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ASN Wikibase Occurrence # 215521
Last updated: 17 October 2018
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Date:01-AUG-2015
Time:17:48 LT
Type:Silhouette image of generic D228 model; specific model in this crash may look slightly different
Dornier 228-100
Owner/operator:Businesswings
Registration: D-IROL
C/n / msn: 7003
Fatalities:Fatalities: 0 / Occupants: 18
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Lelystad Airport (EHLE) -   Netherlands
Phase: Approach
Nature:Domestic Non Scheduled Passenger
Departure airport:Texel Airport (EHTX)
Destination airport:Lelystad Airport (EHLE)
Investigating agency: Dutch Safety Board
Narrative:
On 1 August 2015 a twin-engine turboprop Dornier Do-228 aircraft (D-IROL), conducting a non-scheduled commercial air transport flight from Texel Airport to Lelystad Airport, and a Tecnam P92 Echo Super microlight ({PH-4D3) nearly collided in mid-air near Lelystad Airport, the Netherlands.
Both flights were operating under visual flight rules (VFR) and in total 20 persons were onboard these aircraft. The microlight returned from a local flight on its way to runway 05 (grass runway) of Lelystad Airport. The twin-engine turboprop was approaching the main runway 05 (asphalt). It was not until a late stage of conflict that the pilot of the microlight could make an evasive action. The crew of the turboprop aircraft had not seen the microlight at all.
The investigation showed the limitation of the ‘see-and-avoid’ principle for air safety during VFR operations explaining the direct cause of the event.
Though evasive actions might prevent a mid-air collision, during approach and landing a successful evasive action can still be disastrous when resulting in an aerodynamic stall or loss of control whilst close to the ground. Therefore, in addition to the direct cause of this near mid-air collision, the investigation also focussed on the effectiveness of the ‘straight-in approach’ procedure to prevent near mid-air collisions in circuit areas or Aerodrome Traffic Zones (ATZ).
Additional findings of the investigation revealed that, in particular at uncontrolled aerodromes, safety is impaired when the executed flight path is non-compliant to the prescribed procedure. This also was the case with the twin-engine turboprop aircraft and another company aircraft which both flew to Lelystad Airport several times that day.
Non-compliance may also occur at other comparable uncontrolled aerodromes in the Netherlands where ‘straight-in approaches’ are allowed.
For this incident flight non-compliance likely was the result of misinterpretation of an ambiguous ‘straight-in approach’ procedure by the crew of the turboprop aircraft.
Furthermore, the ‘straight-in approach’ procedure of Lelystad Airport has officially been documented in an aeronautical publication, but its flight path was not shown on the visual approach chart. This also contributed to the non-compliance. Non-adherence to the prescribed ‘straight-in approach’ procedure increases the risk of (near) mid-air collisions with (other) aerodrome traffic.
The safety level of the passengers onboard the twin-engine turboprop aircraft was less than the usual standard for commercial air transport due to absence of radar service (separation) and a traffic collision warning system as a safety net.

Sources:

OVV

Accident investigation:
cover
  
Investigating agency: Dutch Safety Board
Status: Investigation completed
Duration: 3 years 1 month
Download report: Final report


Images:


Revision history:

Date/timeContributorUpdates
20-Sep-2018 18:09 harro Added
20-Sep-2018 18:11 harro Updated [Aircraft type]

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