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Quarterly Aviation Report 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 V1 R81 GEWTSNEID EKJILETSEW GEWTSNEID R81 36L-18R V6 36L-18R V8 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 retractedP40 STRAAT 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 GEWDIURKENNOZ Reference: 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 1 8 L C3 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 R6 3-L81 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 OH 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 EGASSAPKERTREV Terminal 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 O 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 EKJILETSEW GEWDNAR 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 TAARTSOTAH N A V L81-R63 3 6 C R46 BALLON PLATFORM IN P33 T11 T20 R7 24-06 ONTWIKKELING M79 ZANDERIJSTRAAT 3 6 C A10 S8 M77 VIADUCT RINSE HOFSTRAWEG ZUID SITUATIE
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