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The latest news from the Dutch Safety Board (Dutch)

River cruise safety inadequate

The growing popularity of river cruises in the Netherlands demands additional emphasis on safety. This conclusion was drawn by the Dutch Safety Board in a report published today following an investigation into the collision on the Western Scheldt between the river cruise ship Viking Idun and a chemical tanker during the night of 1 April 2019. The often limited coping capacity of passengers on board river cruise ships in combination with the growing popularity of river cruises have led to a series of recommendations aimed at improving safety in the river cruise sector. A recommendation has also been submitted to the Minister of Infrastructure and Water Management to improve the supervision of the river cruise sector.

On 1 April 2019, shortly after midnight, a collision took place on the Western Scheldt between the Swiss river cruise ship Viking Idun and a Maltese chemical tanker. Both ships suffered considerable damage. There were 171 mainly elderly passengers and 49 crew members on board the cruise ship. At the moment of the collision, the majority of passengers were sleeping in closed cabins, and a number suffered minor injuries as a result of the impact. The chemical tanker was transporting a cargo of benzene, heptane and methanol. The collision tore a large hole in the outer skin of the tanker. The use of double-walled tanks for the storage of chemicals prevented the spillage of very toxic substances.

Competence of crew not tested

The river cruise ship Viking Idun was in compliance with all statutory requirements for river cruise ships. The crew members were also in possession of the necessary certificates to allow them to sail in Dutch waters. Nonetheless, the Safety Board notes that these statutory requirements are not always sufficient. The crew of the Viking Idun had insufficient knowledge of the complex Westerschelde navigation zone. They also had insufficient command of the English language, as a result of which communication by VHF marine radio was poorly understood. In addition, for the passage of the Western Scheldt, the captain decided not to place those crew members with the most extensive knowledge of the navigation zone on the bridge. The decision was also taken to not call in the assistance of a pilot. The conclusion of the Safety Board is that, although the crew members were correctly authorized, they were insufficiently competent.

Complex navigation zone

The Western Scheldt is one of the most heavily used areas of water in the world, where inland navigation traffic, sea shipping and recreational shipping come together, day and night. This intensive traffic, combined with narrow navigation channels, shallows, strong currents and tidal effects make this a high-risk navigation zone. The Safety Board concludes that despite the complexity of the area, the knowledge and competence of the crew members of inland navigation ships are not subject to any additional requirements. This differs from the situation in areas of comparable complexity, such as the Rhine.

Supervision of river cruise ships

The investigation by the Safety Board reveals that this collision was not a unique event. The growing popularity of river cruises demands improvement to the level of safety in this sector. Large numbers of passengers, many of them with limited capacity to cope independently, travel on these waters each year. Against that background, the Dutch Safety Board has issued recommendations aimed at improving safety in the inland navigation sector, and specifically the river cruise sector, in the Netherlands. A recommendation has also been submitted to the Minister of Infrastructure and Water Management to improve the effectiveness of the supervision of river cruise ships and to tighten up the competency requirements for crew members of river cruise ships in the Scheldt area.

 

The complete investigation page with the report and recommendations can be found here.

Oorzaak crash NH90 bekend, verdergaand onderzoek nog nodig.

Oorzaak crash NH90 bekend, verdergaand onderzoek nog nodig.

Op 19 juli 2020 stortte een NH90-helikopter van de Koninklijke Marine tijdens een oefening bij Aruba in zee. Twee van de vier bemanningsleden kwamen daarbij om het leven. Direct na het ongeval startte de Onderzoeksraad voor Veiligheid, samen met de Inspectie Veiligheid Defensie (IVD), een onderzoek. In het verkennend onderzoek van de Onderzoeksraad wordt de directe oorzaak van de crash en de eerste bevindingen weergegeven. Het verdiepende onderzoek naar de mogelijk achterliggende factoren wordt door de IVD uitgevoerd.

Oorzaak crash NH90

De NH90 maakte deel uit van de het marineschip Zr.Ms. Groningen, gestationeerd in het Caribisch gebied. Het ongeval vond plaats tijdens het oefenen van deklandingen van de helikopter op het schip. Uit het onderzoek van de Onderzoeksraad blijkt dat de helikopter in de problemen kwam doordat het toestel, door het maken van een bocht, op gelijke snelheid kwam met de wind. Hierdoor hing het toestel als het ware stil in de lucht. Er is dan veel extra vermogen nodig om de helikopter in de lucht te houden. De vlieger zette extra vermogen in, maar door de lage vlieghoogte was het onmogelijk om de ingezette daling nog op tijd te corrigeren. De helikopter verloor snel hoogte en raakte binnen enkele seconden te water.

Vanaf het marineschip zag men de helikopter in zee storten en werd direct een reddingsoperatie ingezet. De twee inzittenden achterin het toestel konden zichzelf bevrijden en werden uit het water gehaald. De vlieger en de tactisch coördinator voorin de helikopter hebben zichzelf niet op tijd kunnen losmaken van het toestel en zijn verdronken. Uit het onderzoek blijkt dat de bemanning van Zr.Ms. Groningen grote inzet hebben getoond om hun collega’s te redden. Door de hoge golven en de beperkte capaciteit en toerusting aan boord was men echter niet in staat de redding met succes uit te voeren.

Onderzoek naar achterliggende factoren

Met het vandaag gepubliceerde rapport sluit de Raad het verkennend onderzoek af. Dit onderzoek geeft inzicht in de directe oorzaak van het ongeval, maar roept ook nieuwe vragen op over achterliggende factoren. Deze vragen hebben betrekking op de opleiding en training van de bemanning, de keuze om met één vlieger per NH90-helikopter te vliegen en de keuzes die zijn gemaakt over de toerusting van het marineschip Zr.Ms. Groningen. De Inspectie Veiligheid Defensie wordt aanbevolen deze vragen mee te nemen in het verdiepende onderzoek dat door de inspectie verder wordt uitgevoerd.

 

Bekijk hier de onderzoekspagina met het rapport.

Dutch Safety Board shares view on emergency number malfunction investigations

The Dutch Safety Board has analysed three investigations that were carried out by three Dutch inspection services. They investigated an incident where the Dutch emergency number was unreachable for nearly three hours, due to a malfunction at the telecom provider. In a letter addressed to the minister of Justice and Security, the Board shares its vision on these investigations.

Investigation by three inspection services

The Dutch Safety Board decided not to launch an investigation following the incident, pending the outcomes of the three investigations. On 25 June 2020 the three investigation reports were offered to the House of Representatives, after which the Safety Board also analysed the outcomes.

Points of concern

Despite the thorough investigation by the inspection services and the useful conclusions, the Safety Board feels that certain subjects are not addressed in the reports. For example, the fact that the emergency number is dependent on one telecom provider and the vulnerability this poses is not addressed. A critical analysis of the emergency number chain is missing in the reports, even though the incident from 2019 - among with two earlier incidents in 2015 and 2017 - shows that a malfunction in one part of the chain affects the total. The Dutch Safety Board therefore questions the learning capacity of the parties concerned. 

By sharing these points of concern, the Board hopes to contribute to the effectivity of the measures to be taken by the minister.