJKE DIENSTWEG RIJBAAN Z WESTELIJKE DIENSTWEG 18C 10 BUS ARR A15 A10 R40 P27 Occurences being usedEXCELLENCE for landing traffic at the same time, the aircraft A10 04-22 L1 COLLISTRAAT P15 PARKING R63-L81 R41

C81-C63 taxied via the southern taxi route along Taxiway Zulu. 31 GL GEPLAND TS LOEVESTEINSE RANDWEG

After Taxiway Zulu, the Boeing continued on its wayNIR along A13 A10 E2 S G Taxiway Quebec. VERTREKPASSAGE HAVENSTR. P16that have not WESTELIJKE DIENSTWEG 32 GEWREIZELP NAJ GEWREIZELP OH E A6 Terminal 2 NIVO 52 F BUS DEP D42 2 525 Maintenance was being performedAANKOMSTPASSAGE on Runway 06-24. Part BUS ARR A08 R42 HANGAR 14 TRAVERSE R12 P9 BUS DEP D06 A24 VIADUCT RINSE HOFSTRAWEG NOORD of the adjacentTRANSPORT Taxiway Bravo was also closed to air WARTS been investigated STRAAT A-B-C-E-F-G-H-K-L CEINTUURBAANtraffic. NOORD As a result, the Boeing JANwas directed to travel along POORTSTRAAT

DELLAERT GE NIELP 04-22 DE GOEDE REE Z5 Z6 T9 T16 P28 P22 the non-standard Taxiway Alpha up to Intersection A9. NAVIGATOR STRAAT STATION SPLEIN EGASSAPKERTREVTerminal 1 G3 GEWDNAR EKJILETSEW GEWDNAR Here, the aircraft turned onto the apron and headed for SCHIPHOLDIJK BUS ARR A04 A9C R43 extensively .R A9 RANDWEG D54. This action was not coordinated with theT ground KRAAYVELD STRAAT SCHIPHOL BOULEVARD S.EPXE controller who was responsible for the apron where the INSP. PASSAGE 04-22 G4 A5 SCRIBENSTRAATKOKS MAAT incident took place. P8 WEG UITKEER BEHOUDENVAARTWEGKAJUITSTRAAT E INKEER R11 STATIONSPLEIN ZW N I E U W A8 HENK Aircraft Stand D27 was occupied by another Boeing 737 VEENENDAAL OPSTELPLAATS WEG COCKPITPLEIN H11 that was beingBINNENWEG pushed backwards in preparation for HALIM P.K.STRAAT BRUGSTRAAT C81-C63 SKIHUT A UGS-B 36 UITBREIDING B W8 departure. CEINTUURBAANAn Embraer ZUID 190HAVENMEESTERWEG parked at D31 was also given A5

C SCHIPHOL A8 permission for pushback. The pushback of the Embraer 22-04 BOULEVARDWEGENERGIESTRAAT BUS ARR A03

started just as the incoming Boeing on Taxiway AlphaBUS DEP C was DAKOTAWEG

C21-C22-C23-C24 A8 A25 BUITENWEG RINSE HOFSTRAWEG R10 4 2 TRIPORT P7 BOSRAND C81-C63 taxiing past the Embraer. PIET GUILLONARDWEG R A8

IND

EBREH

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Intersection A9 and the parking spaces around Pier D. O

A25 A6 4 2 S

A7 TULIP R T18 24-06 P29 GIERSTR. E1 G4 KEMAJORANSTRAAT A When the Boeing executed a left turn at Intersection A9, (Source: Standard Map of Amsterdam Airport Schiphol) N P6 PLATFORM IN D EDAKSLEDNAH W C81-C63 A5 M1

the Embraer entered the field of vision of the Boeing’s A15 ONTWIKKELING E 24-06 M3 24 GEWAIVATAB G BUS ARR A01 BUSBAAN

crew.KOKSPASSAGE The driver of the aircraft tug saw the Boeing at the

GEBOUW A6 S7E VOLT WEG C63-C81 EVERT VD BEEKSTRAAT 523 24-06 04-22 BUS DEP P5 G4 R44 Near-collision on the ground, same moment. Both the crewB1-B8(NIVO of 0) the Boeing and the driver DOORLAATPOST

R23 S6 S7W AMSTERDAM TOEGANG TOT UGS-B W12 W9 A26 Boeing 737 - PH-BGB and Embraer 190 - immediately took action and stopped. According to the A5 24-06 M5 VRACHTVAARDERSPLEIN A GEW

C81-C63 18C-36C WESTEINDE WESTZIJDEWEST OOST people involved, the distance between the two aircraft A7 04-22 NAMLE G-LCYP, AmsterdamG E W Airport D N A R EKJILETSESchiphol, W P4 L81-R63 P30 was no more than a few metres. A4E VIJFHUIZERWEG 20 April 2017 S5 OP 60 GEWTSNEID EKJILEDIUZ GEWTSNEID 60 G5 NE EVERTWESTEINDE VD BEEKSTRAAT A4W A27 DREEW P31 EDAKSLEDNAH LVNL’s investigation report showed that the ground A4 B 3 6 C R45 WESTELIJKE DIENSTWEG 22 TAARTSOTAHN On 20 April 2017, a near-collision occurred at Amsterdam controller involved had not noticed the conflict between A V L81-R63 C 6 3 R46

BALLON Airport Schiphol between two aircraft on the ground. the BoeingPLATF taxiingORM IN to D54 and the Embraer being pushed P33 T11 T20 R7 24-06 ONTWIKKELING M79 ZANDERIJSTRAAT 3 6 C A10

A Boeing 737 was taxiing to its aircraft stand in front of back. This was partly due to the complexity of the volume S8 M77

VIADUCT RINSE HOFSTRAWEG ZUID SITUATIE 24-06 M74

R24 NADARSTRAATthe terminalPAKHUISSTRAAT after landing and an Embraer 190 was being of traffic,20-10-17 in combination TOT with the maintenance work on M7 P3 4 0 M75 SCHIPHOLDIJK W10 30-11-18 A3 HM SOUTHERN W11 Z pushed from its aircraft stand to the apron by an aircraftA75 Runway 06-24 and the use of different taxi routes than CROSSTRAAT MR.JAC.TAKKADE M70 M73 C 6 3 A65 FOKKERWEG

R25 tug. A74 normal. The analysis alsoR6 revealed that the occurrence M.VAN MEELWEG 4 0 M71 P32 VD-E A56 A64 took place due to insufficient collaboration among the S4 06-24 36 A73 A3 06-24 H12 G5 E.L.T.A.STRAAT A55 R5 M66 M69 Air TrafficR Control The NetherlandsRINSE HOFSTRAWEG (LVNL) reported thisA63 ground controllers. A46 A72 M67 Z occurrence 26 to the Dutch Safety Board and initiatedA54 an A62 C A45 A71 R4 P2 M65 T13 T22 PELIKAANWEGinvestigation itself. The Dutch Safety Board did not start A9 M62 GRENS LUCHTHAVENGEBIED A53 A61 BRANDWEER 0 4 A44 A2 S G5 WESTERKIMWEG

its own investigation into the occurrence. This text is Classification: Serious incident POST RIJK M63 Z1 RHP 36C-18C VD-D R27 A35 A52 R3 WEG POSTDUIFWEG A43 M61 SNIPWEG based on the outcomes of the LVNL investigation. Reference:A2 2017065 M9 RIJKWEG 0 4 MANASSEN 18C-36C A34 A51 G JOHANNA AMSTERDAM BATAVIAWEG A42 A1C RIVISIESTRAAT STRAAT GRENS AIRSIDE (BEDRIJVENTERREIN SCHIPHOL-OOST) ZUIDELIJKE DIENSTWEG 06 RIJKWEG R46

Z2 RHP A33 R2

36C-18C A41 04 Z1 TENDER M2 Q PLEIN 24-06 UIVERWEG A32 A1B R47

R28 SECURITY GRENS SCHIPHOL-OOST P21 24-06 PELIKAANWEG P20 M11 ZUIDEINDE

R29 24-06 51 ULD-POST MET TOEZICHT ACHTERTERREIN

VALKWEG R29 24-06 M8

R63 GEWTSNEID EKJILETSOO GEWTSNEID R63 NOODUITGANG NS-TUNNEL VUURSTEEN R

M10 TRUCK FOKKERWEG RINSE HOFSTRAWEG ZUID PARKING 2 LAAN

TAURUSAVENUE HOOFDDORPDREEF N 196 FOLKSTONEWEG BREGUET

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CESSNALAAN KRUISWEG DOUGLASSINGEL P10 REMOTE DE-ICING SPOTS (WINTER) BEECHAVENUE FOKKERWEGKOOL AALSMEERDERDIJK CESSNALAAN

CAPRONILAAN GRENS SENSITIVE AREA TIJDENS BZO SIKORSKYLAAN KOOLHOVENLAAN HOV OOSTTAK NAALNEVOH WATERWOLF TUNNEL G G7 RIJBAANNUMMER

ROZENBURGDREEF KRUISWEG STOPBAR SCHAKELBAAR FOKKERWEG

HERMADIX MOLENWEG

BOEING AVENUE STOPBAR BZO SCHAKELBAAR

KRUISWEG STOPBAR BZO NIET SCHAKELBAAR NARITAWEG MOLENWEG WINDZAK

MOLENWEG PUDONGWEG LICHTMAST H3 VERZAMELPLAATS PROEFDRAAIPLAATS INCHEONWEG A-GEBIED PUDONGWEG © AAS / OPS / SRA • VERSIE: 07 11 17

N 196 N 201 Emergency landing following operating The crew suspected that it was a case of an ‘out-of- problems, CzechACWor SportCruiser, control’ electric trim or servo control of the autopilot, or PH-BEM, Oudewater, 21 April 2018 both. According to the aircraft manufacturer, Czech Sport Aircraft a.s., incidents have occurred in which an excessive quantity of solder on the contact points of the push-to- The pilot was flying under Visual Flight Rules at an altitude talk button on the stick resulted in the elevator trim of 1,300 feet from Breda International Airport to Texel responding in such a way that the nose of the plane tilted International Airport. The autopilot was activated. The up. The manufacturer issued a Service Bulletin on this aircraft had two occupants. The pilot experienced subject in 2010 for the SportCruiser and PiperSport operating problems in the vicinity of Oudewater. He (SB-SC-001, dated 4 June 2010). In the Service Bulletin, an stated that the plane abruptly went into a nose dive. He inspection of the stick grip and the application of had a lot of trouble returning the plane to the horizontal. additional insulation were recommended. The With the help of the autopilot, he tried to keep the plane recommendation in the Service Bulletin was implemented horizontal. When this procedure was unsuccessful, he for PH-BEM on 2 July 2010. switched off the autopilot and tried to trim the plane by making an “up” input. Initially, this action had no The Dutch Safety Board did not visit the crash site and noticeable result. With the help of his passenger, who also was unable to establish how or when the glasses case held a pilot licence, the pilot in command then attempted came to be in the vicinity of the control mechanism. The to lift the nose of the plane. However, the aircraft was Dutch Safety Board did not conduct an investigation into difficult to control. The ailerons and the rudder apparently the functioning of the electric trim or autopilot and can responded normally to the movement of the control neither confirm nor rule out the glasses case scenario as a instruments. The pilot then decided to make an possible cause of the operating problems. emergency landing and selected a field in which to do so. During the emergency landing, the left wheel of the main landing gear got caught in a ditch which the pilot had not Classification: Accident previously noticed. The aircraft then turned to the left and Reference: 2018020 came to a halt with its nose in the ground. Nobody on the aircraft was harmed, although the aircraft was damaged.

The pilot held a valid private pilot licence, a PPL(A) with an The glasses case. (Source: Police aviation division) SEP(land) rating, and a valid Class 2 medical certificate. His total flight experience was 365 hours, 84 of which were acquired on the aircraft type concerned.

After the emergency landing, a glasses case was found in the vicinity of the control mechanisms. The crew stated that the sudden nose dive could not have been caused by this glasses case, because the plane had been flying steadily on autopilot without any course or altitude corrections. According to the crew, the case ended up in that position due to the jolt of the emergency landing or when they were taking their personal possessions out of the plane.

PH-BEM after the emergency landing. (Source: Police aviation division)

Quarterly Aviation Report 3rd quarter 2018 - 17 Runway excursion, New Piper PA-28-181, The pilot held a private pilot licence, a PPL(A) with a valid Occurences PH-VSX, Breda International Airport, SEP(land) rating, and a valid Class 2 (PPL) and LAPL 15 June 2018 medical certificate. His total flight experience was 280 that have not hours, 230 of which were acquired on the aircraft type concerned. The pilot had made two flights in the same been investigated The pilot, who was the sole occupant of the plane, had plane on the day before the incident. conducted a flight under Visual Flight Rules from Lelystad Airport to Breda International Airport. He stated that the This runway excursion was caused because the pilot had extensively flight proceeded without incident. At Breda International performed the approach and landing at a high speed, Airport, Runway 07 was in use, which had an available after which he had failed to execute a go-around. The landing distance of 752 metres. The wind was variable; the runway excursion was preceded by the fact that the direction varied from 100 to 240 degrees and the speed downwind leg was flown at an altitude which was greater from around 6 to 8 knots. When the aircraft flew into the than the prescribed altitude. Although he extended the circuit area, the pilot entered on a downwind leg at an downwind leg in order to fly a longer final approach, the altitude of 1,000 feet AMSL and a speed of 100 knots. The aircraft still had a lot of power at the moment of landing. circuit altitude prescribed for Breda International Airport There was also very little wind at that moment. This by the Aeronautical Information Publication (AIP) is 730 situation meant that the aircraft could not have been feet AMSL. The pilot flew a longer final approach in order brought to a stop before the end of the runway. Marks to reduce his altitude and speed sufficiently. A member of before the end of the runway showed that the pilot Airside Operations declared that the plane approached started to brake at some point, after which the plane left the runway at a steep angle and crossed the extension of the runway on the right-hand side. There were no known the runway centre line, after which it approached the defects in the aircraft that could have contributed to the runway at an angle. According to him, the nose wheel incident. The Dutch Safety Board conducted an touched the ground first. Camera images from the airport investigation on site, but no technical investigation was show that the first contact of the aircraft with the runway performed on the aircraft. took place before the first intersection following the runway threshold. During the landing, the flaps were The pilot stated that he had also flown higher than the selected in a fully downwards position. The aircraft left prescribed altitude in circuits at other airports, because the runway before the end on the south side, smashed he disliked flying low over buildings. The Board through the airport fencing, hit a pole, crossed a road, emphasises that flight procedures including circuit then hit a tree and finally came to a halt in a lower-lying altitudes, as specified in the AIP, are mandatory. Failure to meadow. The pilot was unhurt. The aircraft was severely follow these procedures creates a collision risk, because damaged, including full detachment of the right wing. The other pilots who are flying at the prescribed altitude in the The New Piper PA-28-181 after the runway excursion. pilot was unable to open the door of the plane himself as circuit might not be expecting descending traffic. In a result of the damage to the plane. He was finally freed addition, the pilot must always be prepared to perform a by the airport fire service officers on duty. go-around during an approach, in the event that circumstances prevent the approach from being The pilot stated that he had been flying higher than the completed safely. prescribed altitude because it gave him better visibility of the runway over the trees on the south side of the runway. At a certain point after landing, he realised that the speed Classification: Accident of the plane was too high for him to come to a stop before Reference: 2018053 the end of the runway. However, according to him, it was then too late to execute a go-around.

18 - Dutch Safety Board Rectification The Quarterly Aviation Report over the first quarter of 2018 published the results of an occurrence that was not investigated in detail. It concerned a near- collision in the circuit of Breda International Airport on 25 February 2018 involving a Robin Apex DR400 (PH-VSQ) and an Ultravia Aero Pelican PL (PH-VKL). Due to an oversight at the time that the report was published, the Dutch Safety Board had not sent the draft text to the two pilots involved in order to check the facts. After contacting both pilots, the Dutch Safety Board has decided to issue a rectification. The adjusted text now reads as follows:

The pilot of PH-VKL stated that he had been flying a long tailwind leg due to an aircraft that was flying in front of him. He wished to land and, by extending the tailwind leg, would create sufficient distance between him and the other aircraft to perform the landing with the required separation. The pilot of PH-VKL stated that he had made a call to report his position on final approach. As it turned into its final approach, PH-VSQ ended up above PH-VKL. The pilot of PH-VSQ stated that he had not seen any other aircraft in front of him on the tailwind leg and did not see any on the final approach. The reason that the pilot of PH-VSQ only saw the other plane (PH-VKL) at a later stage may in part have been caused by the fact that PH-VSQ is a low-wing aircraft, which means that the pilot’s visibility was hampered by the wings. The pilot of PH-VKL stated that he had not heard PH-VSQ report its position and it was only during landing that he noticed another plane flying above him. The pilot of PH-VSQ stated that a position report had left him with the impression of another aircraft having been inserted into the circuit behind him. As a result, he was surprised when he saw PH-VKL flying below him. The pilot of PH-VSQ was unable to state why he had not seen PH-VKL earlier.

Quarterly Aviation Report 3rd quarter 2018 - 19 The Dutch

What does the Dutch Who works at the Safety Board Safety Board do? Dutch Safety Board? When accidents or disasters happen, The Safety Board consists of three the Dutch Safety Board investigates permanent board members. in four how it was possible for them to occur, The chairman is Tjibbe Joustra. with the aim of learning lessons for The board members are the face of the future and, ultimately, improving the Safety Board with respect to DUTCH safety in the Netherlands. The Safety society. They have extensive questions Board is independent and is free to knowledge of safety issues. They also SAFETY BOARD decide which incidents to investigate. have wide-ranging managerial and In particular, it focuses on situations social experience in various roles. in which people’s personal safety The Safety Board’s office has around is dependent on third parties, such 70 staff, of whom around two-thirds as the government or companies. are investigators. In certain cases the Board is under an obligation to carry out an investigation. Its investigations do not address issues of blame or liability.

Recently the Dutch Safety Board reported about cooperation on How do I contact the nuclear safety, the environmental Dutch Safety Board? safety of cannabis grow rooms and level crossing accidents on the For more information see the railways. website at www.safetyboard.nl Telephone: +31 70 - 333 70 00

Postal address Dutch Safety Board P.O. Box 95404 2509 CK The Hague Colofon What is the The Netherlands This is a publication of the Dutch Safety Dutch Safety Board? Board. This report is published in the Dutch Visiting address and English languages. If there is a The Safety Board is an ‘independent Lange Voorhout 9 difference in interpretation between the administrative body’ and is 2514 AE The Hague Dutch and English versions, the Dutch text authorised by law to investigate The Netherlands will prevail. incidents in all areas imaginable. In practice the Safety Board currently December 2018 works in the following areas: aviation, shipping, railways, roads, defence, Photos Photos in this edition, not provided with a human and animal health, industry, source, are owned by the Dutch Safety pipes, cables and networks, Board. construction and services, water and crisis management & emergency Source photo frontpage: services. Photo 1: AirBridgeCargo Airlines

20 - Dutch Safety Board