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Dutch Safety Board publishes findings of Amsterdam-Schiphol Airport safety investigation
9 April 2017

In recent decades, Amsterdam Airport Schiphol has expanded to become one of Europe’s main civil aviation hubs. The airport is sandwiched between densely populated urban areas, so trade-offs must continually be made between growth and the consequences thereof for the surrounding area. Safety needs to have a prominent place in these trade-offs, as the effects and impacts of civil aviation accidents can be substantial.
Following a series of incidents (some of which occurred more than once), the Dutch Safety Board carried out an investigation to identify any vulnerabilities in the safety system around Schiphol. The investigation found no evidence to suggest that safety at Schiphol is inadequate. However, the investigation did reveal a number of safety risks that need to be tackled integrally and systematically in order to guarantee safety both now and in the future.

Conclusions:

1. Both Amsterdam Airport Schiphol’s physical infrastructure, its formal usage framework and its everyday operations are highly complex, giving rise to safety risks.
a. The complexity involved in handling air traffic at Schiphol is largely due to historical and recent choices regarding the airport’s design, layout and operation.
b. Schiphol’s plan and layout are complex in nature. The numerous taxiways, runway exits and entries, the relative (sometimes converging) runway orientations, maintenance hangar locations and the location of the S-platform (cargo) introduce risks of incidents and accidents.
c. The complexity in handling air traffic stems from:
— the implemented concept of operations involving a ‘wave system’, featuring peaks in traffic levels;
— the terms of operation relating to noise annoyance mitigation; noise preferential flight operations result in many runway configuration changes;
— the way parties organise their processes.
d. The increase in air traffic adds to the complexity. Since 2014, the increase in air traffic has gone hand in hand with an increase in the number of incidents.
e. Schiphol airport is approaching the limits of its ability to handle air traffic safely within the current operational concept.

2. In decision-making processes about Amsterdam Airport Schiphol, safety is taken into account as a precondition. The impact on safety of various noise abatement measures is factored into the assessment. The way in which safety (as a precondition) is implemented, has the following shortcomings:
a. Decisions are tested against the ATC standard, in which a maximum acceptable accident risk per flight is defined for the air traffic control system. This safety standard covers only a small part of the operational safety risks at and around Schiphol.
b. Prior to the introduction of the new standards and enforcement system, no integral analysis took place of the effects on safety. The safety effects of frequent runway configuration changes have not been examined.
c. The external safety policy is of marginal significance to the safety of local residents.
The standard for local risk provides scant guidance to the sector parties. There are no clear standards for group risk.

3. The cooperation in the field of safety between the main sector parties at Schiphol has a number of shortcomings.
a. At strategic level, there are no safety consultations with common agendas and common safety goals.
b. Cooperation within the Schiphol Safety Platform (Veiligheidsplatform Schiphol) is too noncommittal, primarily reactive, and limited to the operational level.
c. The Schiphol Safety Platform lacks the authority to enforce safety measures at the parties involved.

4. The State assumes responsibility for the integral safety of air traffic at and around Schiphol in a way that is too limited.
a. In the system that is to guarantee air traffic safety at and around Schiphol, the Ministry for Infrastructure and the Environment fulfils several roles that are at odds with each other.
b. the Ministry for Infrastructure and the Environment has no idea about the total level of safety of air traffic at and around Schiphol and the effect of the total amount of changes on that safety level. A testable criterion for integral air traffic safety is lacking. It is unclear how it can be ascertained that safety on the whole is improving.
c. Safety is not given enough priority in the decision-making with regard to the development of Schiphol airport.
d. The Ministry for Infrastructure and the Environment leaves the role of safety watchdog in the Schiphol Community Council (Omgevingsraad Schiphol) to Air Traffic Control the Netherlands (Luchtverkeersleiding Nederland).
e. Subject-knowledge and capacity of the Human Environment and Transport Inspectorate (Inspectie Leefomgeving en Transport) are inadequate for maintaining effective oversight of air traffic safety at and around Schiphol. The Human Environment and Transport Inspectorate has only a limited idea about the safety effects of successive changes to the ATM system.
f. The Aviation Occurrence Analysis Bureau (Analysebureau Luchtvaartvoorvallen) fails in its functions as feedback mechanism for policy and oversight and as an instrument for proactive risks identification.

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