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Request from the Minister

In the Portuguese accident investigation at the time, it was already concluded that upon departure from Amsterdam, the aircraft had been airworthy. According to the Portuguese investigation into the accident, upon landing, the impact on the landing gear was so considerable that the landing gear failed when the design limits were exceeded. Following the broadcasting of the TV news programme EenVandaag on 16 January 2016, doubts arose about the maintenance of the landing gear. It was alleged that due to the wrongfully granting of permission to postpone the compulsory exchange of the landing gear, the aircraft was not airworthy. The then State Secretary for Infrastructure and the Environment requested the Safety Board to investigate whether these claims were accurate. At that time, a second-opinion investigation was underway, commissioned by the District Court of The Hague. The Safety Board therefore considered it inopportune to launch its own supplementary investigation. This second-opinion investigation confirmed the Portuguese investigation, also concluding that the aircraft was airworthy. Following the court judgement in 2020, the Minister of Infrastructure and Water Management again requested the Safety Board to investigate whether the broadcast by EenVandaag in 2016 had revealed any new facts.

Investigation concluded

The Safety Board subsequently conducted an investigation into the maintenance of the landing gear of the aircraft involved in the accident. As part of this investigation, the investigators visited the archives in the Netherlands and Portugal, and spoke to persons directly involved. During the investigation, no evidence was found of non-conformities or any exceeding of maintenance periods and inspections. There was also no indication of any necessity to postpone the exchange of the landing gear. The final conclusion once again confirmed that the aircraft satisfied all maintenance requirements and upon departure from Amsterdam was airworthy.

The COVID-19 restrictions during the visits to the archives in the Netherlands and the archive in Portugal delayed the investigation by more than six months. The Minister of Infrastructure and Water Management has been informed of the findings in a letter (Dutch only).

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.

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.

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'.