What happened
During 2018, the Dutch Safety Board investigated a series of significant aviation occurrences. In the general aviation sector, several notable accidents occurred, including a fatal crash of a Pipistrel Alpha Electro near Onstwedde, where the pilot was killed, and a fatal accident involving a Europa Aviation Limited Europa at Hilversum Airfield. Other notable events included a runway excursion involving an A-211 Aquila, registration G-GAEC, at Breda International Airport, where the nose wheel detached following multiple bounces during landing.
In the realm of serious incidents, several airprox events were recorded. Two separate near-misses occurred near the new Noordkop glider airfield involving gliders and motorized aircraft. Additionally, a high-risk encounter took place over the Flevopolder between a Diamond DA-40 NG, registration PH-EGM, and an HOAC DV-20 Katana, registration PH-MFT, where the aircraft came within an estimated 10 meters of each other.
The investigation
The Board examined various operational and environmental factors across these incidents. For the near-miss near the Noordkop airfield, investigators looked at the recent establishment of the airfield 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 encounter, radar data and flight profiles were analyzed to determine the minimum separation achieved.
In a separate investigation involving an Embraer EMB-120ER, registration EC-JBD, at Amsterdam Airport Schiphol, the Board examined a misaligned takeoff. The investigation focused on how the crew misidentified runway edge lights as centerline lights and the impact of infrastructure, such as the interruption of the centerline by taxiway S5, on pilot navigation.
Findings
Investigations into the airprox incidents near Noordkop revealed that pilots were often unaware of the presence of gliders due to the aircraft's low altitude and the specific flight corridors used by motorized aircraft. In the encounter between the PH-EGM and PH-MFT, the investigation found that the see-and-avoid principle was only effective at the final moment due to a warning from the Diamond's Traffic Avoidable System and the fact that sunlight reduced the visibility of anti-collision lights.
Regarding the Embraer EMB-120ER takeoff, the Board concluded that a combination of operational and infrastructural factors, including a large turning circle and the absence of centerline lighting on a specific taxiway, led to the misalignment. Furthermore, the crew may have been distracted by air traffic control clearances during the maneuver.