“Those who cannot remember the past, are condemned to repeat it.”
George Santayana
After over 30 years, proper accountability and responsibilty taking for the Martinair crash in Faro and its aftermath still lack.
The Court procedure and verdict of January 2020 leaves many questions -even on the actual crash- unanswered.
An open discussion still seems not possible.
For many, this uncertainty continues causing anxiety, frustration and doubts; it gives too much room for biased opinions and alternative truths.
December 21st, 1992. Delayed Martinair early morning flight MP495 crashes at Portugal Faro airport in adverse weather conditions the pilots were aware of (not: because of unexpected weather changes).
The DC10, PH-MBN Anthony Ruys, is bought by the Royal Netherlands Air Force (destined to be converted into a KDC-10) and immediately leased back to Martinair.
As result of the crash 54 passengers and 2 flight attendants die. Over 200 occupants sustain physical injuries.
Also because of the aftermath, many lives become permanently damaged and limited.
Here ends the consensus on the crash, it’s causes and it’s consequences.
With the The Hague court verdict of January 8th, 2020 the basic question whether the pilots properly aligned the plane with Faro-runway center line, still remains unanswered.
It is doubtful whether proper lessons (ICAO Annex 13) of the Martinair crash in Faro itself and, let alone, also of the aftermath and the personal and societal effects and consequences are, willing, to be learned.
The lack of comprehensive investigation and care is an indication for this.
November 2024:
31st annual commemoration
December 21st, 2023, St. John’s Basilica, Laren (NH, Netherlands)
October 2023
Not ‘heavy rain’, but ‘beastly weather’ (according to the pilots)
May 2021
Even after the court verdict of 2020, Martin Schröder ( † October 2024, founder and at the time of the crash CEO of Martinair) denies the errors made by his pilots.
August 2017 (updated January 2018)
AvioConsult publishes a detailed analysis of the last 80 seconds of Flight MP495.
From Main Conlusions: This accident is a classic example of the fatal consequences of not applying the written and well-established procedures and protocols for a non-precision approach.
———————————————————————————
Court cases
January 8th, 2020:
verdict by The Hague court
– the in November 2019 by claimants requested cross examination of the court experts is not granted
– the almost mythical Dutch claim of the (unexpected) windshear as cause of the crash is refuted
– actions of the Dutch Aviation and Safety Board (Board) are qualified as inaccurate and wrongful.
NB In my opinion: this negative attitude of Board probably / possibly affected their total input in the official investigation.
Documentation:
– Dutch Aviation Council Acted Negligently and Unlawfully in 1992 Faro Plane Crash, hg.org
– Faro survivor: “There is justice now, but we remain losers” (also on ‘beastly’ weather), mbs.news
– From the verdict, need for a missed approach procedure
– The verdict. Text mostly in Dutch, from page 6 onwards, information also in English from the report of the court experts.
On the limited 2016 investigation by the Dutch Safety Board (DSB)
This limited investigation by the DSB has its origin in a request by the Dutch Minister of Infrastructure after a whistleblower declared in 2016 that as technician he was “pressured” into signing a form that postponed the replacement of important landing gear for the third time when the replacement should have been delayed no more than twice.
November 18, 2021:
The DSB reports after a limited investigation into the landing gear only; not into the engines.
In its reporting to the to the Dutch Minister of Infrastructure, DSB explicitly states that the whistlebower stands by his original statement.
In the November-2022 Dutch book FARO – 30 years after the disaster states: ‘According to the DSB, since 1992 there have been three maintenance schedules from which a choice can be made, which in any case leaves room for interpretation.’
Note by Cor tenHove:
Based on this DSB-investigation it is not possible to make a positive statement on the airworthiness of the crashed plane: the official (=Portuguese) investigation report states that of only two of the three engines ‘All the applicable ADs [Airworthiness Directives] were introduced up to the date of the accident’ (Pages 31 and 32).
All in all, an unsatisfying conclusion by the DSB.
Causes of the crash (deficient -Dutch- investigation up to 2011)
The day after the crash Martin Schröder (founder and CEO of Martinair), together with the then Dutch Minister of Transport, helt a press conference . In this press conference Mr Schröder stated that an unexpected windshear was the cause of the crash. Some consequences of an unexpected windshear as cause of the crash are diminished responsibility and liability for Martinair.
Despite the findings in the official Portuguese Investigation report, the ‘unexpected windshear theory’ remained the dominant Dutch view.
This partial Dutch view is sustained by the then lack of independent crash investigation in The Netherlands.
The public doubts and questions, as raised by the passengers on the flight, on the crash and its causes never seemed to be taken seriously.
NB The American NTSB also doubts the unexpected windshear theory in it’s letter; annex to the official ( = Portuguese) Investigation Report.
Complicating factor is that the official investigation report only states probable causes. This almost invites speculation and alternative theories.
New analysis of the facts and court cases
In February 2011 (updated December 2012), over 18 years after the plane crash, an investigation by Mr. Harry Horlings of AvioConsult is published.
In my opinion, this investigation deepens the outcome of the official Portuguese report, in which the pilots and their actions and their non-actions are chiefly regarded as leading to the crash.
Complete AvioConsult page in English on the crash.
In July 2015 the court in The Hague appointed three non-Dutch experts to look into this case.
The verdict in January 2020 by the The Hague court did bring some more clarity and relief.
Because of the limited scope of the task of the experts, the lack of open discussion and the limited publication of their findings, many questions remain.
Reports:
– 2016, review by the Claimants Experts (CE) of the Interim Report of the Court Appointed Experts (CAE)
– 2017, Final Report by the CAE with CE comments
– 2017, review by the CE of the Final Report of the CAE
For a more complete picture of also underlying causes leading to the crash, starting with the management and safety culture of Martinair, a Swiss Cheese Model type of investigation was needed.
The unrest in 1998 (6 years after the crash) of Martinair pilots on their workload makes scrutiny of the Management Culture in 1992 even more important.
See, translated, articles in Dutch newspapers Trouw and NRC.
Consequences (too little attention for)
An integrated care approach and monitoring (both per individual as for the total group of occupants and familiy members) lacks.
Partly thanks to the aftermath of the crash of EL Al flight 1862 in Amsterdam, three months earlier, there is attention for possible psycho trauma, as PTSD, and for grief.
The High Energy Impact nature of the crash, due to the kinetic forces, and its possible, cognitive, consequences are largely ignored.
There is hardly any attention for ‘invisible’ physical injuries of head and brain and it’s consequences, such as sensory overload.
Most of the practical and long term real life consequences for surviving occupants and family members remain unseen.
Because the people concerned live scattered all over The Netherlands, and even in other countries, there is too little awareness and recognition of the real impact and consequences of the crash.
There is some progress on better attention for the possible (probable?) occurence of mild head injury in plane crashes.
Mild Traumatic Brain Injury, especially Decelaration Injury, can easily be overlooked and consequences such as Mental Fatigue neglected.
Possible co-existence of Mild Traumatic Brain Injury and Post Traumatic Stress Disorder hampers proper diagnosis and treatment.
A Dutch National Head-Brain Knowledge Center is badly needed.
Documents:
• Investigation report, English (approx. 7 MB)
• Investigation report, Portuguese (approx. 3 MB)
Remarks in English by the web site author, related to investigation report topics:
• Meteorological flight preparation
• On beastly weather or heavy rain (new, October 2023)
• Engines (updated Feb. 2021)
• Experience of the crashed pilots (updated November 2021)
• Fire and alarm before the crash (updated May 2021)
• Premature power reduction
• Survivability of the crash (updated March 2021)
• Thoughts on probable causes in the investigation report
• On departure with faulty thrust reverser without permission
• Aviation is too safe
• Possible Hurry-up syndrome?
• On landing gear: PortugalResident January 20, 2016: ‘Plane…never should have left Amsterdam‘
Amongst other topics in this article: postponement, under pressure, of the replacement of a landing gear of the aircraft for the third time. Such a postponement could only be granted twice.
NB One of the determined probable causes of the crash was the fracture of of the right landing gear.
• Book (The Crisis After The Disaster) in English by survivor / website author
• Book A Última Aterragem (in Portuguese) by Pedro Fernandes
External links:
• Wikipedia English
• Video of wreckage of PH-MBN on YouTube, 3:43
• animation of the incorrect approach and subsequent crash of the DC-10 Anthony Ruys
• YouTube-animation by FlightChannel on flight, crash en questions, approx. 15 minutes
• Algarve Daily News, December 21, 2018: Dutch air crash at Faro airport – 26-years ago on December 21st
Contact
For questions, remarks and/or suggestions, please contact
Cor tenHove (passenger of the crashed plane) at cortenhove -at- outlook.com .
