News

The latest news from the Dutch Safety Board (Dutch)

Clear need for more attention for the fire safety of residential buildings

In the night of New Year’s Eve 2020, a fire in a sofa in the entrance hall of a block of flats in Arnhem left two people dead and two injured. The fire was able to rapidly develop into a major fire that gave off large volumes of toxic smoke. The fire raging on the only escape route made it impossible for the residents to escape from the block of flats. These are the conclusions of the Dutch Safety Board presented in the report ‘Fatal building fire in Arnhem - Lessons for fire safety’.

Jeroen Dijsselbloem, Chairman of the Dutch Safety Board, commented, “This investigation shows there is room for further improvement in the fire safety of furniture and residential buildings. In the Netherlands, we still impose no requirements on the fire safety of furniture. With regard to residential buildings, it is assumed there is always a safe escape route. The fire in Arnhem shows that this is not always self-evident.’’

Fatal fire

In the night of New Year’s Eve 2020, a family with two young children stepped into the lift in a block of flats on the Gelderseplein in Arnhem. At that moment, they were unaware that a fire was raging in the entrance hall on the ground floor. When they arrived in the entrance hall, they were immediately confronted by tremendous heat and clouds of toxic smoke. Because on the way down they had pushed the button for the third floor, the lift doors closed and the lift carried them back up to the third floor where they were later discovered by the fire service; for two of them, assistance arrived too late. The fire was caused by a light-grade firework set off in a sofa that had temporarily been left in the entrance hall by a resident.

Fire hazardous furniture

The majority of seating and mattresses are filled with plastic foam. This was also the case with the sofa that was placed in the entrance hall in the block of flats in Arnhem. Plastic foam can be easily set alight; the fire then develops rapidly and gives off large volumes of toxic smoke. This makes seating and mattresses extremely fire hazardous. In a number of European countries, requirements are imposed on the fire safety of furniture. The Dutch Safety Board calls upon the Dutch government to join these countries in imposing requirements on the fire safety of furniture.

Fire safety of residential buildings

There are many residential buildings in the Netherlands with just a single escape route outside. The presence of flames and smoke on this escape route represents a major risk for the safety of the residents. It is therefore of crucial importance that this single escape route be kept clear of obstacles, and fire safe. This is the responsibility of building owners. They must do more to live up to that responsibility. Municipal authorities must also actively supervise the fire safety of residential buildings. The Safety Board has therefore issued a recommendation to the Dutch Minister of the Interior and Kingdom Relations to ensure that the supervision of fire safety is improved.

Onderzoeksraad waarschuwt voor te snelle toelating nieuwe voertuigen

De Onderzoeksraad stelt vast dat het aangekondigde toelatingskader voor nieuwe licht elektrische voertuigen er nog steeds niet is. Wel is de BSO-bus reeds toegelaten tot de weg en liggen er aanvragen voor nieuwe bijzondere voertuigen. De voertuigen worden nog niet volgens het toekomstige toetsingskader beoordeeld en dat brengt veiligheidsrisico’s met zich mee.

De Raad publiceerde in 2019 het onderzoeksrapport Veilig toelaten op de weg - Lessen naar aanleiding van het ongeval met de Stint. Zoals wettelijk is vastgelegd reageerde de minister Infrastructuur en Waterstaat (IenW) aan de Onderzoeksraad in juli 2020 per brief met de terugkoppeling over de opvolging van de aanbevelingen uit het onderzoeksrapport. In de notitie die vandaag uitkomt reageert de Raad op deze terugkoppeling en de toelating van nieuwe voertuigen.

De minister belooft om, bij de toelating van licht elektrische voertuigen, veiligheid zwaarder mee te laten wegen. Zo schrijft zij in de reactiebrief. Voor deze voertuigen komt een nieuw toelatingskader met een strengere veiligheidskeuring voordat ze de weg op mogen. Het onafhankelijke oordeel van de Rijksdienst voor het Wegverkeer (RDW) wordt daarin leidend.

BSO-bus

Het nieuwe toelatingskader is er nog niet. Wel is, op aandringen van de Tweede Kamer,  kinderopvangorganisaties en verenigingen van ouders, de BSO-bus toegelaten tot de weg. Voor de toelating van de BSO-bus heeft de minister een convenant gesloten met de kinderopvangbranche met afspraken over het gebruik van de BSO-bus. In dit convenant wordt echter afgeweken van het advies van de RDW en van de eigen beleidsregel van het ministerie. De RDW oordeelt dat de nieuwe BSO-bus technisch voldoet aan de eisen, maar dat er een veiligheidsrisico ontstaat wanneer het maximale gewicht wordt overschreden. De beleidsregel bepaalt dat meer dan acht kinderen niet is toegestaan in een dergelijk voertuig. De BSO-bus is echter van tien zitplaatsen voorzien en de minister staat in het convenant het vervoer van tien kinderen toe. Dit verhoogt de kans van overschrijding van het maximale gewicht. Daarnaast zijn de convenantafspraken veel minder verplichtend dan wettelijke voorschriften. Ook zijn niet alle kinderopvangorganisaties aangesloten bij de branchevereniging.

Besluitvorming onder druk

Deze gang van zaken lijkt op de oude werkwijze zoals de Raad in zijn rapport over de toelating van de Stint en andere licht gemotoriseerde voertuigen beschreef. Waarbij het advies en oordeel van een onafhankelijke instantie, zoals de RDW, niet wordt gevolgd na een politieke afweging. Ook staat de toelating van de BSO-bus haaks op de koers van het beloofde toekomstige toelatingskader, waarin veiligheid zwaarder gaat wegen. De Onderzoeksraad roept dan ook de minister, de Tweede Kamer en maatschappelijke organisaties op om consequent en consistent te zijn: laat alleen voertuigen toe tot de weg waarvan de veiligheid onafhankelijk getoetst en positief beoordeeld is.

 

Bekijk hier de volledige onderzoekspagina Veilig toelaten op de weg - Lessen naar aanleiding van het ongeval met de Stint.

Decision on flight prohibition over conflict zones needed sooner

It is taking too long to reach a decision to restrict or avoid the airspace above a rapidly escalating armed conflict, concludes the Dutch Safety Board in its report entitled ‘Safe flight routes - Responses to escalating conflicts’ published today. “Recent years have shown that improbable scenarios can very quickly become reality,” says Jeroen Dijsselbloem, chair of the Dutch Safety Board. “As a precaution, the airspace over a high-risk area should be restricted or avoided sooner than is currently the case.”

Twice in the past decade, a passenger plane has crashed after it was hit by a surface-to-air missile while flying over a conflict zone. On 17 July 2014, flight MH17 crashed in Ukraine. Flight PS752 crashed in Iran on 8 January 2020. This was reason for the Dutch Safety Board to conduct (partly at the request of the Minister of Infrastructure and Water Management) a review into the implementation of the recommendations in the MH17 Crash report and the conclusions in the report Flying over Conflict Zones.

Airspace management

The protection of civil aviation against the risks of flying over a conflict zone is primarily in the hands of the country where the conflict is taking place. This country may decide to restrict its airspace partially or completely. However, the Board concludes that this rarely happens. Even when the conflict between Iran and the United States escalated rapidly in January 2020, Iran’s airspace remained open. To improve this situation, the Board recommends developing international criteria for when a country should restrict its airspace.

Better risk assessments

In addition to the country of conflict, the airlines have an important responsibility of their own. When tensions rose in Iran in the early 2020s, this did not prompt airlines to avoid the country’s airspace and aircraft continued to fly over this high-risk area. The airlines did not refrain from flying over Iran because they concluded that the risk of being hit by a surface-to-air missile was unlikely, even while the consequences could have been catastrophic. But nor did any countries advise their own airlines to avoid flying over Iran. The Board recommends that all possible scenarios with catastrophic consequences should be given more weight in the risk assessments of both airlines and governments. In addition, when a conflict rapidly escalates, countries are still taking too long to collect and share new information, carry out a risk assessment and publish an advice. The Board recommends accelerating this process at the European level.

Advising and regulating the Dutch airlines

The provision of information to the Dutch airlines by the Dutch government has improved significantly in the years since the MH17 crash, but the Dutch government still only provides information, and does not come with advice or a flight prohibition. Moreover, there is currently no legal basis for the minister to impose a flight prohibition over a certain area. This does happen in other countries, including important allies of the Netherlands. The Board advises the Minister of Infrastructure and Water Management and the Minster of Justice and Security to consider the possibility of imposing a flight prohibition in the law.

 

View the investigation page 'Safe flight routes - Responses to escalating conflicts'. Also view the investigation pages 'MH17 Crash' and 'Flying over Conflict zones - Follow-up recommendations MH17 Crash'. 

Structural solutions needed for risks to beam trawlers

The Dutch Safety Board has published the findings in response to the capsizing and sinking of the Urk-based beam trawlers UK-165 Lummetje and UK-171 Spes Salutis. The two occurrences provided definitive proof that beam trawling is not without risk. During the investigation, the Safety Board observed a safety risk on theses fishing boats, relating to their stability. This risk was so serious that in April 2021, the Safety Board decided to publish an interim warning.

On 28 November 2019, the trawler UK-165 Lummetje was lost in coastal waters near Texel. The two crew members lost their lives. The investigation revealed that the fishing boat first capsized before sinking. In December 2020, while the investigation into the UK-165 was underway, the UK-171 Spes Salutis also capsized. The three-men crew of this boat were scarcely able to be rescued. These two occurrences made it clear that on fishing boats of this type, stability can be rapidly and dangerously compromised as a consequence of asymmetric loading conditions. This finding was reinforced by calculating the stability in asymmetric loading conditions of the TX-21 Pieter van Aris, a different type of fishing boat.

Real risk of capsizing due to asymmetric loading conditions

The fact that under asymmetric loading conditions stability decreases is not in itself new. However the fact that stability can be compromised so rapidly and dangerously was a surprise. It increases the risk of capsizing. These realizations led the Safety Board to publish an interim warning in April 2021, ahead of today’s publication. The aim of this warning was to inform the crews of similar trawlers to the UK-165 and UK-171 as quickly as possible of this risk, to allow them to take the appropriate action.

Certification process for beam trawlers

In response to the warning, the fishery sector took immediate action. In addition to informing trawler crews and other parties involved in sea fishing in the Netherlands, work was started on developing structural solutions to mitigate this risk.

In the certification process for beam trawlers, asymmetric loading conditions are not included in stability calculations. In its report, the Dutch Safety Board recommends that the Minister of Infrastructure and Water Management rectifies this situation in the future, as indeed specified by law. In addition, the Safety Board has issued a series of recommendations that should bring about preventive measures, knowledge development and alterations to ship design for current and future fishing boats. However, awareness of the safety risk remains essential, at all times.

Broader study needed into entire trawler fleet

The investigation published today focuses on beam trawlers with a length of less than 24 metres. The Safety Board recommends that the Minister of Infrastructure and Water Management launches a broader investigation, with a view to increasing the safety benefits for the entire Dutch fishing fleet. The aim of this investigation should be to map out the safety risk of asymmetric loading conditions on trawlers of all lengths.