Dutch Safety Board 2018 Quarterly Review: Analysis of Aviation Incidents

Casualties unknown • Near-miss, Diamond DA-40 NG, PH-EGM, HOAC DV-20 Katana, PH-MFT, above the Flevopolder, 23 February 2018, NL

A review of the 2018 Dutch aviation safety landscape reveals a variety of serious incidents, ranging from mid-air near-misses to fatal general aviation accidents.

What happened

In 2018, the Dutch Safety Board (OVV) monitored a significant number of aviation occurrences, including 13 accidents and 18 serious incidents. The majority of these events involved general aviation aircraft. Notable incidents included a series of airprox events near the new Noordkop glider airfield, where a RV-12 and an ASW 24 glider experienced a close encounter, and a subsequent encounter between a Cessna 182RG and a Discus glider with only 40 meters of vertical separation.

Fatal accidents were also recorded, including the crash of a Pipistrel Alpha Electro in Onstwedde, which resulted in one fatality, and a fatal crash of a Europa aircraft at Hilversum Airfield. In the realm of near-misses, a Diamond DA-40 NG (PH-EGM) and an HOAC DV-20 Katana (PH-MFT) came within an estimated 10 meters of each other over the Flevopolder. Additionally, a runway excursion occurred at Breda International Airport involving an Aquila (G-GAEC) after the aircraft bounced during landing, causing the nose wheel to detach.

The investigation

The OVV examined various operational and technical factors across these incidents. For the airprox events near Noordkop, the investigation looked at the impact of the new airfield's location and the proximity of flight paths used by aircraft traveling to and from Texel International Airport. In the case of the PH-EGM and PH-MFT near-miss, investigators analyzed radar data and the effectiveness of the 'see-and-avoid' principle under bright sunlight conditions.

Regarding the misaligned take-off of an Embraer EMB-120ER (EC-JBD) at Amsterdam Airport Schiphol, the Board examined how the pilot misidentified runway edge lights as centerline lights. The investigation also reviewed an incident involving an Embraer ERJ-170 at Rome Fiumicino, where tire fragments were left on the runway following heavy vibrations during take-off.

Findings

Investigations into the mid-air near-misses highlighted that excellent visibility and sunlight can reduce the effectiveness of anti-collision lights, making the 'see-and-avoid' method difficult. In the Noordkop airprox cases, the pilot of the motorized aircraft was unaware of the glider airfield's presence.

For the Embraer EMB-120ER incident, the Board found that a combination of infrastructure and operational factors, such as the interruption of the centerline by taxiway S5 and the lack of centerline lighting on that taxiway, led to the misaligned take-off. In the case of the G-GAEC runway excursion, the pilot's decision to continue the landing after a bounce contributed to the structural failure of the nose gear.

Probable cause

Key safety concerns identified include the limitations of visual separation in bright light, the risks posed by new airfield locations near established flight corridors, and infrastructural deficiencies like missing taxiway lighting that can lead to runway misalignment.

Frequently asked questions

What happened in the 2018-02-23 aircraft accident near Near-miss, Diamond DA-40 NG, PH-EGM, HOAC DV-20 Katana, PH-MFT, above the Flevopolder, 23 February 2018, NL?

A review of the 2018 Dutch aviation safety landscape reveals a variety of serious incidents, ranging from mid-air near-misses to fatal general aviation accidents.

What aircraft was involved and where did it happen?

The accident on 2018-02-23 involved a aircraft, registration PH-EGM, at Near-miss, Diamond DA-40 NG, PH-EGM, HOAC DV-20 Katana, PH-MFT, above the Flevopolder, 23 February 2018, NL.

What was the probable cause of the accident?

Key safety concerns identified include the limitations of visual separation in bright light, the risks posed by new airfield locations near established flight corridors, and infrastructural deficiencies like missing taxiway lighting that can lead to runway misalignment.

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