Quarterly Aviation Report
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Quarterly Aviation Report DUTCH SAFETY BOARD page 7 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 January - March 2019 open sea. Its investigations are conducted in accordance with the Safety Board Kingdom Act In this first Quarterly Aviation Report of 2019 attention is given to published and Regulation (EU) no. 996/2010 reports, one of which is the report ‘Flying over conflict zones – Follow-up of the European Parliament and recommendations MH17 Crash investigation’. of the Council of 20 October 2010 on the investigation and Flying over conflict zones is a current risk in aviation. The MH17 Crash prevention of accidents and report published by the Dutch Safety Board contains eleven recommen- incidents in civil aviation. If a dations for better management of the risks associated with overflying page 10 description of the events is conflict zones. The recommendations focus on airspace management, sufficient to learn lessons, the sharing threat information, and risk assessment. The Board investigated Board does not conduct any which actions parties have taken in response to these recommendations. further investigation. The subject of ‘flying over conflict zones’ is not an obvious subject for an The Board’s activities are aviation accident investigation, as international standards are aimed at mainly aimed at preventing increasing safety of civil aviation. In the MH17 crash investigation it was occurrences in the future or possible to carry out an investigation within that framework in which the limiting their consequences. If essence of the risk was more about security. any structural safety short- comings are revealed, the Board may formulate recommendations To manage the risks related to flying over conflict zones and other risks at to remove these. The Board’s the interface of safety and security as good as possible, closer cooperation investigations explicitly exclude between both worlds is necessary. Vital to this is the willingness of parties any culpability or liability to actively inform each other about (potential) threats, in order to protect aspects. civilians and passengers across the world. Jeroen Dijsselbloem Chairman of the Dutch Safety Board page 11 AAN Z Z I P1 2 U H 526 C F Z 8 B J A 1 I W7 - P26 V C 6 3 P1 3 T P1 4 WESTELIJKE DIENSTWEG RIJB WESTELIJKE DIENSTWEG 18C 10 P27 P1 5 C 8 1 - C 6 3 P1 6 Near-collision on the ground of two 525 Occurrences into Airbus A320 aircraft, Amsterdam Airport Runway 18C A24 Schiphol, 3 February 2019 Z5 Z6 T9 T16 P28 P22 which an An Airbus A320 (red line in the figure with the route of Taxiway Z both aircraft) landed on runway 18C in the evening; air C SKIHUT 36 8 1 traffic control gave permission to taxi to the parking W8 - C 6 investigation has position at pier C via taxiway Q (Quebec). In approaching C 3 A25 taxiway Q the crew was also instructed to give way to C 8 1 - C A25 6 another Airbus A320 (blue line in figure with the route of T18 3 P29 1 C 8 8 both aircraft) approaching from the right via taxiway Z C 1 - - 3 C 6 6 C been launched 3 (Zulu). The crew of the latter A320 was told that the G WE R23 R W12 W9 A26 (recently landed) A320 would let them pass. Both aircraft E Taxiway Q C IZ 1 WE 8 8C 1 - -3 P30 S FHU C J T 6 approached the taxiway crossing. However, the crew of 6 E 3 VI C IN D A27 E the first, recently landed A320 did not give way, forcing C 6 P31 3 the crew of the other A320 to come to an emergency 3 6 P33 C BA C T11 T20 AT 6 L RA 3 LO stop. The two aircraft passed within a very short distance RST V N A I D ADUC R24 NA T of each other. W11 W10 Z RIN SE HOFST 3 6 R25 E C RA D- W V P32 EG 36 ZUI Z D Classification: Serious incident T13 C T22 C PELIKA 18 - -D Reference: 2019017 VD G 36C E A Z1 RHP W R27 N IP P W SN O 18C E ST G C D - 36 18 U Z2 RHP - IFW C Z1 36C U E C G VD- IV Z5 E R W 18C Z2 E K G - 36 C TREE DOORLAATPOST B Z7 RS VD- E TOEGANG TOT UGS-A JK DIENSTWEG RI The route of both aircraft basedKOP 36Con the radar data. (Source: ATC the A G VD- E NW Netherlands) AA LIK PE 2 - Dutch Safety Board Collision during pushback, Boeing 747- Runway incursion, SOCATA TB-10 Tobago Runway incursion, Diamond HK-36 TC and 400 and Boeing 787-9, Amsterdam and Sequoia Aircraft Corporation F.8L Rans S-6S Coyote II, Lelystad Airport, Airport Schiphol, 13 February 2019 Falco, Teuge Airport, 15 February 2019 24 February 2019 As a Boeing 747 was pushed back from gate E7 to taxiway During a cross-country flight, a student pilot approached The Rans S-6S landed on runway 23. The Diamond HK-36 A14, a collision with a Boeing 787 occurred. The Boeing the circuit of Teuge Airport in a TB-10. At that moment, TC, which was on final approach behind the Rans, 787 had been pushed back from gate F8 earlier and was runway 08 was in use with a right-hand circuit. However, overflew the Rans and landed further down the runway. stationary on taxiway A16. Both pushbacks were the student flew a left-hand circuit for runway 26. As the The pilot of a third aircraft, a Diamond HK-36 TTC, on its performed after permission had been obtained from air student realised that runway 08 was in use, she left the final approach as this incident occurred, performed a traffic control. A winglet of the Boeing 747 was damaged, circuit and rejoined the final approach leg for runway 08 go-around. as well as the horizontal stabiliser of the Boeing 787. No via the northerly circuit area. Simultaneously, there was persons were injured. another aircraft on the final approach which the student flying above it did not notice. The aircraft on the lower Classification: Serious incident approach performed a short landing, after which the Reference: 2019016 Classification: Accident student overflew the aircraft and made a touch-and-go. Reference: 2019009 After another circuit followed by a full-stop landing, the student returned to the beginning of the runway and took off for a flight to Texel Airport. Classification: Serious incident Reference: 2019013 Runway 23 at Lelystad Airport. (Source: Lelystad Airport) The damaged horizontal stabiliser. (Source: AAS) Quarterly Aviation Report 1st quarter 2019 - 3 The Argentinian Junta de Investigación de Accidentes de Gear-up landing, Fokker F28 Mark 0100, Aviación Civil (JIAAC) launched an investigation in Mehrabad Airport, Tehran (Iran), Occurrences response to this occurrence. The Dutch Safety Board is 19 March 2019 providing assistance. abroad with Dutch The Fokker 100 with 33 occupants was on a domestic Classification: Serious incident flight from Qeshm Airport to Mehrabad Airport. On its Reference: 2019011 final approach to Mehrabad Airport, the crew involvement into experienced trouble with hydraulic system 1. The main landing gear could not be lowered. The crew landed the aircraft with the nose gear down only. The aircraft was which an damaged. The Iranian Aircraft Accident Investigation Board (AAIB) launched an investigation in response to this incident. investigation was The Dutch Safety Board offered its assistance. launched by a Classification: Accident foreign authority Reference: 2019018 Failure of steering actuator in right main landing gear, Boeing 747-400F, Ministro Pistarini International Airport (Argentina), 12 February 2019 As a Boeing 747-400F, a Dutch registered cargo aircraft, taxied to its parking position at Ministro Pistarini Right main landing gear. (Source: JIAAC) International Airport in Argentina, one of the steering actuators in the right main landing gear failed. The aircraft came to a full stop on the taxiway and could not be towed to its parking position until its cargo had been unloaded. 4 - Dutch Safety Board Off-airfield landing with damage, The pilot was in possession of a glider pilot licence and Rolladen-Schneider LS 4, PH-989, had a total flight experience of 203 hours (746 starts), 52 Other occurrences Bracht (Germany), 30 June 2018 hours (171 starts) of which were in the glider type in question. In the 3 months prior to the occurrence, he had flown 25 hours (47 starts). outside the A single-seat glider with Dutch registration departed from the Venlo glider airfield for a cross-country flight over The incident underlines the importance of flying a circuit German territory. At some point the glider lost height; at after a field for an off-airfield landing has been selected. Netherlands with an altitude of approximately 700 metres the pilot started looking for off-airfield landing options. However, he also The Bundesstelle für Flugunfalluntersuchung (BFU) has continued searching for thermals, hoping to reach Venlo decided not to open an investigation into this incident. Dutch involvement after all. Since the glider lost even more height, the pilot eventually decided to perform an off-airfield landing. He selected a field near Bracht (Germany). Classification: Accident Reference: 2018063 When the pilot flew towards the landing field he had selected, he felt some thermals at an altitude of 150 to 200 metres and tried to regain altitude.