quarterly report aviation - onderzoeksraad...emergency descent, fokker f28 mark 0100, vh-nhf, newman...

Quarterly Report Aviation

April-June 2016

In the second quarter of 2016, the Dutch Safety Board started an investigation into the cause of a mid-air collision between two fighter jets involved in a training session for the ‘Air Force Days’ at Leeuwarden Air Base. Furthermore, the Board published investigation reports about an airliner performing an automatic approach followed by a hard landing and about an aeroplane that crashed during an aerobatic flight.

Also this quarter, foreign authorities have initiated investigations into occurrences in which the Board provides assistance due to Dutch involvement.

The Board investigated an airspace infringement near Soesterberg by a powered glider. As a result of this infringement, the Dutch Safety Board would like to emphasize that it is the responsibility of a pilot-in-command to consult all available information necessary for safe flight execution.

Tjibbe Joustra, Chairman, Dutch Safety Board

InvestigationsWithin 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 investigations are conducted in accordance with the Safety Board Kingdom Act and Regulation (EU) no. 996/2010 of the European Parliament and of the Council of 20 October 2010 on the investiga-tion and prevention of accidents and incidents in civil aviation. If a description of the events is enough to learn lessons, the Board does not conduct any further investigation.

The Board’s activities are mainly aimed at preventing occurrences in future or limiting their conse-quences. If any structural safety shortcomings are revealed, the Board may formulate recommen-dations to remove these. The Board’s investigations explicitly exclude any culpability or liability aspects.

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2 - Dutch Safety Board

Occurrences into which an investigation has been initiated

Mid-air collision, 2 x Northrop F-5E Tiger II, J-3086, J-3088, Bitgum, 9 June 2016

The Swiss military aerobatic display team Patrouille Suisse was training for its display at the Luchtmachtdagen (‘Air Force Days’) at Leeuwarden Air Base. Four fighter jets from the team had split into two formations of two aeroplanes. After having completed a manoeuvre, the two formations joined up once again into a formation of four. At this point, two jets made contact. One of these (J-3086) was damaged to such a degree that it began to roll uncontrollably and the pilot was forced to use his ejector seat. Both the pilot and the ejector seat landed in a greenhouse. The aeroplane ended up in a small lake some distance away. The second jet (J-3088) sustained severe damage to its right-hand wing and right-hand horizontal stabiliser, but the pilot was able to safely land the aeroplane at Leeuwarden Air Base.

Classification: accidentReference: 2016059

Damage to J-3088’s right-hand horizontal stabiliser.

The J-3086 crash site

Quarterly Report Aviation 2nd quarter 2016- 3

Occurrences abroad with Dutch involvement that foreign authorities have initiated investigations into

Runway excursion, Fokker F28 Mark 0100, YR-FZA, Gällivare Airport (Sweden), 6 April 2016

The Fokker 100 aeroplane was on a domestic flight from Arvidsjaur Airport to Gällivare Airport with five crew and 51 passengers on board. After landing on runway 30 in winter conditions, it experienced a runway excursion. The aeroplane came to rest beyond the end of the runway and suffered no damage. The occupants sustained no injuries.

The Swedish Accident Investigation Authority (SHK) has initiated an investigation in response to this occurrence. The Dutch Safety Board is providing assistance.

Classification: serious incidentReference: 2016024

Loss of control during launch, Schleicher K7, PH-1070, Long Mynd Airfield, Shropshire (United Kingdom), 6 April 2016

The glider made a so-called bungee launch. With this method, the glider is launched from a slope using an elastic band that is pulled taut by multiple persons. During the take-off run, the glider turned to the left. The wind caught the right wing and the glider was then lifted, rolled over its nose and came to rest upside down. The two occupants were not injured; the glider was severely damaged.

The investigation has been delegated by the British Air Accidents Investigation Branch (AAIB) to the British Gliding Association. The Dutch Safety Board is providing assistance.


YR-RZA after the runway excursion.

(Photo: SHK)The crashed PH-1070. (Photo: pilot-in-command PH-1070)


Engine problems followed by emergency landing, Cessna 210 Centurion, HA-SZE, Csesztreg (Hungary), 10 April 2016

The Cessna 210 aeroplane, which was previously registered in the Netherlands, encountered engine problems during a flight from Kaposvar Kaposújlak Airport, after which the pilot had to make an emergency landing. Both occupants were not injured. The aircraft suffered minor damage. The investigation of the engine showed that the crankshaft was broken.

The Hungarian Transport Safety Bureau (KBSZ) has initiated an investigation in response to this occurrence. The Dutch Safety Board is providing assistance.

Classification: serious incident Reference: 2016064

Low on fuel, Boeing 737-700, PH-XRZ, Barcelona Airport (Spain), 17 April 2016

During landing at Barcelona Airport the Boeing 737-700 aeroplane, which had departed from Schiphol Airport, performed a go-around on runway 25R as a result of a tailwind. The flight crew then declared an emergency with air traffic control because their aeroplane was low on fuel. The aeroplane landed on runway 07.

Spain’s CIAIAC has initiated an investigation in response to this occurrence. The Dutch Safety Board and the involved Dutch airline are providing assistance.


HA-SZE after the emergency landing. (Photo: KBSZ)



Recovery of SE-LEZ after the accident. (Photo: ANSV)

Landing with nose landing gear retracted, Fokker F27 Mark 050, SE-LEZ, Catania Airport (Italy), 30 April 2016

On a domestic flight from Rimini Airport to Catania Airport, the aeroplane landed with the nose landing gear retracted. The fuselage of the aeroplane was damaged. None of the 21 occupants (three crew and eighteen passengers) were injured.

The Italian air accident investigation authority (ANSV) has initiated an investigation in response to this occurrence. The Dutch Safety Board is providing assistance.


Hard landing, Grob G103 TWIN ASTIR, D-3953, SOCATA Rallye 180, F-BPMB, Saint-Florentin Chéu (France), 20 May 2016

The glider, with two persons on board (both of them Dutch nationals), was being towed by a motorised aeroplane while conducting a training flight. During a low-towing training exercise, the towing combination flew at low altitude on the final approach leg, over a rapeseed field in front of the grass runway, at which point the towing cable touched the ground and got stuck. The glider then flew into the ground and sustained severe damage. The instructor bruised a rib and his sternum; the trainee was not injured.

The French Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) has initiated an investi-gation in response to this occurrence. The Dutch Safety Board is providing assistance.


Crash, Van’s RV-4, PH-EIL, Vendée Coëx (France), 1 June 2016

The Dutch-registered two-person aeroplane flew into the ground. Both occupants were French nationals. The pilot lost his life and the passenger suffered serious injuries. The aircraft was completely destroyed.

The French Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile (BEA) has initiated an investi-gation in response to this occurrence. The Dutch Safety Board is providing assistance.


Archive picture of PH-EIL. (Photo: K. van Aggelen)


Damage to PH-EZB tail and to D-AKNU wing tip. (Photo: BFU)

Emergency descent, Fokker F28 Mark 0100, VH-NHF, Newman Airport (Australia), 7 June 2016

The Fokker 100 aeroplane performed a flight from Christmas Creek Airport to Perth Airport with five crew and 28 passengers on board. During climb, while passing FL305, the pilots heard a lot of noise and observed a sharp decrease in cabin air pressure. They performed an emergency descent and diverted to Newman Airport, where they landed safely.

The Australian Transport Safety Bureau (ATSB) has initiated an investigation in response to this occurrence. The Dutch Safety Board is providing assistance.


Collision on the ground, Airbus A319, D-AKNU, Embraer ERJ 190-100 STD, PH-EZB, Stuttgart Airport (Germany), 15 June 2016

The Embraer 190 aeroplane was keeping its position on a taxiway as per instructions from air traffic control. The Airbus A319 aeroplane was being pushed back from its parking position by a vehicle. During this process, the right-hand wing tip of the Airbus A319 came in contact with the tail of the Embraer 190. Both aircraft were damaged. The occupants were not injured.

The German Bundesstelle für Flugunfalluntersuchung (BFU) has initiated an investigation in response to this occurrence. The Dutch Safety Board is providing assistance.




Published reports Crashed during aerobatic flight, Extra EA-300L, D-EXIR, Bussloo, 19 March 2014

The single-engine aeroplane, model Extra EA-300L, conducted an aerobatic flight from Teuge Airport. On board were the pilot and a passenger. Early in the flight, multiple manoeuvres were flown between about 1.000 and 3.500 feet. A climb was then initiated to about 4.100 feet, which was followed by a steep descending movement. This steep descent was not timely aborted, after which the aircraft flew into the ground. The aeroplane crashed on a golf course near Bussloo and was completely destroyed. Both occupants lost their lives.

The investigation did not reveal an obvious cause for the accident. A number of possible causes was identified by

means of exclusion and probability. During the investigation it was established that the laws and regulations, as well as supervision on the performing of aerobatic flights, can be improved. Although not directly related to the occurrence of the accident, this issue is included in the report to encourage the parties concerned to implement these improvements.

The Dutch Safety Board published the report on 23 June 2016.

https://www.onderzoeksraad.nl/en/onderzoek/2009/crashed-during-aerobatic-flight-19-march-2014

Crash site.


Hard landing after automated approach, Embraer ERJ 190-100 STD, PH-EZV, Amsterdam Airport Schiphol, 1 October 2014

The pilots prepared for an automated landing at Schiphol Airport. At a low altitude, the captain realised that the aeroplane was not going to perform the intended automated landing. He pulled back on the control column to reduce the rate of descent. The aeroplane made a hard landing. An inspection after the occurrence found that the aeroplane was damaged. No one on board was injured.

An automated landing was not possible in the selected configuration. In accordance with the selected system settings, the aeroplane did not perform a landing flare

and maintained a constant rate of descent in the direction of the runway.

The indications on the Flight Mode Annunciator panel, which show the status of the automatic pilot and autothrottle, did not lead the pilots to suspect that the aeroplane was actually configured for a manual landing. The system indications received by the pilots were the same as what they were used to seeing, as they had previously performed mostly manual landings. Moreover, the aeroplane was in a valid configuration, which meant that no error messages were generated and the pilots had no reason to think that the aeroplane was not flying in the correct configuration.

The procedures for reporting occurrences, as described in the airline’s operations manual leave room for interpretation. The airline ultimately reported the occurrence to the Dutch Safety Board 20 days after it took place. As a result, at the start of the investigation various information sources were no longer available and the crew’s recollections were possibly not as sharp.

The Dutch Safety Board published the report on 31 May 2016.

https://www.onderzoeksraad.nl/en/onderzoek/2090/hard-landing-after-automatic-approach-em-braer-190-1-october-2014

Embraer 190 cockpit. (Photo: W. Scolaro)

Published reports


Near-miss, Aviat Pitts S-2B, PH-PEP, HOAC DV 20, PH-USJ, Lelystad Airport, 19 February 2016

PH-USJ departed Lelystad Airport with an instructor and a trainee on board, for an hour of circuit training. PH-PEP was approaching Lelystad Airport’s air traffic circuit via reporting-points Bravo and Sierra, and its pilot-in-command (the only occupant) made the corresponding radio calls. After the first touch-and-go, the PH-USJ crew reported via the radio while on the downwind leg for runway 23. Somewhat later, PH-PEP joined the downwind leg. At that moment, PH-PEP’s pilot observed one aeroplane before him, not being PH-USJ, which was on final approach towards runway 23. When he turned towards his final approach leg a little later, he reported this through the radio after which he heard a call from the PH-USJ crew reporting that they were on long final. The PH-PEP pilot was then surprised to observe an aeroplane, PH-USJ, which was flying behind him at low altitude. He had not seen this aeroplane before nor heard it on the radio. The PH-PEP pilot immediately aborted his approach in order to prevent a potential collision, made a climbing 270 degrees right turn from the final approach and flew back in the direction of reporting-point Bravo. The PH-PEP pilot stated that he had flown a standard circuit and had turned to base leg and then final leg over the orange markers which lie on the ground. He stated that he had missed PH-USJ as it had been on a long final approach leg rather than flying a standard circuit.

The instructor on board PH-USJ performed a go-around and rejoined the circuit. He stated that he had flown a standard circuit with his trainee.

The remainder of the flights of both aeroplanes was uneventful. The PH-PEP pilot estimated the minimum vertical separation between both aircraft to be approximately 100 feet at a lateral separation of 0.2 NM.

In the Quarterly Report Aviation for the first quarter of 2015, the Dutch Safety Board focussed on preventing near-misses in air traffic circuits on the basis of a number of principles. The ultimate responsibility for avoiding collisions in the air always lies with the pilot. He must look out for other traffic, determine which flight path to follow, interpret the rules and anticipate possible collision hazards. With the correct execution of radio communication procedures, he helps other circuit users to maintain a high degree of situational awareness.


Occurrences that were not investigated extensively


Landing with retracted landing gear, Piper PA-28R-201, PH-SAI, Maastricht Aachen Airport, 21 March 2016

The single-engine propeller aeroplane departed Maastricht Aachen Airport for a local training flight under instrument flight rules. On board were the instructor and a trainee pilot. The trainee was receiving initial flight training.

As a result of icing conditions at FL050, the instructor decided to fly a few circuits at Maastricht Aachen Airport. After an ILS approach for runway 03, followed by a touch-and-go, the aeroplane joined the right-hand circuit. The instructor agreed to the trainee’s request to carry out a landing without using the flaps (flapless landing). The landing was planned to be followed by a go-around. The trainee performed the downwind checks and flew a wider circuit than usual. The instructor explained the procedure for a flapless landing and coached the trainee during the

approach. For the trainee, this was the first flapless landing in the type of aircraft he was flying.

During landing, the bottom of the aeroplane fuselage and its propeller made contact with the runway. At that moment, both occupants realised that the aeroplane’s landing gear had not been lowered during the approach and a climb was initiated. During climb, the trainee selected gear down. The airspeed subsequently did not exceed 80 knots, after which the trainee selected gear up once again. The instructor then took control of the aeroplane. As the available runway length remaining was insufficient to make a safe landing, he flew a shortened circuit. After selecting gear down he made a safe landing. After the landing, it turned out that the aeroplane’s propeller had been severely damaged and that the aeroplane had suffered some minor damage to its lower fuselage. Neither occupant was injured.

The instructor had not briefed the trainee on the flapless landing before the flight. He stated that, as a result of the intensive coaching of the trainee during the flight, he had forgotten to perform the landing checklist and to check if the landing gear had been selected down. Both occupants stated that no warning had been generated in the cockpit, that might have drawn their attention to the fact that the landing gear had not been lowered. This was due to the trainee selecting more engine power than usual during the wide circuit.

The trainee did not possess a licence yet. He had a total flying experience of 53 hours, 4 of which had been on the involved aircraft type. The instructor was in possession of an Airline Transport Pilot Licence (ATPL(A)) and his flying experience totalled 17,900 hours, 3,950 of which had been on the involved aeroplane type.

The flying school conducted an internal investigation into the cause of the incident and drew up a report. This report was made available to the Dutch Safety Board.


The damaged PH-SAI. (Photo: flying school)



Loss of control, Cirrus SR22, PH-JEG, en route, 22 March 2016

During a flight under instrument flight rules (IFR) from Teuge Airport to Groningen Airport Eelde, in preparation for a ‘prof check’, the pilot reported to Groningen Airport Eelde approach control (Eelde Approach). His intention, under the prevailing instrument meteorological conditions (IMC), was to fly two holding patterns at 3,000 feet altitude, before landing at the airport. In order to correct for the wind, a change was made from flying on autopilot to manual flight during the holding pattern. During the subsequently performed steering correction, the right wing stalled. The aeroplane then briefly went into a spin, rapidly losing altitude. When the pilot regained control at an altitude of around 1,700 feet under visual meteorological conditions (VMC), he found himself at the same altitude as another aeroplane in the circuit. There was no risk of collision. After stabilising the aircraft, the pilot climbed to 2,000 feet in consultation with air traffic control, and performed an ILS approach to runway 23; the aircraft was landed without any further issues.

The pilot was in possession of a Private Pilot Licence with instrument, radio telephony and night ratings and a class 2 medical certificate. He had a total flying experience of 544 hours, 51 of which had been on the involved aeroplane type, and indicated the following course of events as possible cause of the stall of the right wing:

• A relatively low airspeed (100 knots) while the aeroplane was not in a landing configuration;

• An overly abrupt steering correction to the right during the holding pattern;

• Possibly some icing on the right-hand wing;• A lack of experience with flying in a holding pattern in

IMC and limited experience in recognising and coping with a spin (one-off training in VMC).


Rod of nose landing gear broken during landing, Mitsubishi MU-2, D-IAHT, Groningen Eelde Airport, 30 April 2016

Upon completing multiple training flights, including a few landings, the flight crew returned to Groningen Airport Eelde. The pilot-in-command set up the landing for runway 23, and no specific issues were noted. Once the aeroplane had flared, the aeroplane’s nose continued to drop and touched the ground. The aeroplane then slid along the runway with its nose on the ground and came to a standstill 600 metres after the initial contact with the runway. The occupants left the aeroplane without injury.

The aeroplane was damaged on the plates by the nose and the nose landing gear.

Research by the aeroplane manufacturer showed that a pin, drag strut and strut assembly (on the right-hand side) of the nose wheel had been broken. As a result of these components being broken, the nose landing gear collapsed during landing and the nose of the aeroplane came into contact with the ground. The technical investigation was unable to establish the cause of these failures with certainty.


D-IAHT after the occurrence. (Photo: Royal Netherlands Military Police)



Belly landing after hitting edge of ditch, Tecnam P 92 ECHO SUPER, PH-4D3, Texel Airport, 4 May 2016

PH-4D3 landed at Texel Airport. The pilot reported to the airport authority that he would make two local flights with a passenger. The first flight lasted 15 minutes. There was a light wind from a south-westerly direction. Runway 22 was

in use. During the second flight the circuit was flown normally, according to the airport manager. The pilot stated that, as a result of an error in judgement, he did not have sufficient altitude when approaching the runway. According to his statement, he then made the mistake of raising the nose of the aeroplane instead of selecting extra engine power. This resulted in the aeroplane’s wheels coming into contact with the edge of a ditch located just before the runway. As a consequence, the landing gear folded backwards and the aeroplane made a belly landing. The two occupants were not injured.

The pilot was in possession of a Recreational Pilot Licence with a MLA (microlight aeroplane) rating and a class 2 medical certificate. He had a total flying experience of 307 hours, of which 282 were on the type of aircraft concerned.


Airspace infringement, DG-808, D-KHMI, near Soesterberg, 4 May 2016

The pilot of the powered glider was preparing for a cross country flight from Hilversum airport. During the cockpit check, the pilot switched on the transponder. This goes through a start-up procedure before it is ready for use and goes into standby mode. Meanwhile, the pilot started the engine and taxied to the beginning of runway 18, where he gave way to landing traffic before lining up on the runway and taking off at 11.43. The aircraft climbed to an altitude of around 800 metres (approx. 2,650 feet) at which point the pilot turned off and retracted the engine. After gaining altitude in a thermal, the pilot set course for Soesterberg to search for more thermals. At an altitude of around 700 metres (2,300 feet) the glider approached the centre of the main runway at former Soesterberg Air Base, flying from a north-northwesterly direction towards the south-southeast. Around 1 kilometre before he would be crossing the runway, the pilot noticed a formation of four F-16 fighter jets approaching from the east, along the line of the runway, at an altitude of 500 feet. He lost sight of the formation when it disappeared under the nose of his own aircraft. Somewhat later he saw an F-16 on his right-hand side pulling up sharply, and he thought this looked like a ‘missing man’ manoeuvre. The F-16 climbed to an

altitude of around 8,000 feet. The pilot wondered whether air traffic control hadn’t seen his glider on the radar and then realised that his transponder was still in standby mode, after which he switched it into ALT mode. From 11.57, air traffic control radar screens showed a 7000 (VFR) code at an altitude of 2,200 feet and around 1 to 2 NM north of Soesterberg. The pilot found another thermal and continued his flight.

At the time of the occurrence, a NOTAM was in force indicating a prohibited area around Soesterberg. This NOTAM stated the following:

TEMPORARY RESTRICTED AREA ‘SOESTERBERG’ ACTIVATED.AREA: 520745N0051646E RADIUS 5NM BTN GND/FL090, EHP 25 EXCLUDED.AREA PROHIBITED. AUTHORIZED CROSSING TFC CONTACT DUTCH MIL ACC PRIOR ENTRY.

LOWER: GNDUPPER: FL090FROM: 04 MAY 2016 09:00 TO: 04 MAY 2016 11:00

M0739/16

During the preparation of his planned cross country flight, the pilot of D-KHMI had not consulted any NOTAMs. As a result, he was not aware of the fact that the area around former Soesterberg Air Base was not accessible to him on that day from 11.00 to 13.00. During the morning briefing by the duty instructor, the relevant NOTAM was not mentioned, but the Board stresses that it is any pilot’s responsibility to consult all available information that might be relevant for a safe flight operation, during his flight preparations.

In addition, during the flight a pilot can make use of the Flight Information Service from air traffic control, by reporting to the frequency of Amsterdam Information or Dutch MIL INFO. This may serve as an extra safety barrier.

The Safety Management Team of the involved glider club carried out an internal investigation into the cause of the incident and wrote a report. This report was made available to the Dutch Safety Board. The glider club has since taken

PH-4D3 after the belly landing. (Photo: Texel Airport)


measures to improve the infrastructure regarding flight preparation. A dedicated corner in the club house has been created where maps and computers have been made available.

The pilot of the glider was in possession of a Glider Pilot Licence with ratings for towing, winching, self-launch, flight instruction and radio telephony. He had a total gliding experience of 4,301 hours (3,072 flights), of which around 700 hours (over 100 flights) involved this type of aircraft. In addition, he had gained experience of around 1,000 hours on single-engine and multi-engine aircraft and a vast experience in passenger aircraft.


Stall during circuit flight, Diamond HK 36 TTC, D-KVOK, near Hilversum Airport, 7 May 2016

The Touring Motor Glider was coming from Texel with two occupants. The pilot-in-command, who was piloting the aircraft, stated that speed and altitude during the approach of Hilversum Airport (from Maartensdijk) were not constant. He was thus frequently selecting extra engine power and had to regularly correct the nose position. This problem remained on the downwind leg of the right-hand circuit of runway 13 even though, according to the pilot, the aircraft remained in the correct configuration.

According to his statement the pilot flew the downwind leg towards the runway, rather than parallel to it, as a result of being distracted. He therefore turned to base leg under an angle that was too tight and flew past the extended centerline of the runway. Turning to the final leg, the aeroplane flew high and close to the runway threshold. The pilot therefore had to make a choice between re-joining the circuit or landing. He decided to

make a steep approach with the air brakes fully open (a glide approach). In order to line the aeroplane up with the runway, he steered the plane to the right and then (using the pedals) to the left.

Completely unexpectedly, the left wing dropped and the aeroplane went into a nosedive. The pilot then pulled on the stick and selected full engine power in order to level off. He stated that he had ignored the advice of the passenger not to pull on the stick but to push this forward because he felt the aeroplane was flying too low. The Touring Motor Glider did not recover from the stall. The aeroplane fell backwards, gliding onto pastures, and came to a standstill above a ditch; it was severely damaged. The pilot was taken to hospital with back injuries; the passenger was not injured.

The passenger, a relatively experienced glider pilot, stated that the pilot had become confused. The passenger had made several suggestions but the pilot had not responded. The passenger had then tried to take the controls but the pilot was holding the stick so tightly that the passenger could not move it. On the day of the accident, the pilot was interviewed by the aviation police while in hospital. He provided a description of events which corresponded to the passenger’s statement.

The pilot was in possession of a Sailplane Pilot Licence (SPL) with a TMG rating and a class 2 medical certificate. He had a total flying experience of 672 starts in various types of gliders (with a total of 155 hours) and 227 starts in Touring Motor Gliders (with a total of 69 hours), 30 of which had been on the type concerned.

The passenger was in possession of an SPL and had a total (glider) flying experience of around 380 hours (670 starts).


The crashed D-KVOK



Ground loop during start, Schempp-Hirth, Discus b, PH-806, Lemelerveld airfield, 9 May 2016

The glider was ready, at the launching location, for a winch launch. The aircraft was carrying 100 litres of water in its wing tanks and 4 litres in the tail tank. The left-hand wing lay on a wing support in order to keep the wings as level as possible so that the wing tanks would not empty. The intention was to make a cross country flight. There was a gentle breeze of around 20/35 km/h from the south-east. The launch direction was to the east. A helper hooked the winch cable to the glider. The pilot noticed that he had to tilt the tip substantially to keep the water in the wing horizontally balanced. Once the cable was pulled taut, the pilot felt the glider accelerate at usual speed. After a few metres of rolling, the left wing tip dropped and touched the ground, after which the aeroplane yawed about 90 degrees to the left. The pilot immediately disconnected the winching cable. The aeroplane juddered a few metres to the side and rolled to the right, at which point the right tip touched the ground. Then the tail struck the ground. Once the pilot had stepped out, there was no external damage visible. A technician who inspected the glider later discovered damage to the horizontal stabiliser fittings and the fittings on the vertical stabiliser and the horizontal stabiliser connection. The pilot was not injured.

The pilot concluded that he should have provided better instructions to the wing-tip holder when assisting with a glider with 100 litres of water ballast in the wings. A tip-holder must walk with the wing tip in his hands for as far as possible during the launch. The water in the wings,

however, should have been given more time to distribute across both wings, so that they would have been balanced and the wing-tip holder would only have to grab the tip of the wing without force.

The pilot reported that, when setting the various instruments after assembly of the aeroplane, it appeared that the flight computer was not receiving a GPS signal. He had run through the computer cycle several times but without success. He had then decided to use an external flight computer. The pilot concluded that this might have distracted him and affected his alertness during the launch procedure.

The glider club conducted an internal investigation into the cause of the occurrence. The findings of the investigation were made available to the Dutch Safety Board. These correspond with the aforementioned conclusion of the pilot with regard to providing better instructions to the wing-tip holder, who had never assisted with a glider with water ballast before. The glider became unbalanced and had accumulated insufficient speed to allow the pilot to correct the situation.

The pilot was in possession of a Glider Pilot Licence with ratings for winching and towing. He had a total gliding experience of over 800 hours (over 1,600 flights) of which around 35 hours (80 flights) on the glider type involved.



Damage to cockpit canopy. (Photo: pilot PH-1440)

Turbulence during final glide, Grob Standard Cirrus, PH-1440, near Terlet, 21 May 2016

The pilot, the only person on board the glider, stated that during the Open Benelux glider championships, on his first final glide and finish at Terlet glider airfield, he had not wanted any surprises and so had gained a little extra altitude before commencing his final glide. When it became clear that he could reach Terlet, he began to fly at a speed of around 200 km/h. The arrival at Terlet would be higher than planned so the finish line would be crossed at an altitude over 50 metres. The pilot decided to leave that as it was, and upon passing the finish line to pull up and land on runway 22.

When approaching the high-voltage cables, near the motorway, to the east of the airfield, the glider encountered severe turbulence and the pilot hit his head against the canopy. His drinking bag and items that had been placed behind the headrest flew forwards and the air brakes were unlocked. The pilot was disoriented for a short time. Shortly afterwards, he realised that he was still flying. There was a great deal of murmuring and he noticed that the flaps had been extended. The pilot retracted the flaps and decided to land on runway 30. Landing occurred normally. After landing, a hole was discovered in the canopy. The pilot’s head had gone through the canopy during the severe turbulence. He had suffered a few scratches to his head as a result.

The pilot stated that he had not performed a final check on the shoulder belts but that he would always fly with belts tightly closed due to the instability of the aeroplane as a result of the pendulum elevator. According to the pilot, the high speed in a light glider in combination with severe turbulence and his lack of familiarity with the Terlet airfield environment had possibly contributed to the occurrence.

The pilot was in possession of a Glider Pilot Licence (GPL) with ratings for winching and towing. He had a total gliding experience of around 490 hours (580 flights) of which around 18 hours (12 flights) on the involved glider type.


16 - Onderzoeksraad voor Veiligheid

Credits

This is a publication of the Dutch Safety Board. This report is published in the Dutch and English languages. If there is a difference in interpretation between the Dutch and English versions, the Dutch text will prevail.

July 2016

PhotosPhotos in this edition, not provided with a source, are owned by the Dutch Safety Board.

Sources photos frontpage: photo 1: W. Scolarophoto 2: Royal Netherlands Military Policephoto 3: Texel Airport

What does the Dutch Safety Board do?

When accidents or disasters happen, the Dutch Safety Board investigates how it was possible for them to occur, with the aim of learning lessons for the future and, ultimately, improving safety in the Netherlands. The Safety Board is independent and is free to decide which incidents to investigate. In particular, it focuses on situations in which people’s personal safety is dependent on third parties, such as the government or companies. In certain cases the Board is under an obligation to carry out an investigation. Its investigations do not address issues of blame or liability.

Recently the Dutch Safety Board reported about the investigation into the causes of the crash of flight MH17, about the lifting incident in Alphen aan den Rijn and an investigation about medical assistance on the North Sea.

What is the Dutch Safety Board?

The Safety Board is an ‘independent administrative body’ and is authorised by law to investigate incidents in all areas imaginable. In practice the Safety Board currently works in the following areas: aviation, shipping, railways, roads, defence, human and animal health, industry, pipes, cables and networks, construction and services, water and crisis management & emergency services.

Who works at the Dutch Safety Board?

The Safety Board consists of three permanent board members. The chairman is Tjibbe Joustra. The board members are the face of the Safety Board with respect to society. They have extensive knowledge of safety issues. They also have wide-ranging managerial and social experience in various roles. The Safety Board’s office has around 70 staff, of whom around two-thirds are investigators.

How do I contact the Dutch Safety Board?

For more information see the website at www.safetyboard.nlTelephone: +31 70 - 333 70 00

Postal addressDutch Safety BoardP.O. Box 954042509 CK The HagueThe Netherlands

Visiting addressAnna van Saksenlaan 502593 HT The HagueThe Netherlands

The Dutch Safety Board in four questions

quarterly report aviation - onderzoeksraad...emergency descent, fokker f28 mark 0100, vh-nhf, newman...

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