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Netherlands Aerospace Centre (NLR) report

The NLR published their Integral Safety Analysis Report in February 2018. The report investigated the effects of limited traffic increase at Schiphol in 36 ICAO accident categories. 9 categories were identified as having a possible negative effect on accident probability per flight at Schiphol.

The report concluded that ‘The combination of Schiphol-specific measures identified in this study and autonomous improvements in safety enable limited traffic growth within Schiphol’s current operational concept without increasing the risk of an accident per year’.

The analysis of NLR is based on an assessment of the autonomous improvement of aviation safety due to global developments and an analysis of the potential local effects of growth at Schiphol. This latter analysis is structured according to ICAO accident categories, where 9 categories were identified as having a possible negative effect on accident probability per flight at Schiphol. The Netherlands Aerospace Centre Report (NLR) proposes specific measures for each of these accident categories, which are expected to remove the negative effects of traffic growth on the accident probability per flight.

The 9 accident categories are:

Airprox/TCAS Alert/Loss of Separation/(Near) Mid-air Collisions (MAC)

NLR identified a number of measures in the integral safety analysis that remove the negative effects of traffic growth on the risk of (near) collisions between aircraft. All are included on the roadmap. The only exceptions are the replacement of the AAA- Air Traffic Control System by ICAS, improved Arrival Management, and reduced congestion of radio-frequencies.

These are elaborated further below:

The replacement of the AAA- Air Traffic Control System is not on the roadmap because it is a technical replacement and as such not a safety improvement. The new system applications, such as the increased use of trajectory prediction, are on the roadmap instead.

The improved arrival management largely concerns the interaction of LVNL with its international partners, which is outside the scope of ISMS. The improved arrival management is, however, part of the measures to prevent last-minute runway combination changes to landing traffic.

The introduction of 3 new ground controllers already alleviated the overloaded radio frequencies. And we are still to establish the contribution of frequency congestion to the top five flight risks. Based on the outcomes, additional measures may be added to the roadmap this year.

The following measures are included in the roadmap:

Studies

Implementation

Completed

Ground Handling (GROUND)
Analysis

Several potential measures were identified in the integral safety analysis by the NLR that remove the negative effects of traffic growth on ground handling risks. A number of these measures provided alternative solutions for the reduction of overcrowding on the aprons.

These include:

  • Reduction to the number of ground handlers
  • Engaging no new ground handling organisations
  • Allocation of aprons to a specific ground handler
  • Pooling of ground vehicles and equipment
  • Introduction of track and trace on ground equipment.

The main ground handling risks involved were analysed in the ISMS. The analysis found that the introduction of equipment pooling was the most promising solution in terms of risk reduction and feasibility. As a result, a sector taskforce was initiated to introduce this measure. Other solutions will be considered if it seems that this measure cannot be successfully implemented.

In addition, the NLR included an existing measure to include ‘ground handler quality’ in their ground handler selection process. This existing measure may need to be intensified. The individual company safety management systems and the joint sector ISMS continuously monitor whether the measures need to be intensified. The ISMS will evaluate the effectiveness of this measure in 2019.

All other measures proposed by NLR are on the roadmap.

It appeared that staff deviation from rules and regulations on platforms and service roads was an important source of risk, both in addition to the NLR measures and according to the ISMS’ risk analysis. An in-depth analysis of the root cause of these deviations was carried out to identify effective measures for these risks. The measures that result from this will be worked out in a roadmap.

Activities

The following measures have been included on the roadmap:

Studies

Implementation

Completed

Ground Collision (GCOL)

Several potential measures were identified in the integral safety analysis by the NLR that remove the negative effects of traffic growth on risks involved with ground collisions. The roadmap includes all of these measures.

Furthermore, a number of additional sector initiatives were placed on the roadmap as well, either as a result of the safety management systems of sector parties or resulting from separate ISMS analysis.

Studies

Implementation

Completed

Runway Incursion (RI)

Several potential measures were identified in the integral safety analysis by the NLR that remove the negative effects of traffic growth on risks involved with runway incursions. A number of structural improvements were identified by NLR, such as:

  • 

Runway status lights
  • 
Introduction of follow the greens
  • Reduction of the impact of runway combination changes
  • Use of three ground controllers
  • Colocation towing movement control and ground control.

These measures are all on the roadmap; the others are being considered by the runway safety team.

The NLR measures labelled 'construction of additional high-speed exits (on runways 22, 36C and 36R)' and 'placement of additional signs at exit N3, N4 and W7' are aimed at reducing the runway occupation time. We decided not to put these measures on the roadmap because the runway occupation time was sufficiently reduced as a result of an LVNL campaign. 

A decision as to whether to add the other measures from the NLR report to the roadmap should be made in 2019.

In addition, a number of other measures which were not included in the NLR report were placed on the roadmap as well. These initiatives were either a result of the safety management systems of sector parties, the result from ISMS analysis or the follow-up of the recommendations of the Dutch Safety Board.

The following measures have been included on the roadmap:

Studies

Implementation

Completed

Abnormal Runway Contact (ARC)

The NLR report refers to the existing measures in terms of abnormal contact with the runways, which may be intensified. The individual safety management systems and the ISMS joint sector constantly monitor whether or not the measures need to be intensified. These activities take place in the occurrence investigation, safety audits, training programmes for cockpit crews, and flight data monitoring programmes. The roadmap states one new measure in addition, which is ‘reduced risk of misaligned take-offs’. The sector gives substance to the recommendations of an incident investigation conducted by the Dutch Safety Board (Onderzoeksraad voor Veiligheid or OVV) with this measure. The effectiveness of the current measures in the ISMS will be evaluated in 2019.

Studies

Runway Excursion (RE)

The NLR report refers to existing measures which may need to be intensified. The individual company safety management systems and the joint sector ISMS continuously monitor whether the measures need to be intensified via their occurrence management processes, safety audits, flight crew training programs and their Flight Data Monitoring programs. In the ISMS system, the current measures effectiveness will be evaluated in 2019.

Undershoot/overshoot (USOS)

The NLR report refers to existing measures which may need to be intensified. The individual company safety management systems and the joint sector ISMS continuously monitor whether the measures need to be intensified via their occurrence management processes, safety audits, flight crew training programs and their Flight Data Monitoring programs. In the ISMS system, the current measures effectiveness will be evaluated in 2019.

Controlled Flight Into/toward Terrain (CFIT)

The NLR report refers to existing measures which may need to be intensified. The individual company safety management systems and the joint sector ISMS continuously monitor whether the measures need to be intensified via their occurrence management processes, safety audits, flight crew training programs and their Flight Data Monitoring programs. In the ISMS system, the current measures effectiveness will be evaluated in 2019.

Loss of control – In Flight (LOC-I)

The NLR report refers to existing measures which may need to be intensified. The individual company safety management systems and the joint sector ISMS continuously monitor whether the measures need to be intensified via their occurrence management processes, safety audits, flight crew training programs and their Flight Data Monitoring programs. In the ISMS system, the current measures effectiveness will be evaluated in 2019.