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Follow-up to the Dutch Safety Board’s recommendations

The Dutch Safety Board published a report on Schiphol’s aviation safety in April 2017. In this report, recommendations were made in order to address the identified safety issues.

The ISMS sector parties work together to follow-up on the Dutch Safety Board’s recommendations. The Schiphol Safety Improvement Roadmap contains, but is not limited to, the studies and measures which are necessary to implement the Safety Board recommendations. Depending on outcomes of studies, additional measures may be added to the roadmap to further address the recommendations of the Dutch Safety Board.

The concrete steps taken for each point will be detailed below.

Please click here to read the full text of the recommendations

You can expand the sections below for more details.

1. Develop a new future-proof operational concept for handling air traffic at Amsterdam Airport Schiphol that will reduce current and future safety risks.


The development of the operational concept is taking place in conjunction with the Ministry of Infrastructure and Water Management, airspace users, the military, local residents, European partners and other stakeholders. The operational concept describes how humans, technologies and procedures are used to handle traffic at Schiphol. It is developed in a number of programmes in which the sector actively participates:

  • The development of the Aviation Policy (Luchtvaartnota), in 2019
  • Airspace redesign project, design phase between 2021 - 2023
  • Deployment of European SESAR technology, between 2014 - 2026.

Changes to the operational concept are implemented in a number of smaller steps. Each step will be deemed safe prior to implementation, including their aggregation.

The sector is currently working on a number of structural elements to improve safety under the new operational concept, which include:




1A. Reduce the number of runway configuration changes

The sector conducted an in-depth risk analysis into the topic of runway combination changes in the current operation, in response to the Dutch Safety Board concerns. Possible solutions to reduce risks further include better information about runway combination changes, optimising human factors and workload, better planning and reducing the frequency of runway combination changes. An ad-hoc task force has now started to take measures with regard to these risks.

The following studies were placed on the roadmap as a follow-up of this analysis:

The measures taken should be robust for future developments including limited growth of traffic in the current operational concept.

1B. Reduce the complexity of the airport’s infrastructure

A number of projects are carried out to reduce the complexity of the airport’s infrastructure. The taxiway across the highway A4 motorway will be doubled. That means taxi traffic will travel by a double-ring which structurally reduces the airport’s complexity. Furthermore, short-term safety improvements will be made within the current airport infrastructure to reduce risks. In addition, a task force has been established to reduce identified future risks in Schiphol South-West.

The ISMS plan has scheduled a preliminary risk analysis of the Schiphol Masterplan in order to proactively account for safety in the development of the airport’s infrastructure. This analysis will be completed July 2019.

The following items on the roadmap reduce the complexity of the infrastructure.




2. Reduce current and future safety risks by implementing measures such as:

2A. Minimising the number of crossings of active runways

The crossing of active runways mainly concerns runway 06/24 (Kaagbaan) and runway 18L/36R (Aalsmeerbaan) due to the location of freight operations and aircraft maintenance activities in the hangars.

The sector performed an in-depth risk analysis on the runway 06/24 crossing. That resulted in the Runway Safety Team working out solutions to reduce the risk of crossing this runway at intersection S2 (which is located halfway along the runway).

Schiphol is expanding the Uniform platform where aircraft maintenance activities can take place without necessitating a runway crossing. In the ISMS, an analysis will be carried out as to whether the expansion of the Uniform platform sufficiently reduces the risk of crossings of the runway 18L/36R or that additional measures will need to be taken.

The following items to reduce the number of crossings are on the roadmap:



2B. Monitoring and evaluating any deviations from procedures and standards by air traffic controllers

In total, LVNL monitors more than 20 parameters that relate to deviations in its safety management system. Relevant safety performance indicators based on operational data are periodically reported to management. This facilitates trend monitoring and, if deemed necessary, in depth analysis and corrective action. In order to further develop this system as recommended by the Dutch Safety Board, LVNL developed 5 additional safety performance indicators which were incorporated this year.

2C. Assessing the risks of an accumulation of safety risks and the associated mitigation measures

The prevention of risk accumulation will be formalised in the ISMS system. Risk accumulation will be considered in the periodic verification whether the declared capacity can be safely executed. Furthermore, the safety risks and associated mitigation measures of the changes in the past 3 years were analysed in the ISMS system as well. Although there was a potential for accumulation in several cases, it appeared that the organisations involved recognised the potential interference and took measures to prevent this on a case-by-case basis.

2D. Systematically reducing the number of runway incursions

The Runway Safety Team (RST) is a team of experts who identify the ways to reduce the number of runway incursions. Trends are continuously monitored to identify locations at the airport where runway incursions take place. This resulted in a number of ongoing studies and implementation projects. In addition, NLR identified measures to reduce the number of runway incursions which are placed on the roadmap as well. For an elaboration of these measures, please refer to the NLR measures page.

In the ISMS structure, there is an executive chairman of the RST. That shifts the groups status from an advisory panel into an action-focused group. They will develop a plan to structurally reduce risks involved with runway incursions, which will include objectives and measures on how to reduce them.

The following items are currently being carried out:




Over time, new initiatives from the RST will be placed on this roadmap.

3. Carry out in advance an integral investigation of the impact of an air traffic increase on safety, and take measures to systematically manage this impact.

The integral investigation will be carried out in 3 ways:

  • The Ministry of Infrastructure and Water Management commissioned an Integral Safety Analysis by the Netherlands Aerospace Centre (NLR). The analysis contained an investigation of a limited air traffic increase on safety within the current operational concept and identified measures to manage its effects. Several roadmap items are related to the proposed measures, and we foresee another evaluation of their effectiveness before a decision will be made about Schiphol’s future development.
  • The sector will thoroughly analyse the safety risks of major changes in the context of the ISMS. For example, these include a risk analysis of the combined impact of the realisation of the A-pier, extension of the Sierra platform, and restructuring of the Romeo platform. The safety of major changes to the operational concept will also be analysed, with a focus on opportunities to structurally improve safety.
  • The ISMS framework will allow us to verify whether the declared capacity can be safely executed, for each capacity declaration as referred to in the Slot Allocation Decree, from 2019 onwards. This means that the safety of an increase of traffic is verified at beforehand within the ISMS.

4. Draw up a shared vision on safety at Schiphol, especially including details of the safety targets to be achieved, together with the corresponding deadlines.

The ISMS work plan establishes a joint safety policy, due December 2018. This policy is defined in the context of the State Safety Programme. A joint dashboard on interface risks will be established and targets will be set for relevant safety performance indicators, including a new ambition for the reduction of runway incursions, in 2019.

5. Set-up an Integrated Safety Management System (IVMS) to which all of the parties in VPS are committed. This system must include at least the following elements:

  1. Joint approach to the safety risks associated with relationships and interactions between the individual parties (interfaces)
  2. Joint investigations of incidents and proactive safety analyses.

The sector set-up an ISMS which jointly manages the safety risks associated with relationships and interactions between the individual parties. The ISMS mimics the structure prescribed by the ICAO and EASA for individual safety management systems. In January 2018, the first ISMS Safety Review Board Meeting took place.

Since then, the following results have been achieved:

  • Joint risk analyses were carried out with respect to ground handling, changes of runway combinations and infrastructural changes in the Schiphol South-West area. Subsequently, taskforces were initiated to develop safety measures to reduce the identified risks.
  • The ISMS will decide whether a joint investigation should take place for each incident. 3 joint incident investigations have already been initiated. One of these investigations led to the establishment of an ad-hoc taskforce to further reduce the risks of converging go-arounds and departures, the other two will be finalised this year. The initiation and execution of joint incident investigations will be formalised in the working processes of the sector partners in 2019.
  • The top 5 ground risks and top 5 flight risks are being investigated. The top 5 will be used to develop a safety dashboard and to give priority to safety improvement measures in 2019.

The working processes of the ISMS are being standardised to enable external auditing in 2019.

6. See to it that the Schiphol Safety Platform is given a formal status and the authority to enforce operational and strategic decisions on safety at Amsterdam Airport Schiphol.

The safety accountabilities in aviation are defined by regulations, most of which originate in European law and worldwide standards. In this context, it seemed legally impossible to give the ISMS (as the successor of VPS) formal authority over safety decisions, as parties are not allowed to transfer safety responsibilities. Instead, decisions are made by consensus.

In order to ensure the effectiveness of ISMS, a number of measures were taken:

  • A common risk matrix is used to jointly decide on the acceptability of safety risks
  • Parties are represented by functionaries with the appropriate mandate
  • Representation is used to streamline multi-party decision-making
  • Strict adherence to EASA and ICAO safety management principles to secure the process
  • A covenant about the development of ISMS was signed with the Minister of Infrastructure and Water Management

The effectiveness of the ISMS will be evaluated by external experts in 2019.