Press release Emergency assistance after Turkish Airlines aircraft incident, Haarlemmermeer, 25 February 2009

Safety Board publishes report on emergency assistance after Turkish Airlines crash

The shortcomings that should not have occurred

On 6 July 2010, the Dutch Safety Board, chaired by Professor Pieter van Vollenhoven, has presented its final conclusions of the investigation into the emergency assistance after the accident of Turkish Airlines’ Boeing which took place on 25 February 2009. This accident took the lives of five passengers and four crew members, 117 passengers and three crew members sustained injuries. The Boards’ report on the cause of the crash was published on 6 May 2010.

The objective of this investigation was to assess whether lessons can be learned from the emergency assistance process after the aircraft accident, to improve the emergency assistance provided during major accidents in the future. Contradicting signals about the process, such as the late release of the names of the victims, reports that victims were trapped for a long time in the aircraft before they could be freed by the emergency services workers and the criticism of the emergency services workers about the way in which the communication system C2000 operated, induced the Board to start the investigation. During the investigation it emerged that important lessons to be learned from five previous investigations into the emergency assistance provision during disasters and major accidents have been insufficiently adopted. For example, the lessons learned after the café fire in Volendam were acknowledged but the observed problems keep emerging.

Despite the made efforts of all those involved, it has been determined that the emergency assistance was flawed with regard to specific issues. For example, time was lost before the actual arrival of the emergency services because information was not exchanged properly and because the determination of the accident location was not coordinated. Besides that, time was lost when the mobile medical teams were not alerted by the Kennemerland control room which delayed the arrival of the mobile medical teams at the accident site by nearly an hour. Also, there was a long period of uncertainty about the names and location of the victims and the type of their injuries due to the poor registration of victims. It turned out that the experienced C2000 problems were not caused by capacity shortage of the masts but by incorrect use. A lacking uniform system set-up for supraregional deployment of emergency assistance, too many users and call groups, together with the lack of direction and ‘ether discipline’ resulted in congestion. The system appeared to fail, while from a technical point of view it functioned well. Finally, to many plans exist on and around Schiphol relating to the emergency assistance in case of aircraft accidents, that also vary mutually. Plans vary widely depending on the location of the aircraft, inside or outside of Schiphol terrain. This is an unworkable situation for, inter alia, the people in the emergency room. This applies not only to the surroundings of Schiphol but is also true for the other airports in the Netherlands.

In 2007, it was decided that the municipality of Haarlemmermeer including Amsterdam Airport Schiphol, would transfer from Amsterdam to the safety region Kennemerland. The Public Order and Safety Inspectorate (IOOV) gave in 2008, 2009 and, most recently, in 2010, a positive judgement on the safety region Kennemerland. This region was according to the IOOV ready to deal systematically and uniformly with any large aircraft accident. The Board is of the opinion that the above-mentioned imperfections, in view of this positive view of the IOOV, therefore, should not have occurred. The safety region Kennemerland should have been able to handle this accident without any problems. In fact, with a dominant risk on an aircraft accident around Schiphol, it was not the question of whether, but when such an accident would occur.

The council of the safety region Kennemerland is recommended to ensure that the mentioned imperfections are addressed quickly and effectively. It is important that the tasks assigned are enforceable in the daily routine. The Minister of the Interior and Kingdom Relations is recommended to procure uniform, national arrangements for medical assistance at major accidents and disasters. The Board intends to include a clear procedure for the registration of large numbers of victims.

Finally, the Ministers of the Interior and Kingdom relations and of Health, Welfare and Sport are jointly recommended to ensure that in major supraregional deployment of mobile medical teams, supraregional ambulance assistance and the release of hospital capacity, the emergency assistance residual coverage for other regions remains secure. The Safety Board is aware of the intention of the Minister of Health, Welfare and Sport to terminate the National Ambulance Dispatch Center in 2011. The Board is of the opinion however, that first it has to be determined which tasks have to be dealt with regionally and which nationally.