Quarterly Aviation Report

DUTCH SAFETY BOARD

page 4 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 open sea. Its July - September 2020 investigations are conducted in accordance with the Safety Board Kingdom Act and Regulation (EU) During the past quarter, the Dutch Safety Board published two aviation no. 996/2010 of the European reports. One discussed the fi rst accident involving an electrically powered Parliament and of the Council of microlight aeroplane in the . The Board concluded that a 20 October 2010 on the minimum safety level for microlight aeroplanes must be established in investigation and prevention of Europe. The second report related to a Boeing 737 which was engaged in a accidents and incidents in civil go-around and experienced an undesirable loss of separation from another aviation. If a description of the Boeing 737 which had just started its take-off procedure from a converging page 10 events is suffi cient to learn at Airport Schiphol. The Board issued a recommendation lessons, the Board does not to Air Traffi c Control the Netherlands to no longer deviate from the basic conduct any further investigation. rule that clearance to take off should only be issued after the landing on the converging runway has actually been confi rmed by the runway controller. The Board’s activities are mainly aimed at preventing occurrences During the third quarter of 2020, a fatal accident occurred at the Gilze- in the future or limiting their Rijen airbase involving a glider. The Dutch Safety Board has initiated an consequences. If any structural investigation. In Germany, two Dutch gliders lost their lives after colliding safety short-comings are revealed, and crashing. The German authorities have launched an investigation, the Board may formulate recommendations to remove assisted by the Dutch Safety Board. In addition, a Dutch armed forces NH90 these. The Board’s investigations helicopter crashed in the Caribbean Sea, resulting in the loss of life of two explicitly exclude any culpability crew members. The Dutch Safety Board completed a preliminary report on or liability aspects. this occurrence and has recommended that the Defence Safety Inspectorate conducts a further investigation.

Jeroen Dijsselbloem Chairman of the Dutch Safety Board page 8 Additional investigation into Loss of part of flap, Boeing 747-406F ER, Crashed, Drone DJI M210, port area Crashed after winch launch, Airprox, Piper PA-18-135, Socata TB-9, aircraft accident Faro (1992) Harare (Zimbabwe), 8 July 2019 , 4 July 2020 Rolladen-Schneider LS8-18, Teuge, 17 July 2020 Occurrences into Gilze-Rijen Air Base, 12 July 2020

At the request of the Dutch Minister of Infrastructure and During the final approach to Harare International Airport, The DJI Matrice 210 (M210) drone was deployed for a On base leg of the circuit, the two aeroplanes came into which an Water Management, the Dutch Safety Board launched the Dutch-registered aeroplane of a Dutch airline lost a fire brigade mission in the Waalhaven in Rotterdam, the After a premature cable release during the winch launch, each other’s vicinity, after which the pilot of the Piper a short additional investigation into the accident during part of the right-hand inboard fore flap. The pilots were objective of which was to use its cameras to monitor a the glider made a turn and crashed. The glider was made an evasive maneuver. the landing of a McDonnell Douglas DC-10-30F at Faro able to keep the aeroplane under control, and subse- fire on board a ship. After completing the mission, the completely destroyed. The pilot did not survive the crash. investigation has Airport in Portugal on 21 December 1992. The commer- quently landed safely. pilot started the drone’s return flight to the take-off and cial air transport aeroplane with 340 occupants made a landing location. At a distance of between 100 and 150 Classification: Serious incident hard landing, causing the right main landing gear to fail. Zimbabwe, the state of occurrence has delegated the metres from the dockside, the pilot initiated the drone’s Classification: Accident Reference: 2020058 been launched Subsequently, the right wing broke off from the fuselage. whole of the conducting of the investigation to the descent. After a few seconds, the horizontal flight of the Reference: 2020047 The aircraft left the runway and burst into flames. 56 of Netherlands, as the state of registry and state of the drone stopped suddenly, the drone entered a spin and it the occupants were killed. operator. The Dutch Safety Board has instituted an inves- crashed into the water, where it sank. tigation into the circumstances of the occurrence. At the time, the Portuguese investigation body inves- tigated the accident. The Board believes that a short Classification: Accident investigation will be able to provide answers to specific Classification: Serious incident Reference: 2020043 technical questions about the landing gear, which gave Reference: 2019060 rise to the call for the additional investigation. The Board aims to complete this investigation and publish as quickly as possible, but no later than the start of 2021.

The right wing with the damaged inboard flap. (Source: Airline) The crashed LS8-18.

DJI M210 drone. (Source: Skytools)

2 - Dutch Safety Board Quarterly Aviation Report 3rd quarter 2020 - 3 Hard landing, Alexander Schleicher Emergency landing after loss of engine Gear-up landing, Socata TB-20, Airprox, Cessna 208B, Reims Aviation Airprox, Rolladen-Schneider LS 4-b, Occurrences into ASK 21 B, Terlet glider airfield, power, Cessna A152 Aerobat, Airport Eelde, S.A. F172N, International Airport Teuge, Cessna 172P, Nistelrode glider airfield, which an investigation 17 July 2020 Veelerveen, 8 August 2020 14 August 2020 20 August 2020 22 August 2020

The glider made a hard landing, with the tail breaking off. The pilot experienced engine problems and subsequently The aeroplane, with an instructor and student on board, The F172N flew on final for Runway 26 when it was overta- During the winch launch of the glider, an aeroplane flew has been launched The occupants were unharmed. decided to perform an emergency landing in a field. made a gear-up landing, sustaining damage to the ken by a Cessna 208, which flew over the F172N and then over the glider airfield. The pilot in the glider released the During landing, the nose wheel broke off and the aero- propeller and underside of the fuselage. The occupants landed in front of it. The pilot of the F172N then made a winch cable to avoid a collision. Some time later the glider plane came to rest upside down. Both occupants were were unharmed. go-around. made a safe landing. Classification: Accident unharmed. Reference: 2020050 Classification: Accident Classification: Serious incident Classification: Serious incident Classification: Accident Reference: 2020056 Reference: 2020081 Reference: 2020061 Reference: 2020055

The TB-20 after the gear-up landing. (Source: GAE)

The Cessna A152 after the emergency landing. (Source: Dutch Aviation Police)

The ASK 21 B after the hard landing. (Source: Dutch Aviation Police)

4 - Dutch Safety Board Quarterly Aviation Report 3rd quarter 2020 - 5 Occurrences into Emergency landing, Prematurely released winch cable, Right main landing gear collapsed, Damaged during off-fi eld landing, Diamond DA40 TDI, Den Bommel, ASK-23, Soesterberg glider airfi eld, Occurrences abroad Fokker F27 MK50, Bardere (Somalia), Alexander Schleicher ASW24-e, which an investigation 19 September 2020 26 September 2020 5 July 2020 Kranenburg (Germany), 15 July 2020 The pilot experienced engine problems, which were The single-seater glider took off using the winch launch with Dutch Following the landing on the aerodrome of Bardere, the During an off-fi eld landing, the Dutch registered glider has been launched followed by a complete engine failure. He made an emer- method. At a low altitude, the winch cable released, aircraft taxied to the stand. During taxiing, the right main hit a ditch in the fi nal phase of the run-out. The glider was gency landing in a crop fi eld, which damaged the aircraft. after which the pilot fl ew straight ahead and made a landing gear collapsed. The aircraft sustained damage. damaged at the bottom of the nose. The Dutch pilot was safe landing. The winch cable caught under the left wing involvement into There were no injuries. unharmed. of a two-seater glider that just had landed. This glider Classifi cation: Accident sustained damage to the left wing. The occupants were The Somalian Aircraft Accident Investigation Branch has The German Federal Bureau of Aircraft Accident Reference: 2020064 unharmed. which an launched an investigation into the occurrence. The Dutch Investigation (BFU) has launched an investigation into Safety Board has offered its assistance. the occurrence. The Dutch Safety Board has offered its assistance. Classifi cation: Serious incident Reference: 2020067 investigation has Classifi cation: Serious incident Reference: 2020045 Classifi cation: Accident been launched by a Reference: 2020048 Defence Crashed, NH90 helicopter, Caribbean Sea, foreign authority Mid-air collision, Glaser-Dirks DG-300 19 July 2020 Elan, Rolladen-Schneider LS4-b, Dülmen (Germany), 11 July 2020 The Dutch Safety Board has launched an exploratory investigation into the accident with an NH90 helicopter in the Caribbean Sea, in which two crew members were Two gliders, registered in the Netherlands, collided with killed. The Dutch Safety Board was on site together with each other during cross country fl ights in Germany and the Defence Safety Inspectorate for this purpose. crashed. Both Dutch pilots were killed.

The German Federal Bureau of Aircraft Accident Investigation (BFU) has launched an investigation into the The ASW24-e after the off-fi eld landing. (Source: Glider’s owner) The Diamond DA40 after the emergency landing. (Source: Dutch occurrence. The Dutch Safety Board provides assistance. Aviation Police) The BFU published an interim report on 25 September 2020. This report can be found on page 20 of the Bulletin, July 2020.

Classifi cation: Accident Reference: 2020046

Archive photo NH90. (Source: Ministry of Defence)

6 - Dutch Safety Board Quarterly Aviation Report 3rd quarter 2020 - 7 Runway excursion, Cirrus SR22, Nancy Loss of cabine pressure, Fokker F28 Incorrect mode of autothrottle, Runway excursion, BOMBARDIER CRJ-900, Runway excursion, Fokker F27 Mk 0050, Occurrences abroad – Essey Airport (France), 28 July 2020 Mk 0100, 67 KM south-southeast of Fokker F28 Mk 0100, West Angelas Gällivare Lapland Airport (Sweden), Aden Adde International Airport (Somalia), Geraldton (Australia), 10 August 2020 Aerodrome (Australia), 1 September 2020 10 September 2020 19 September 2020 with Dutch involvement During the landing at the destination Nancy - Essey, the into which an Dutch registered single-engine aircraft, with a Dutch During cruise, an “Excessive cabin altitude” warning During landing, the crew determined that the autothrottle During take-off the CRJ-900 swerved to the left. The The Fokker 50 had taken off from Mogadishu’s Aden pilot and three Dutch passengers on board, made a was generated in the cockpit of the Fokker 100, along was in the incorrect mode and they were unable to select take-off was rejected and the aircraft came to a stop, Adde Airport for a domestic cargo flight to Beledweyne hard landing on the runway and collided with the runway with a drop in cabin pressure indication. The crew and reverse thrust. partly next to the runway. Airport. Shortly after take-off, the aircraft turned back due investigation has been lighting. The aircraft went off the runway, breaking the passengers then put on the oxygen masks. The crew then to potential landing gear problems. During landing, the nose and main landing gear and damaging the left wing initiated an emergency descent, after which the aircraft The Australian Transport Safety Bureau (ATSB) has The incident is being investigated by the Swedish Acci- aircraft went off the runway and collided with a concrete launched by a foreign and fuselage. The occupants were unharmed. made a landing at Geraldton Aerodrome. launched an investigation into the occurrence. The Dutch dent Investigation Authority (SHK). Because of questions wall of the airport fence. The aircraft was badly damaged Safety Board has offered its assistance. about recent maintenance on the aircraft, carried out by a and two occupants were seriously injured. The two other authority The French Bureau d’Enquêtes et d’Analyses (BEA) has The Australian Transport Safety Bureau (ATSB) has company in the Netherlands, SHK approached the Dutch occupants sustained minor injuries. launched an investigation into the occurrence. The Dutch launched an investigation into the occurrence. The Dutch Safety Board. The Dutch Safety Board provides assistance Safety Board has offered its assistance. Safety Board has offered its assistance. Classification: Incident with the investigation. The Somalian Aircraft Accident Investigation Branch has Reference: 2020062 launched an investigation into the occurrence. The Dutch Safety Board has offered its assistance. Injuries during landing, Theo Schroeder Classification: Accident Classification: Accident Classification: Incident Fire Balloons G, Heinsberg (Germany), Reference: 2020054 Reference: 2020057 Reference: 2020073 15 July 2020 Classification: Accident Reference: 2020065

During the landing of the Dutch registered hot air balloon, with the captain and five passengers on board, two passengers were seriously injured.

The German Federal Bureau of Aircraft Accident Investigation (BFU) has launched an investigation into the occurrence. The Dutch Safety Board has offered its assistance.

Classification: Accident Reference: 2020049

The Cirrus SR22 after the de runway excursion. (Source: BEA)

The Fokker 50 after the runway excursion. (Source: Goobjoog News)

8 - Dutch Safety Board Quarterly Aviation Report 3rd quarter 2020 - 9 This was the first accident with an electric-powered The Dutch Safety Board published the report on 10 July Loss of separation following go-around, aeroplane in the Netherlands and the first worldwide with 2020. Boeing 737-700, PH-BKG and Boeing Published reports a Pipistrel Alpha Electro. The investigation has shown that 737-800, PH-HXF, Amsterdam Airport the batteries played no role in the cause of the accident. The accident was caused by a low airspeed situation, Schiphol, 29 March 2018 close to the stall speed. This led to a stall followed by an incipient spin from which the aeroplane did not recover. A Boeing 737-700, which was engaged in a go-around Contributing factors to the accident were the aeroplane’s on Runway 18C, experienced an undesirable loss of full wing span flaperons in combination with the unusual separation from another aircraft, a Boeing 737-800, which aeroplane’s landing configuration of +25° flaps on base had just started its take-off procedure from Runway 24. leg, the aeroplane’s stall properties, the lack of a stall Because the two runways converge, the aircraft found warning system and the pilot’s limited flying experience, themselves on a course which was set to intersect. Thanks proficiency and training with the Pipistrel Alpha Electro. to the almost simultaneous intervention by the runway The investigation did not reveal any technical defect that controller and the response from the two flight crews, could have been a factor to the cause of the accident. a potential hazardous situation occurred, but no actual collision hazard. No pan-European regulations exist that apply to the design and use of microlight aeroplanes. Regulations Allowing reduced separation during the use of dependent concerning microlight aeroplanes are a national matter. take-off and landing runways is a procedure which can Microlight aeroplanes have become more advanced and Archive photo Pipistrel Alpha Electro. (Source: H. Ranter) result in the occurrence of undesirable and potentially increasingly popular over the years and they are also hazardous situations. Aside from the uncertainty about operated across borders. With the growing numbers and the legitimacy of this procedure, the question is whether the increasing complexity of the design of microlight the advantage gained – namely increased capacity – aeroplanes, the Dutch Safety Board believes also for these outweighs the potential hazard that can arise. aircraft a minimum level of safety within Europe should be determined. The Dutch Safety Board therefore recommends to Air Fatal loss of control accident with a Traffic Control the Netherlands to remove the procedure Pipistrel Alpha Electro near Stadskanaal The Dutch Safety Board therefore issues the following “Reduced separation between take-off and landing airfield, I-D057,13 October 2018 recommendations to the Minister of Infrastructure and traffic” from the Operations Manual and adhere to the Water Management. First, to improve the safety of standard procedure for using dependent runways. The microlight aeroplanes registered and/or operating in the Minister of Infrastructure and Water Management is The electric-powered aeroplane, an Italian registered Netherlands and the safety of third parties, by setting recommended to have the Netherlands’ Pipistrel Alpha Electro, departed from Drachten airfield up and implementing effective oversight of the sector. procedures regarding the use of dependent runways and set course towards Stadskanaal airfield. The pilot Second, with regard to the innovation of microlight assessed against current legislation and regulations. The flight paths of both aircraft. was its only occupant. At the destination, he joined the aeroplanes, determine additional requirements that aerodrome traffic circuit. In the circuit, after turning microlight aeroplanes registered and/or operating in the The Dutch Safety Board published the report on 24 from downwind to base leg, the aeroplane suddenly lost Netherlands must meet and implement them within the September 2020. altitude and impacted the ground. Shortly thereafter the Netherlands. Then actively strive to accept these require- aeroplane caught fire. The pilot was fatally injured. The ments as standard within the member states of European aeroplane was destroyed as a result of the crash and the Civil Aviation Conference (ECAC), with the aim of creating post-impact fire. a minimum level of safety for this category of aircraft. Third, for the long term to promote that the requirements and oversight of microlight aeroplanes will be evaluated and reconsidered by European Union Aviation Safety Agency (EASA).

10 - Dutch Safety Board Quarterly Aviation Report 3rd quarter 2020 - 11 Runway excursion, Aquila AT01, PH-DHB, The French Bureau d’Enquêtes et d’Analyses pour la Soon after the wing walker had let go of the wing tip, the investigation into the occurrence and shared its findings Moutiers, Ille-et-Vilaine (France), Sécurité de l’Aviation civile (BEA) published the report on tip of the left wing tilted downwards and hit the ground. with the Dutch Safety Board. The gliding club has issued Reports published 14 July 2015 26 June 2020. Occurrences that Steering corrections by the pilot in an attempt to once two recommendations concerning additional attention for again raise the wing tip proved fruitless. At the moment wing walking on gliders with water ballast and improved Classification: Accident that the pilot decided to abort the take-off, and released awareness among members of responsibilities when fulfil- by foreign The pilot decided to undertake a flight from the private Reference: 2015058 have not been the cable, the glider rotated 90 degrees to the left, and ling a task in the field. airfield at Moutiers, accompanied by a passenger for the continued sliding in the launch direction. The glider came first time. The take-off weight was close to the aircraft’s to a rolling standstill, travelling backwards. The pilot was investigation maximum take-off weight. The pilot initiated his take-off investigated unharmed. The glider suffered severe damage to the Classification: Accident from the downward running Runway 35, which had been fuselage, among others. Reference: 2020027 mowed two days earlier. During the take-off run, the pilot authorities realized that the take-off distance had increased and that extensively At the time of the occurrence, the average wind speed was the aircraft’s acceleration was too low. Believing that he 16-17 knots with gusts of up to 27 knots from a direction of would be unable to stop the aircraft before it reached the 230-260 degrees. The winch was set up on Runway 23. obstacles beyond the end of the runway, he continued his take-off procedure. After the main landing gear had hit The pilot had a Sailplane Pilot Licence (SPL) and a medical the top of a fence, the pilot landed in a field in line with certificate. He had a total glider flight experience of 3,246 the runway. The nosewheel broke off when it hit a pothole hours (4,844 starts), of which 490 hours (around 140 starts) in the ground. The aircraft came to a standstill on its nose. on the glider type in question. Both occupants were unharmed. The occurrence was probably caused by the uneven distribution of the water in the wing tanks. Until shortly before launch, the glider had stood with its left wing on the ground. Between the moment that the wings were raised to a horizontal position and the start of launch, there was insufficient time for the water to spread evenly between The Ventus 2cxT after the ground loop. (Source: Pilot) Ground loop during winch launch, the two non-linked tanks. As a consequence, there was Schempp-Hirth Ventus 2cxT, D-KLXH, more water in the end of the left wing, so that during the Twente Airport, 23 May 2020 launch procedure, the left wing dropped and the glider completed a ground loop.

The pilot of the Ventus 2cxT was preparing the glider, with The flight manual of the aircraft specifically states that for partially filled water tanks in the wings, for a cross-country a launch with partially filled water tanks, it is essential that flight. Prior to the flight, the pilot asked a club member to the wings be held straight and level to ensure that the keep hold of a wing tip during the winch launch. Then he water is evenly distributed. It is also important that during briefed the club member on the necessity to maintain the launch, the wing walker keeps hold of the wing tip for as glider in a horizontal position for some time, so that the long as possible, and runs alongside the glider, due to the water could be distributed over the wings and the glider additional weight in the wings. It is the responsibility of would remain in balance. However, at the moment of the the pilot to ensure that the wing walker is briefed on the launch, another person took over the role of wing walker. presence of water in the tanks, and the launch can only be The pilot had not briefed this person. After the wing walker initiated once the glider is balanced. It is also essential that had connected the winch cable, he raised the wings to a the winch cable be immediately released, if a wing touches horizontal position. After the pilot indicated that he was (or threatens to touch) the ground. ready for launch, the wing walker raised his hand, the signal that the cable could be tightened. He then lowered his The above report is based on the statement issued arm, at which point the glider was winched away. by the pilot. The gliding club itself also carried out an

PH-DHB after the accident. (Source: Pilot)

12 - Dutch Safety Board Quarterly Aviation Report 3rd quarter 2020 - 13 Runway excursion, Van’s Aircraft, Inc. RV-8, Damage during off-field landing, The safety committee of the gliding club involved carried Occurrences that PH-LRV, , 12 June 2020 Alexander Schleicher ASW 27-18 E, out an investigation into the occurrence, and shared PH-1399, Elst, 26 June 2020 the results with the Dutch Safety Board. The committee have not been issued a series of recommendations including increasing The pilot, in possession of a Commercial Pilot Licence knowledge of the functioning of the flight computer, by investigated (CPL), was involved in a private flight on board the RV-8 The pilot took off, assisted by an aerotow, from the Soes- providing further training. During this training, attention (a home-built aircraft) from Mühldorf am Inn airfield in terberg glider airfield in a single-seat glider. The exten- should be focused on those factors that influence reserve Germany to Kempen Airport in the Netherlands, where he dable turbomotor on the glider was unusable due to a altitude and arrival altitude, and wind calculations. It was extensively landed on Runway 03 at 09.45 hours. The pilot had more technical problem. After having flown for about 1.5 hours, also recommended that a protocol and checklist be drawn than 5,950 hours flying experience, of which 220 hours on and having returned early because he had not found any up for off-field landings with damage, since this was not the RV-8 type. Recorded at the nearby Belgian air force more thermals, the pilot decided at an altitude of approx. yet part of the emergency plan. base Kleine Brogel, the prevailing wind was blowing in an 300 meters to make an off-field landing near Elst. Landing easterly direction, at a speed of 8 knots. According to the options were limited there. The pilot chose the most suit- pilot, during the runway roll-out at a speed of approxima- able field, with a length of approximately 300 meters, for Classification: Accident tely 30 knots, the wind suddenly caused the aircraft’s nose a landing. He flew a left-hand circuit and on final approach Reference: 2020041 to change direction. Despite the pilot’s attempt to correct selected flaps in the landing setting. He assumed that the the steering, the aircraft left the runway and the left main wind was approaching from the right during the landing. landing gear broke off. The pilot was unharmed. The field rose in gradual undulations in the direction of the landing. During the ground roll, whereby the airbrakes were opened, according to the pilot, the glider failed to Classification: Accident lose sufficient speed. Approximately 50 metres before Reference: 2020037 he reached a row of trees, he initiated a ground loop estimating that the glider could not be stopped before it reached the end of the field. The glider sustained damage The RV-8 after the runway excursion. (Source: Kempen Airport to the fuselage, the horizontal stabilizer and the landing Authorities) gear. The pilot was unharmed.

The qualified pilot had a total glider flying experience of 434 hours (997 starts), of which 87 (117 starts) in the glider model in question.

The glider landed on a heading of 015. In the vicinity of Elst, at an altitude of 500 feet, the wind was blowing from 150 degrees (south-southeast) at a speed of 13 knots. The glider experienced a tail wind component, resulting in a rise in ground speed. This extended the distance the glider covered during the roll-out after landing, before it came to a stop. The glider could not be stopped in time. Given the wind direction, which the pilot had failed to recognize, the field the pilot selected turned out to be less suitable for the off-field landing. The glider after the ground loop. (Source: Dutch Aviation Police)

14 - Dutch Safety Board Quarterly Aviation Report 3rd quarter 2020 - 15 The Dutch What does the Dutch Safety Who works at the Dutch Safety Board Board do? Safety Board? Living safely, working safely, safety. It The Board consists of three seems obvious, but safety cannot be permanent board members under the in three guaranteed. Despite all knowledge chairmanship of Jeroen Dijsselbloem. and technology, serious accidents The board members are the public happen and disasters sometimes face of the Dutch Safety Board. They DUTCH occur. By carrying out investigations have extensive knowledge of safety questions and drawing lessons from them, issues. They also have extensive SAFETY BOARD safety can be improved. In the administrative and social experience Netherlands the Dutch Safety Board in various roles. investigates incidents, safety issues and unsafe situations which develop The Safety Board’s bureau has gradually. The objective of these around 70 staff, two-thirds of whom investigations is to improve safety, to are investigators. learn and to issue recommendations to parties involved. Visit the website for more information www.safetyboard.nl.

What is the Dutch Safety Board?

The Dutch Safety Board is independent of the Dutch government Colofon and other parties and decides for itself which occurences and topics will be This is a publication of the Dutch Safety Board. This report is published in the Dutch investigated. and English languages. If there is a difference in interpretation between the The Dutch Safety Board is entitled to Dutch and English versions, the Dutch text carry out investigations in virtually all will prevail. areas. In addition to incidents in aviation, on the railways, in shipping December 2020 and in the (petro-)chemical industry, the Board also investigates Photos occurrences in the construction sector Photos in this edition, not provided with a source, are owned by the Dutch Safety and healthcare, for example, as wel as Board. military incidents involving the armed forces. Source photos cover: Photo 1: Dutch Aviation Police Photo 2: Dutch Aviation Police Photo 3: BEA

16 - Dutch Safety Board