Crash Martinair flight MP495 in Faro, Portugal

Even over 29 years after the crash, proper accountability or open discussion still lacks.
After the Court verdict of January 2020, many facts -even on the actual crash itself- but also on causes, responsibilities and consequences remain uncertain and disputed.
This uncertainty continues causing anxiety, frustration and doubts.

Cockpit view of crash Anthony Ruys
December 21st, 1992.  Delayed, early morning flight Martinair MP495 crashes at the airport of Faro (Portugal), after an approach in known 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, it’s causes and it’s consequences.

Even after the The Hague court verdict of January 8th, 2020 the basic question whether the pilots aligned the plane properly with Faro-runway center line remains unanswered.

It is doubtful whether all proper safety lessons (ICAO Annex 13) are learned from this crash.


May 2022:

December 19, 2021: annual commemoration cancelled.
Due to the Covid situation, the annual commemoration of Dec. 21st was cancelled.
In order to still commemorate together, it was suggested to light a candle on December 21st at 2 PM, Dutch time.

December 1, 2021: Dutch Minister answers formal questions of MP Omtzigt.

November 18, 2021Dutch Safety Board  (DSB) reports after a limited investigation into the landing gear only; not into the engines.
Cor tenHove: With this limited investigation, the far-reaching DSB conclusion of airworthiness of the crashed plane is not well substantiated.
DSB-reporting letter (in Dutch) to Minister of Infrastructure.
In this letter is mentioned that the whistlebower stands by his original statement.
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.

October 11, 2021: Dutch MP Pieter Omzigt submits formal questions on the Martinair crash investigation to the Minister of Infrastructure and Water Management 

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 (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.

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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. 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.

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 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) 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 and its possible consequences is largely ignored.
There is hardly any attention for ‘invisible’ ‘material’ head and brain injuries and their consequences.

Most of the practical and long term real life consequences for surviving occupants and family members there remain unseen.
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  and consequences of the crash.

There is some progress on better attention for possible mild head injury after 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
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 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…