Quarterly Report Aviation

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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 April-June 2016 investigate occurrences involving page 11 Dutch aircraft over open sea. Its investigations are conducted in In the second quarter of 2016, the Dutch Safety Board started an accordance with the Safety Board investigation into the cause of a mid-air collision between two Kingdom Act and Regulation (EU) fighter jets involved in a training session for the ‘Air Force Days’ no. 996/2010 of the European at Leeuwarden . Furthermore, the Board published Parliament and of the Council of investigation reports about an airliner performing an automatic 20 October 2010 on the investiga- approach followed by a hard landing and about an aeroplane tion and prevention of accidents that crashed during an aerobatic flight. and incidents in civil aviation. If a description of the events is Also this quarter, foreign authorities have initiated investigations into occurrences in which the Board provides assistance due to Dutch enough to learn lessons, the involvement. Board does not conduct any page 12 further investigation. The Board investigated an airspace infringement near Soesterberg by a powered glider. As a result of this infringement, the Dutch Safety The Board’s activities are mainly Board would like to emphasize that it is the responsibility of a pilot-in- aimed at preventing occurrences command to consult all available information necessary for safe flight in future or limiting their conse- execution. quences. If any structural safety Tjibbe Joustra, shortcomings are revealed, the Chairman, Dutch Safety Board Board may formulate recommen- dations to remove these. The Board’s investigations explicitly exclude any culpability or liability aspects. Mid-air collision, 2 x Northrop F-5E Tiger Occurrences II, J-3086, J-3088, Bitgum, 9 June 2016

into which an The Swiss aerobatic display team Patrouille Suisse was training for its display at the Luchtmachtdagen (‘Air Force Days’) at . Four fighter jets from investigation the team had split into two formations of two aeroplanes. After having completed a manoeuvre, the two formations joined up once again into a formation of four. At this point, has been initiated two jets made contact. One of these (J-3086) was damaged to such a degree that it began to roll uncontrollably and the pilot was forced to use his ejector seat. Both the pilot and the ejector seat landed in a greenhouse. The aeroplane ended up in a small lake some distance away. The second jet (J-3088) sustained severe damage to its right-hand wing and right-hand horizontal stabiliser, but the pilot was able to safely land the aeroplane at Leeuwarden Air Base.

Classification:accident Reference: 2016059 The J-3086 crash site

Damage to J-3088’s right-hand horizontal stabiliser.

2 - Dutch Safety Board Runway excursion, Fokker F28 Mark Loss of control during launch, Schleicher Occurrences abroad 0100, YR-FZA, Gällivare Airport K7, PH-1070, Long Mynd Airfield, with Dutch (Sweden), 6 April 2016 Shropshire (), 6 April 2016 The Fokker 100 aeroplane was on a domestic flight from The glider made a so-called bungee launch. With this Arvidsjaur Airport to Gällivare Airport with five crew and method, the glider is launched from a slope using an involvement that 51 passengers on board. After landing on runway 30 in elastic band that is pulled taut by multiple persons. winter conditions, it experienced a runway excursion. The During the take-off run, the glider turned to the left. The aeroplane came to rest beyond the end of the runway and wind caught the right wing and the glider was then lifted, foreign authorities suffered no damage. The occupants sustained no injuries. rolled over its nose and came to rest upside down. The two occupants were not injured; the glider was severely have initiated The Swedish Accident Investigation Authority (SHK) has damaged. initiated an investigation in response to this occurrence. The Dutch Safety Board is providing assistance. The investigation has been delegated by the British investigations into Air Accidents Investigation Branch (AAIB) to the British Classification:serious incident Gliding Association. The Dutch Safety Board is providing Reference: 2016024 assistance.

Classification:accident Reference: 2016030

YR-RZA after the runway excursion. The crashed PH-1070. (Photo: pilot-in-command PH-1070) (Photo: SHK)

Quarterly Report Aviation 2nd quarter 2016- 3 Occurrences abroad Engine problems followed by emergency Low on fuel, Boeing 737-700, PH-XRZ, with Dutch landing, Cessna 210 Centurion, HA-SZE, Barcelona Airport (Spain), 17 April 2016 Csesztreg (Hungary), 10 April 2016 involvement that During landing at Barcelona Airport the Boeing 737-700 The Cessna 210 aeroplane, which was previously aeroplane, which had departed from Schiphol Airport, foreign authorities registered in the , encountered engine performed a go-around on runway 25R as a result of a problems during a flight from Kaposvar Kaposújlak tailwind. The flight crew then declared an emergency with have initiated Airport, after which the pilot had to make an emergency air traffic control because their aeroplane was low on fuel. landing. Both occupants were not injured. The aircraft The aeroplane landed on runway 07. investigations into suffered minor damage. The investigation of the engine showed that the crankshaft was broken. Spain’s CIAIAC has initiated an investigation in response to this occurrence. The Dutch Safety Board and the The Hungarian Transport Safety Bureau (KBSZ) has involved Dutch airline are providing assistance. initiated an investigation in response to this occurrence. The Dutch Safety Board is providing assistance. Classification:serious incident Reference: 2016031 Classification:serious incident Reference: 2016064

HA-SZE after the emergency landing. (Photo: KBSZ)

4 - Dutch Safety Board Landing with nose landing gear Hard landing, Grob G103 TWIN ASTIR, Crash, Van’s RV-4, PH-EIL, Vendée Coëx retracted, Fokker F27 Mark 050, SE-LEZ, D-3953, SOCATA Rallye 180, F-BPMB, (), 1 June 2016 Catania Airport (Italy), 30 April 2016 Saint-Florentin Chéu (France), 20 May 2016 The Dutch-registered two-person aeroplane flew into the On a domestic flight from Rimini Airport to Catania ground. Both occupants were French nationals. The pilot Airport, the aeroplane landed with the nose landing gear The glider, with two persons on board (both of them lost his life and the passenger suffered serious injuries. retracted. The fuselage of the aeroplane was damaged. Dutch nationals), was being towed by a motorised The aircraft was completely destroyed. None of the 21 occupants (three crew and eighteen aeroplane while conducting a training flight. During a passengers) were injured. low-towing training exercise, the towing combination flew The French Bureau d’Enquêtes et d’Analyses pour la at low altitude on the final approach leg, over a rapeseed sécurité de l’aviation civile (BEA) has initiated an investi- The Italian air accident investigation authority (ANSV) has field in front of the grass runway, at which point the gation in response to this occurrence. The Dutch Safety initiated an investigation in response to this occurrence. towing cable touched the ground and got stuck. The Board is providing assistance. The Dutch Safety Board is providing assistance. glider then flew into the ground and sustained severe damage. The instructor bruised a rib and his sternum; the Classification:accident Classification:accident trainee was not injured. Reference: 2016055 Reference: 2016036 The French Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) has initiated an investi- gation in response to this occurrence. The Dutch Safety Board is providing assistance.

Classification:accident Reference: 2016048

Recovery of SE-LEZ after the accident. (Photo: ANSV) Archive picture of PH-EIL. (Photo: K. van Aggelen)

Quarterly Report Aviation 2nd quarter 2016- 5 Occurrences abroad Emergency descent, Fokker F28 Collision on the ground, Airbus A319, with Dutch Mark 0100, VH-NHF, Newman Airport D-AKNU, Embraer ERJ 190-100 STD, (Australia), 7 June 2016 PH-EZB, Stuttgart Airport (), involvement that 15 June 2016 The Fokker 100 aeroplane performed a flight from foreign authorities Christmas Creek Airport to Perth Airport with five crew The Embraer 190 aeroplane was keeping its position on a and 28 passengers on board. During climb, while passing taxiway as per instructions from air traffic control. The have initiated FL305, the pilots heard a lot of noise and observed a Airbus A319 aeroplane was being pushed back from its sharp decrease in cabin air pressure. They performed an parking position by a vehicle. During this process, the investigations into emergency descent and diverted to Newman Airport, right-hand wing tip of the Airbus A319 came in contact where they landed safely. with the tail of the Embraer 190. Both aircraft were damaged. The occupants were not injured. The Australian Transport Safety Bureau (ATSB) has initiated an investigation in response to this occurrence. The German Bundesstelle für Flugunfalluntersuchung The Dutch Safety Board is providing assistance. (BFU) has initiated an investigation in response to this occurrence. The Dutch Safety Board is providing Classification:serious incident assistance. Reference: 2016061 Classification:serious incident Reference: 2016060

Damage to PH-EZB tail and to D-AKNU wing tip. (Photo: BFU)

6 - Dutch Safety Board Crashed during aerobatic flight, Extra means of exclusion and probability. During the Published reports EA-300L, D-EXIR, Bussloo, 19 March 2014 investigation it was established that the laws and regulations, as well as supervision on the performing of aerobatic flights, can be improved. Although not directly The single-engine aeroplane, model Extra EA-300L, related to the occurrence of the accident, this issue is conducted an aerobatic flight from . On included in the report to encourage the parties concerned board were the pilot and a passenger. Early in the flight, to implement these improvements. multiple manoeuvres were flown between about 1.000 and 3.500 feet. A climb was then initiated to about 4.100 feet, which was followed by a steep descending The Dutch Safety Board published the report on movement. This steep descent was not timely aborted, 23 June 2016. after which the aircraft flew into the ground. The aeroplane crashed on a golf course near Bussloo and was https://www.onderzoeksraad.nl/en/onderzoek/2009/ completely destroyed. Both occupants lost their lives. crashed-during-aerobatic-flight-19-march-2014

The investigation did not reveal an obvious cause for the accident. A number of possible causes was identified by

Crash site.

Quarterly Report Aviation 2nd quarter 2016- 7 Published reports Hard landing after automated approach, and maintained a constant rate of descent in the direction Embraer ERJ 190-100 STD, PH-EZV, of the runway. Amsterdam Airport Schiphol, The indications on the Flight Mode Annunciator panel, 1 October 2014 which show the status of the automatic pilot and autothrottle, did not lead the pilots to suspect that the The pilots prepared for an automated landing at Schiphol aeroplane was actually configured for a manual landing. Airport. At a low altitude, the captain realised that the The system indications received by the pilots were the aeroplane was not going to perform the intended same as what they were used to seeing, as they had automated landing. He pulled back on the control column previously performed mostly manual landings. Moreover, to reduce the rate of descent. The aeroplane made a hard the aeroplane was in a valid configuration, which meant landing. An inspection after the occurrence found that the that no error messages were generated and the pilots had aeroplane was damaged. No one on board was injured. no reason to think that the aeroplane was not flying in the correct configuration. An automated landing was not possible in the selected configuration. In accordance with the selected system The procedures for reporting occurrences, as described in settings, the aeroplane did not perform a landing flare the airline’s operations manual leave room for interpretation. The airline ultimately reported the occurrence to the Dutch Safety Board 20 days after it took place. As a result, at the start of the investigation various information sources were no longer available and the crew’s recollections were possibly not as sharp.

The Dutch Safety Board published the report on 31 May 2016.

https://www.onderzoeksraad.nl/en/onderzoek/2090/ hard-landing-after-automatic-approach-em- braer-190-1-october-2014

Embraer 190 cockpit. (Photo: W. Scolaro)

8 - Dutch Safety Board Near-miss, Aviat Pitts S-2B, PH-PEP, The instructor on board PH-USJ performed a go-around Occurrences HOAC DV 20, PH-USJ, , and rejoined the circuit. He stated that he had flown a 19 February 2016 standard circuit with his trainee. that were not The remainder of the flights of both aeroplanes was PH-USJ departed Lelystad Airport with an instructor and uneventful. The PH-PEP pilot estimated the minimum a trainee on board, for an hour of circuit training. PH-PEP vertical separation between both aircraft to be investigated was approaching Lelystad Airport’s air traffic circuit via approximately 100 feet at a lateral separation of 0.2 NM. reporting-points Bravo and Sierra, and its pilot-in- command (the only occupant) made the corresponding In the Quarterly Report Aviation for the first quarter of extensively radio calls. After the first touch-and-go, the PH-USJ crew 2015, the Dutch Safety Board focussed on preventing reported via the radio while on the downwind leg for near-misses in air traffic circuits on the basis of a number runway 23. Somewhat later, PH-PEP joined the downwind of principles. The ultimate responsibility for avoiding leg. At that moment, PH-PEP’s pilot observed one collisions in the air always lies with the pilot. He must look aeroplane before him, not being PH-USJ, which was on out for other traffic, determine which flight path to follow, final approach towards runway 23. When he turned interpret the rules and anticipate possible collision towards his final approach leg a little later, he reported hazards. With the correct execution of radio this through the radio after which he heard a call from the communication procedures, he helps other circuit users to PH-USJ crew reporting that they were on long final. The maintain a high degree of situational awareness. PH-PEP pilot was then surprised to observe an aeroplane, PH-USJ, which was flying behind him at low altitude. He had not seen this aeroplane before nor heard it on the Classification:serious incident radio. The PH-PEP pilot immediately aborted his approach Reference: 2016017 in order to prevent a potential collision, made a climbing 270 degrees right turn from the final approach and flew back in the direction of reporting-point Bravo. The PH-PEP pilot stated that he had flown a standard circuit and had turned to base leg and then final leg over the orange markers which lie on the ground. He stated that he had missed PH-USJ as it had been on a long final approach leg rather than flying a standard circuit.

Quarterly Report Aviation 2nd quarter 2016- 9 Occurrences Landing with retracted landing gear, approach. For the trainee, this was the first flapless Piper PA-28R-201, PH-SAI, Maastricht landing in the type of aircraft he was flying. that were not Aachen Airport, 21 March 2016 During landing, the bottom of the aeroplane fuselage and investigated its propeller made contact with the runway. At that moment, The single-engine propeller aeroplane departed Maastricht both occupants realised that the aeroplane’s landing gear Aachen Airport for a local training flight under instrument had not been lowered during the approach and a climb extensively flight rules. On board were the instructor and a trainee was initiated. During climb, the trainee selected gear pilot. The trainee was receiving initial flight training. down. The airspeed subsequently did not exceed 80 knots, after which the trainee selected gear up once As a result of icing conditions at FL050, the instructor again. The instructor then took control of the aeroplane. decided to fly a few circuits at Maastricht Aachen Airport. As the available runway length remaining was insufficient After an ILS approach for runway 03, followed by a touch- to make a safe landing, he flew a shortened circuit. After and-go, the aeroplane joined the right-hand circuit. The selecting gear down he made a safe landing. After the instructor agreed to the trainee’s request to carry out a landing, it turned out that the aeroplane’s propeller had landing without using the flaps (flapless landing). The been severely damaged and that the aeroplane had landing was planned to be followed by a go-around. The suffered some minor damage to its lower fuselage. trainee performed the downwind checks and flew a wider Neither occupant was injured. circuit than usual. The instructor explained the procedure for a flapless landing and coached the trainee during the The instructor had not briefed the trainee on the flapless landing before the flight. He stated that, as a result of the intensive coaching of the trainee during the flight, he had forgotten to perform the landing checklist and to check if the landing gear had been selected down. Both occupants stated that no warning had been generated in the cockpit, that might have drawn their attention to the fact that the landing gear had not been lowered. This was due to the trainee selecting more engine power than usual during the wide circuit.

The trainee did not possess a licence yet. He had a total flying experience of 53 hours, 4 of which had been on the involved aircraft type. The instructor was in possession of an Airline Transport Pilot Licence (ATPL(A)) and his flying experience totalled 17,900 hours, 3,950 of which had been on the involved aeroplane type.

The flying school conducted an internal investigation into the cause of the incident and drew up a report. This report was made available to the Dutch Safety Board.

Classification:serious incident Reference: 2016021

The damaged PH-SAI. (Photo: flying school)

10 - Dutch Safety Board Loss of control, Cirrus SR22, PH-JEG, Rod of nose landing gear broken during The aeroplane was damaged on the plates by the nose en route, 22 March 2016 landing, Mitsubishi MU-2, D-IAHT, and the nose landing gear. Groningen Eelde Airport, 30 April 2016 Research by the aeroplane manufacturer showed that a pin, During a flight under instrument flight rules (IFR) from drag strut and strut assembly (on the right-hand side) of the Teuge Airport to , in preparation Upon completing multiple training flights, including a few nose wheel had been broken. As a result of these for a ‘prof check’, the pilot reported to Groningen Airport landings, the flight crew returned to Groningen Airport components being broken, the nose landing gear collapsed Eelde approach control (Eelde Approach). His intention, Eelde. The pilot-in-command set up the landing for during landing and the nose of the aeroplane came into under the prevailing instrument meteorological conditions runway 23, and no specific issues were noted. Once the contact with the ground. The technical investigation was (IMC), was to fly two holding patterns at 3,000 feet altitude, aeroplane had flared, the aeroplane’s nose continued to unable to establish the cause of these failures with before landing at the airport. In order to correct for the drop and touched the ground. The aeroplane then slid certainty. wind, a change was made from flying on autopilot to along the runway with its nose on the ground and came to manual flight during the holding pattern. During the a standstill 600 metres after the initial contact with the subsequently performed steering correction, the right runway. The occupants left the aeroplane without injury. Classification:accident wing stalled. The aeroplane then briefly went into a spin, Reference: 2016034 rapidly losing altitude. When the pilot regained control at an altitude of around 1,700 feet under visual meteorological conditions (VMC), he found himself at the same altitude as another aeroplane in the circuit. There was no risk of collision. After stabilising the aircraft, the pilot climbed to 2,000 feet in consultation with air traffic control, and performed an ILS approach to runway 23; the aircraft was landed without any further issues.

The pilot was in possession of a Private Pilot Licence with instrument, radio telephony and night ratings and a class 2 medical certificate. He had a total flying experience of 544 hours, 51 of which had been on the involved aeroplane type, and indicated the following course of events as possible cause of the stall of the right wing:

• A relatively low airspeed (100 knots) while the aeroplane was not in a landing configuration; • An overly abrupt steering correction to the right during the holding pattern; • Possibly some icing on the right-hand wing; • A lack of experience with flying in a holding pattern in IMC and limited experience in recognising and coping with a spin (one-off training in VMC).

Classification:serious incident Reference: 2016022

D-IAHT after the occurrence. (Photo: Royal Netherlands Military Police)

Quarterly Report Aviation 2nd quarter 2016- 11 Occurrences in use. During the second flight the circuit was flown altitude of around 8,000 feet. The pilot wondered whether normally, according to the airport manager. The pilot stated air traffic control hadn’t seen his glider on the radar and that were not that, as a result of an error in judgement, he did not have then realised that his transponder was still in standby sufficient altitude when approaching the runway. According mode, after which he switched it into ALT mode. From investigated to his statement, he then made the mistake of raising the 11.57, air traffic control radar screens showed a 7000 (VFR) nose of the aeroplane instead of selecting extra engine code at an altitude of 2,200 feet and around 1 to 2 NM power. This resulted in the aeroplane’s wheels coming into north of Soesterberg. The pilot found another thermal extensively contact with the edge of a ditch located just before the and continued his flight. runway. As a consequence, the landing gear folded backwards and the aeroplane made a belly landing. The two occupants were not injured. At the time of the occurrence, a NOTAM was in force The pilot was in possession of a Recreational Pilot Licence indicating a prohibited area around Soesterberg. This with a MLA (microlight aeroplane) rating and a class 2 NOTAM stated the following: medical certificate. He had a total flying experience of 307 hours, of which 282 were on the type of aircraft concerned. TEMPORARY RESTRICTED AREA ‘SOESTERBERG’ ACTIVATED. AREA: 520745N0051646E RADIUS 5NM BTN GND/ Classification:accident FL090, EHP 25 EXCLUDED. Belly landing after hitting edge of ditch, Reference: 2016040 AREA PROHIBITED. AUTHORIZED CROSSING TFC Tecnam P 92 ECHO SUPER, PH-4D3, Texel CONTACT DUTCH MIL ACC PRIOR ENTRY. Airport, 4 May 2016 Airspace infringement, DG-808, D-KHMI, LOWER: GND near Soesterberg, 4 May 2016 UPPER: FL090 PH-4D3 landed at Texel Airport. The pilot reported to the FROM: 04 MAY 2016 09:00 TO: 04 MAY 2016 11:00 airport authority that he would make two local flights with a passenger. The first flight lasted 15 minutes. There was a The pilot of the powered glider was preparing for a cross M0739/16 light wind from a south-westerly direction. Runway 22 was country flight from Hilversum airport. During the cockpit check, the pilot switched on the transponder. This goes through a start-up procedure before it is ready for use and goes into standby mode. Meanwhile, the pilot started During the preparation of his planned cross country flight, the engine and taxied to the beginning of runway 18, the pilot of D-KHMI had not consulted any NOTAMs. As a where he gave way to landing traffic before lining up on result, he was not aware of the fact that the area around the runway and taking off at 11.43. The aircraft climbed to former was not accessible to him on an altitude of around 800 metres (approx. 2,650 feet) at that day from 11.00 to 13.00. During the morning briefing by which point the pilot turned off and retracted the engine. the duty instructor, the relevant NOTAM was not mentioned, After gaining altitude in a thermal, the pilot set course for but the Board stresses that it is any pilot’s responsibility to Soesterberg to search for more thermals. At an altitude of consult all available information that might be relevant for a around 700 metres (2,300 feet) the glider approached the safe flight operation, during his flight preparations. centre of the main runway at former Soesterberg Air Base, flying from a north-northwesterly direction towards the In addition, during the flight a pilot can make use of the south-southeast. Around 1 kilometre before he would be Flight Information Service from air traffic control, by crossing the runway, the pilot noticed a formation of four reporting to the frequency of Amsterdam Information or F-16 fighter jets approaching from the east, along the line Dutch MIL INFO. This may serve as an extra safety barrier. of the runway, at an altitude of 500 feet. He lost sight of the formation when it disappeared under the nose of his The Safety Management Team of the involved glider club own aircraft. Somewhat later he saw an F-16 on his right- carried out an internal investigation into the cause of the PH-4D3 after the belly landing. (Photo: Texel Airport) hand side pulling up sharply, and he thought this looked incident and wrote a report. This report was made available like a ‘missing man’ manoeuvre. The F-16 climbed to an to the Dutch Safety Board. The glider club has since taken

12 - Dutch Safety Board measures to improve the infrastructure regarding flight Stall during circuit flight, Diamond HK 36 make a steep approach with the air brakes fully open (a preparation. A dedicated corner in the club house has been TTC, D-KVOK, near Hilversum Airport, glide approach). In order to line the aeroplane up with the created where maps and computers have been made 7 May 2016 runway, he steered the plane to the right and then (using available. the pedals) to the left.

The pilot of the glider was in possession of a Glider Pilot The Touring Motor Glider was coming from Texel with two Completely unexpectedly, the left wing dropped and the Licence with ratings for towing, winching, self-launch, flight occupants. The pilot-in-command, who was piloting the aeroplane went into a nosedive. The pilot then pulled on instruction and radio telephony. He had a total gliding aircraft, stated that speed and altitude during the approach the stick and selected full engine power in order to level experience of 4,301 hours (3,072 flights), of which around 700 of Hilversum Airport (from Maartensdijk) were not constant. off. He stated that he had ignored the advice of the hours (over 100 flights) involved this type of aircraft. In He was thus frequently selecting extra engine power and passenger not to pull on the stick but to push this forward addition, he had gained experience of around 1,000 hours had to regularly correct the nose position. This problem because he felt the aeroplane was flying too low. The on single-engine and multi-engine aircraft and a vast remained on the downwind leg of the right-hand circuit of Touring Motor Glider did not recover from the stall. The experience in passenger aircraft. runway 13 even though, according to the pilot, the aircraft aeroplane fell backwards, gliding onto pastures, and remained in the correct configuration. came to a standstill above a ditch; it was severely damaged. The pilot was taken to hospital with back Classification:serious incident According to his statement the pilot flew the downwind injuries; the passenger was not injured. Reference: 2016042 leg towards the runway, rather than parallel to it, as a result of being distracted. He therefore turned to base leg The passenger, a relatively experienced glider pilot, under an angle that was too tight and flew past the stated that the pilot had become confused. The passenger extended centerline of the runway. Turning to the final had made several suggestions but the pilot had not leg, the aeroplane flew high and close to the runway responded. The passenger had then tried to take the threshold. The pilot therefore had to make a choice controls but the pilot was holding the stick so tightly that between re-joining the circuit or landing. He decided to the passenger could not move it. On the day of the accident, the pilot was interviewed by the aviation police while in hospital. He provided a description of events which corresponded to the passenger’s statement.

The pilot was in possession of a Sailplane Pilot Licence (SPL) with a TMG rating and a class 2 medical certificate. He had a total flying experience of 672 starts in various types of gliders (with a total of 155 hours) and 227 starts in Touring Motor Gliders (with a total of 69 hours), 30 of which had been on the type concerned.

The passenger was in possession of an SPL and had a total (glider) flying experience of around 380 hours (670 starts).

Classification:accident Reference: 2016041

The crashed D-KVOK

Quarterly Report Aviation 2nd quarter 2016- 13 Occurrences Ground loop during start, Schempp- however, should have been given more time to distribute Hirth, Discus b, PH-806, Lemelerveld across both wings, so that they would have been balanced that were not airfield, 9 May 2016 and the wing-tip holder would only have to grab the tip of investigated the wing without force. The glider was ready, at the launching location, for a The pilot reported that, when setting the various winch launch. The aircraft was carrying 100 litres of water instruments after assembly of the aeroplane, it appeared extensively in its wing tanks and 4 litres in the tail tank. The left-hand that the flight computer was not receiving a GPS signal. wing lay on a wing support in order to keep the wings as He had run through the computer cycle several times but level as possible so that the wing tanks would not empty. without success. He had then decided to use an external The intention was to make a cross country flight. There flight computer. The pilot concluded that this might have was a gentle breeze of around 20/35 km/h from the distracted him and affected his alertness during the south-east. The launch direction was to the east. A helper launch procedure. hooked the winch cable to the glider. The pilot noticed that he had to tilt the tip substantially to keep the water in The glider club conducted an internal investigation into the wing horizontally balanced. Once the cable was pulled the cause of the occurrence. The findings of the taut, the pilot felt the glider accelerate at usual speed. investigation were made available to the Dutch Safety After a few metres of rolling, the left wing tip dropped Board. These correspond with the aforementioned and touched the ground, after which the aeroplane yawed conclusion of the pilot with regard to providing better about 90 degrees to the left. The pilot immediately instructions to the wing-tip holder, who had never disconnected the winching cable. The aeroplane juddered assisted with a glider with water ballast before. The glider a few metres to the side and rolled to the right, at which became unbalanced and had accumulated insufficient point the right tip touched the ground. Then the tail speed to allow the pilot to correct the situation. struck the ground. Once the pilot had stepped out, there was no external damage visible. A technician who The pilot was in possession of a Glider Pilot Licence with inspected the glider later discovered damage to the ratings for winching and towing. He had a total gliding horizontal stabiliser fittings and the fittings on the vertical experience of over 800 hours (over 1,600 flights) of which stabiliser and the horizontal stabiliser connection. The around 35 hours (80 flights) on the glider type involved. pilot was not injured.

The pilot concluded that he should have provided better Classification:serious incident instructions to the wing-tip holder when assisting with a Reference: 2016043 glider with 100 litres of water ballast in the wings. A tip-holder must walk with the wing tip in his hands for as far as possible during the launch. The water in the wings,

14 - Dutch Safety Board Turbulence during final glide, Grob Standard Cirrus, PH-1440, near Terlet, 21 May 2016

The pilot, the only person on board the glider, stated that during the Open Benelux glider championships, on his first final glide and finish at Terlet glider airfield, he had not wanted any surprises and so had gained a little extra altitude before commencing his final glide. When it became clear that he could reach Terlet, he began to fly at a speed of around 200 km/h. The arrival at Terlet would be higher than planned so the finish line would be crossed at an altitude over 50 metres. The pilot decided to leave that as it was, and upon passing the finish line to pull up and land on runway 22.

When approaching the high-voltage cables, near the motorway, to the east of the airfield, the glider encountered severe turbulence and the pilot hit his head against the canopy. His drinking bag and items that had been placed behind the headrest flew forwards and the air brakes were unlocked. The pilot was disoriented for a short time. Shortly afterwards, he realised that he was still flying. There was a great deal of murmuring and he noticed that the flaps had been extended. The pilot retracted the flaps and decided to land on runway 30. Landing occurred normally. After landing, a hole was discovered in the canopy. The pilot’s head had gone through the canopy during the severe turbulence. He had suffered a few scratches to his head as a result.

The pilot stated that he had not performed a final check on the shoulder belts but that he would always fly with belts tightly closed due to the instability of the aeroplane as a result of the pendulum elevator. According to the pilot, the high speed in a light glider in combination with severe turbulence and his lack Damage to cockpit canopy. (Photo: pilot PH-1440) of familiarity with the Terlet airfield environment had possibly contributed to the occurrence.

The pilot was in possession of a Glider Pilot Licence (GPL) with ratings for winching and towing. He had a total gliding experience of around 490 hours (580 flights) of which around 18 hours (12 flights) on the involved glider type.

Classification:accident Reference: 2016062

Quarterly Report Aviation 2nd quarter 2016- 15 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 in four the Dutch Safety Board investigates permanent board members. 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 questions the future and, ultimately, improving of the Safety Board with respect safety in the Netherlands. The Safety to society. They have extensive Board is independent and is free to knowledge of safety issues. They also 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 is The Safety Board’s office has around dependent on third parties, such as 70 staff, of whom around two-thirds the government or companies. In are investigators. 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 the investigation How do I contact the into the causes of the crash of Dutch Safety Board? flight MH17, about the lifting incident in Alphen aan den Rijn For more information see the and an investigation about medical website at www.safetyboard.nl assistance on the . Telephone: +31 70 - 333 70 00 Credits Postal address Dutch Safety Board This is a publication of the Dutch Safety P.O. Box 95404 Board. This report is published in the 2509 CK The Hague Dutch and English languages. If there is a The Netherlands difference in interpretation between the What is the Dutch and English versions, the Dutch text Dutch Safety Board? Visiting address will prevail. Anna van Saksenlaan 50 The Safety Board is an ‘independent 2593 HT The Hague July 2016 administrative body’ and is authorised The Netherlands by law to investigate incidents in all Photos areas imaginable. In practice the Photos in this edition, not provided with Safety Board currently works in the a source, are owned by the Dutch Safety following areas: aviation, shipping, Board. railways, roads, defence, human and animal health, industry, pipes, cables Sources photos frontpage: and networks, construction and photo 1: W. Scolaro services, water and crisis management photo 2: Royal Netherlands Military Police & emergency services. photo 3: Texel Airport

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