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.