Crash Martinair flight MP495 in Faro, Portugal

After over 28 years, even after the Court verdict of January 2020, many facts regarding the crash -even on the actual crash itself-, are still uncertain.
This uncertainty continues causing anxiety, frustration and doubts.

The markings and debris on the right side of the plane show that the plane first slided on it’s right side before rolling on it’s left side. This gives an indication of the forces the occupants of this part of the were exposed to during the crash.
The ‘ditch’ shows that this part of the fuselage moved, with great force, backwards instead of forwards in the crash. A further indication of the additional violent forces on the occupants.
December 21st, 1992.  Martinair flight MP495 crashes at the airport of Faro, Portugal while the crew  attempts to land the plane in bad weather conditions.
The DC10, PH-MBN Anthony Ruys, is owned by the Royal Netherlands Air Force and is destined to be converted into a KDC-10.
As result of the crash 54 passengers and 2 flight attendants die. Over 200 occupants sustain physical injuries.
Here ends the consensus on the crash, the crash events, it’s causes and it’s consequences.

After the court verdict of January 8th, 2020 even the basic question whether the pilots properly aligned the plane with Faro-runway center line remains unclear.
Are proper safety lessons (ICAO Annex 13) learned?


April 2021:

2020 Annual commemoration canceled due to CORONA.
The communal annual commemoration  was canceled because of the Covid19 situation.

Additional investigation by Dutch Safety Board
May 12th, 2020: Dutch Minister of Infrastructure asks the Dutch Safety Board (Board) to partially reinvestigate possible causes of Martinair crash in Faro. MBS.news.

The request of the Minister has its origin in the  2016 statement of a technician that he was “pressured” into signing a form that postponed the replacement of important landing gear for the third time when it should have been delayed no more than twice.

With this request, the Board is asked to looked into the dealings of a direct predecessor: the Dutch Aviation and Safety Board (DASB).
Work by the DASB relating to the Martinair-crash in Faro the The Hague-court qualified in January 2020 as ‘
negligently and unlawfully‘.
Furthermore the DASB reacted unprofessional and biased to the investigation that was published in 2011.
All combined, the DASB does not seem independent and unpartial enough to credibly conduct and publish the investigation as requested by the Dutch minister.
Crediblity is all the more important since the crashed plane was owned by the Dutch government.

The Board will conduct a shortened investigation. The investigation will focus solely on the technical questions about the landing gear.
Other important questions, like  for instance on the engines, will not be looked into.
The Board aims to complete and publish the report no later than the beginning of 2021.

Court cases.
April 20, 2020: Dutch State will not appeal January 2020 verdict.
Neither the claimants will appeal. The verdicht is final.
Most probably the court case, on hold since 2014, of claimants versus Martinair has also been terminated as a result of the Janaury 2020 verdict.

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 (DASB) are qualified as inaccurate and wrongful.
NB In my opinion: this attitude of DASB probably / possibly also affected their 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”, mbs.news

From the verdict, need for a missed approach procedure
– The verdict. From page 6 and onwards, information also in English from the report of the court experts.

———————————————————————————-

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 Schroeder 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 seems to doubt the unexpected windshear theory in it’s letter; annex to the official ( = Portuguese) Investigation Report.
Complicating factor is that the official 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. This investigation strengthens in my opinion the outcome of the official Portuguese report, in which the pilots and their actions and non-actions are chiefly regarded as leading to the crash.
In January 2018 AvioConsult published a detailed analysis on the last 80 seconds of Flight MP495.

Perhaps because of the court cases against Martinair (court in Amsterdam) and the State of The Netherlands (court in The Hague), that were started end of 2012 on basis of above mentioned analysis, there were no public reactions regarding content and/or refutations to the ‘Investigation Horlings’.
In July 2015 the court in The Hague appointed three non-Dutch experts to look into this case.

Hope was that the outcome of the analysis by these court experts, and subsequently the outcome of the court cases, would bring more clarity and hopefully peace of mind.
The January 2020 – verdict of the The Hague court did bring some more clarity and relief. Because of the limited scope of the task of the experts and the limited publication of their findings, many questions remain.

For a more complete picture of also the underlying causes of the crash, starting with the management and safety culture of Martinair, a  Swiss Cheese Model type of investigation was needed.

Consequences (too little attention for)
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 mourning.
For all the practical and long term real life consequences for surviving occupants and family members there is insufficiënt attention.
Because the people concerned live scattered all over The Netherlands, and even in other countries, there is too little awareness for and recognition of the real impact (High Energy Trauma) and consequences of the crash.
There is hardly any attention for invisible head injuries.

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 interferes with the process of proper diagnosis and treatment.

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
Engines (page updated Feb. 2021)
Experience of the crashed pilots  (page updated March 2021)
Fire and alarm before the crash
Premature power reduction

Survivability of the crash (updated March 2021)
Thoughts on probable causes in the investigation report
Aviation is too safe

• 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 via cortenhove -at- outlook.com .

 

Monument in Basilica Saint John (Laren - The Netherlands) for Martinair crash in Faro
Monument in Basilica Saint John (Laren – The Netherlands) for the victims of Martinair crash in Faro

 

Omdat de gevolgen zo ingrijpend, vaak onzichtbaar en mogelijk nog onbekend zijn…