What happened
On 28 May 2012, a Cessna 172M, registration PH-SKJ, crashed at the Maasvlakte 2 site near Rotterdam. The aircraft was carrying four occupants on a flight from Midden-Zeeland Airport to Rotterdam Airport. During the return leg, the pilot chose a coastal route despite a forecast indicating deteriorating weather. As the aircraft approached the coast, the pilot encountered thick sea fog and attempted to descend below the cloud layer to maintain visibility. During this second descent near Maasvlakte 2, the pilot failed to monitor the aircraft's altitude and struck the ground.
The crash occurred on a newly reclaimed piece of land that was not yet in active use. Due to the heavy fog, the accident was not witnessed by anyone. The occupants remained at the crash site for five hours before the wreckage was located once the fog lifted. The pilot later died from his injuries, while two of the three passengers sustained serious and permanent physical injuries.
The investigation
The Dutch Safety Board (OVV) investigated why the aircraft remained missing for such an extended period and why the search operation was delayed. The investigation revealed that the aircraft lacked an Emergency Locator Transmitter (ELT), meaning no automated distress signal was triggered.
Investigators examined the coordination between Air Traffic Control the Netherlands (ATCNL), the Coastguard Centre, and the Rotterdam-Rinmond Security Region. The inquiry found that while ATCNL had identified the aircraft as missing, the Coastguard Centre did not immediately initiate a large-scale search. Furthermore, the investigation looked into the technical accuracy of the coordinates provided by ATCNL, noting that an initial error suggested the aircraft had plunged into the sea, which led rescuers to focus their efforts on maritime rather than land-based searches.
Findings
- The pilot failed to monitor altitude during a descent into heavy sea fog.
- The search was significantly hindered by a lack of coordination and a failure to share a common operating picture among the involved agencies.
- The Coastguard Centre focused primarily on a sea-based search because the initial reported coordinates placed the aircraft in the water and because ATCNL had provided subjective interpretations of the data.
- Information exchange was inefficient; for example, the Coastguard Centre did not immediately utilize updated coordinates that placed the wreckage on land.
- The use of outdated maps, which still showed the Maasvlakte 2 area as water, contributed to the oversight of the land-based crash site.
- There was a lack of simultaneous searching; agencies performed sequential tasks rather than conducting communication searches, radar analysis, and mobile phone localization concurrently.
Safety action
The Dutch Safety Board issued several recommendations to improve future emergency responses:
- The Ministry of Infrastructure and the Environment, Ministry of Defence, and Ministry of Security and Justice should develop standardized protocols for information sharing and communication between ATCNL, the Coastguard, and security regions.
- ATCNL and the Coastguard should implement procedures to perform search activities, such as radar review and mobile phone tracking, concurrently during the uncertainty phase of a missing aircraft report.
- ATCNL should implement a system to more accurately determine the last known geographical positions of aircraft after they disappear from radar.
- The Coastguard should train staff to maintain an open mind and critically evaluate incoming information to avoid an inward focus on a single search area.