What happened
On September 11, 2016, a Piper PA-28-161 Warrior III, registration G-OBFS, was performing an overland flight from Ameland to Lelyst and entered the airport traffic circuit. After being denied a straight-in approach for runway 05, the pilot intended to follow a right-hand circuit. However, the pilot mistakenly initiated a left-hand circuit for runway 23.
While the G-OBFS was on its base leg, a Piper PA-34 Seneca was cleared for departure on runway 05. Because radio transmissions did not specify the runway direction, neither crew was aware they were approaching one another from opposite directions. The pilot of the G-OBFS only realized the error when they saw the Piper PA-34 Seneca rotating for takeoff. Air traffic services immediately ordered a go-around, and the aircraft safely exited the circuit.
The investigation
The Dutch Safety Board examined the circumstances leading to the near-collision, focusing on the pilot's actions and the communication environment at Lelystad Airport. The investigation looked into the pilot's state of mind, the information provided by airport services, and the visibility of the opposing aircraft during the departure phase.
Findings
Several contributing factors were identified in the near-miss. The pilot of the G-OBFS admitted to feeling fatigued and noted that they had become distracted by questions from passengers during the circuit entry. Additionally, the pilot had limited experience operating at Lelystad Airport.
Crucially, the investigation found that the radio communications lacked essential directional information. Neither the arrival nor the departure transmissions indicated which runway was in use, preventing the pilots from identifying the conflict. The examiner on the departing Piper PA-34 Seneca noted that the G-OBFS was not visible until the aircraft had already rotated, leaving a minimum vertical separation of only approximately 200 to 500 feet.