Zone

Crash of a Cessna 402B in Rome: 2 killed

Date & Time: Sep 7, 2012 at 1300 LT
Type of aircraft:
Operator:
Registration:
I-ERJA
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rome - Brescia
MSN:
402B-0918
YOM:
1975
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Circumstances:
Shortly after takeoff from Rome-Ciampino Airport, while in initial climb, the twin engine aircraft went out of control and crashed in a car demolition, bursting into flames. The aircraft was totally destroyed by impact forces and a post impact fire as well as more than 30 cars. Both crew were killed.

Crash of a Cessna 650 Citation III in Trigoria: 2 killed

Date & Time: Feb 7, 2009 at 0602 LT
Type of aircraft:
Operator:
Registration:
I-FEEV
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Rome - Bologna
MSN:
650-0105
YOM:
1986
Flight number:
AOE301
Location:
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
6077
Captain / Total hours on type:
877.00
Copilot / Total flying hours:
3000
Copilot / Total hours on type:
58
Aircraft flight hours:
6977
Circumstances:
The crew was engaged in a positioning flight from Rome to Bologna to pick up a medical team for an ambulance mission. At 0554LT, the crew was cleared for takeoff. The aircraft departed Rome-Ciampino Airport runway 15 at 0600LT. During initial climb, after being cleared to Bolsena at FL240, the aircraft entered an uncontrolled descent and crashed near a cattle barn. The aircraft disintegrated on impact and both pilots were killed. At the time of the accident, weather conditions were as follow: wind from 140 at 18 knots, light rain, few at 1,800 feet, broken 3,000 feet and scattered at 7,000 feet with an OAT of 13° C.
Probable cause:
The cause of the accident was due to an impact with the ground resulting from the loss of control of the aircraft by the captain, who was also the PF. It appears very likely that during the initial phase inadequate attention was replaced by a phase of spatial disorientation, resulting in a loss of situational awareness, which prompted an inadequate intervention on the flight controls by the PF, resulting in total loss of control of the aircraft (having accentuated the tilt to the left wing, instead of leveling the aircraft). It is reasonable to assume that the PF, based on the conviction of being in a right turn for Bolsena in IMC night conditions, misinterpreted the unusual turn, using the controls in order to accentuate the bank angle to the left, drastically reducing the vertical component of lift. This turn has consequently caused the aircraft to assume an attitude of increasing bank, a condition that has been aggravated by the continued application on the controls of a positive load factor in order to stop the sudden loss of altitude, without first leveling the wings. Or the aircraft is stabilized in a pronounced downward spiral to the left. The first officer (PNF), engaged in the management of navigation equipment, has created the unusual turn of the aircraft in conjunction with the commander (PF). Nevertheless, the considerable gradient of experience on the airplane and hierarchy within the organization between the captain and the first officer has probably prevented him to intervene in a more directive or authoritative way in the recovery phase of the situation. Also contributing to the outcome of the event was the lack of detail in the definition of the duties of the crew procedures and inadequate adherence to the basic principles of CRM/MCC, with reference to the monitoring and statement of the navigation modes active, navigation procedures and in particular to the lack of requests for inclusion of turns and routes, the deficiency in the performance of controls and optimization of automation that can lighten the workload in a time unfavorable from the point of view of the circadian rhythm and IMC night. In this respect, it seems fitting to remember the problem of spatial disorientation, although known and studied for decades, is still relevant, and that the only way to counter it is the application of proper use of instruments in compliance with the basic principles of CRM/MCC, which should be part of the normal operating procedures of an operator. This is especially true when working outside of normal circadian rhythms, when it is most easily seen a slowing of cognitive processes.
Final Report:

Crash of a Falcon 900EX EASy in Brindisi

Date & Time: Nov 28, 2008 at 1900 LT
Type of aircraft:
Operator:
Registration:
I-FLYI
Survivors:
Yes
Schedule:
Athens - Rome
MSN:
204
YOM:
2008
Location:
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Aircraft flight hours:
100
Circumstances:
The aircraft was on its way from Athens-Elefterios Venizelos Airport to Rome with 3 passengers and 3 crew members on board. While at cruising level over the Adriatic Sea, the crew informed ATC about burn smell on board (possible smoke), declared an emergency and elected to divert to Brindisi-Papola Casale Airport. Upon arrival at Brindisi, weather conditions were poor with rain showers and strong crosswinds. In the meantime, the runway 14/32 (3,330 meters long) was closed to traffic due to works in progress. After landing on runway 23, the aircraft skidded, veered off runway and lost its right main gear before coming to rest. Three occupants were evacuated to local hospital with minor injuries while the aircraft was damaged beyond repair due to severe damages to the right wing and the right part of the fuselage. Brand new, it was delivered this year and completed 100 flying hours only.

Crash of a Boeing 737-8AS in Rome

Date & Time: Nov 10, 2008 at 0756 LT
Type of aircraft:
Operator:
Registration:
EI-DYG
Survivors:
Yes
Schedule:
Hahn - Rome
MSN:
33639/2557
YOM:
2008
Flight number:
FR4102
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
164
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
9883
Captain / Total hours on type:
6045.00
Copilot / Total flying hours:
600
Copilot / Total hours on type:
400
Aircraft flight hours:
2419
Aircraft flight cycles:
1498
Circumstances:
The airplane departed Hahn Airport at 0630LT on a flight to Rome-Ciampino Airport, carrying 14 passengers and a crew of 8. The first officer was the Pilot Flying on the leg whilst the captain was the Pilot Monitoring. The flight was uneventful until the approach phase at the destination airport. The aircraft established the first radio contact with Ciampino Tower, communicating that it was 9 NM from the runway and stabilised on the ILS for runway 15. The aircraft, authorized and configured for the approach, was proceeding for landing, when, at a height of 136 ft and a distance of about 300 m from the runway, the captain noticed birds on the flight trajectory. He stated "Ahi", repeated in rapid sequence. At a distance of about 100 m from the runway, the TO/GA pushbutton was activated. The first officer acknowledged: "Go around, flaps 15", setting the go around attitude. At the same time as the TO/GA was activated, the aircraft collided with a thick flock of some 90 starlings. A loud bang was heard and both engines stalled. The aircraft climbed to 173 feet and then continued to lose height, despite the nose-up command. There was a progressive speed reduction and an increase of the angle of attack until the activation of the stick shaker, which was recorded at 21 feet. The aircraft hit the ground in aerodynamic stall conditions, near taxiway AC, about half way along the total length of the runway at a vertical acceleration of 2.66g. First contact with the runway occurred with the main landing gear properly extended and with the lower part of the fuselage tail section. The left main landing gear detached from its attachment during the landing run and the lower part of the left engine nacelle came into contact with the runway. The aircraft stopped near the threshold of runway 33. The fire brigade sprayed extinguishing foam around the area where the engine nacelle had come into contact with the runway. The captain then arranged for the disembarkation of the passengers and crew using a ladder truck from the right front door, with the addition of the right rear slide, later activated and used.
Probable cause:
The accident has been caused by an unexpected loss of both engines thrust as a consequence of a massive bird strike, during the go-around manoeuvre. The loss of thrust has prevented the aircrew from performing a successful go around and has led the aircraft to an unstabilized runway contact. The following factors have contributed to the event:
- The inadequate effectiveness of bird control and dispersal measures put in place by the airport operator at the time of the accident,
- The captain decision to perform a go around, when the aircraft was at approximately 7 seconds from touchdown. The above decision was significantly influenced by:
- The lack of instructions to flight crew concerning the most suitable procedures to adopt in the case of single or multiple bird strikes in the landing phase,
- The absence of specific training in the management, by the flight crew, of the "surprise" and "startle" effects in critical phases of the flight.
Final Report:

Crash of a Cessna 501 Citation I/SP in Rome

Date & Time: Sep 9, 2005 at 1830 LT
Type of aircraft:
Operator:
Registration:
I-AROM
Survivors:
Yes
Schedule:
Lugano – Rome
MSN:
501-0042
YOM:
1978
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
After landing on runway 15 (2,207 metres long) at Rome-Ciampino Airport, the aircraft was unable to stop within the remaining distance. It overran, collided with the localizer antenna and came to rest. While the aircraft was considered as damaged beyond repair, all five occupants escaped uninjured. It was raining at the time of the accident and the runway was wet.

Crash of a Canadair CL-415 in Forte dei Marmi: 2 killed

Date & Time: Mar 18, 2005 at 1805 LT
Type of aircraft:
Operator:
Registration:
I-DPCK
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Rome - Rome
MSN:
2051
YOM:
2001
Flight number:
Tanker 22
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
2000
Captain / Total hours on type:
1500.00
Copilot / Total flying hours:
2000
Copilot / Total hours on type:
1232
Aircraft flight hours:
1733
Circumstances:
The crew departed Rome-Ciampino Airport in the afternoon on a fire fighting mission in Forte dei Marmi, north of Pisa. Following two successful missions, the crew was attacking the fire in hilly terrain and low altitude when the aircraft collided with power cables. A fire erupted on the right side of the aircraft and the crew lost control of the airplane that crashed in a residential area. Both pilots were killed while there were no injuries on the ground.
Probable cause:
The accident was the consequence of an in-flight collision with a power line because the crew adopted a wrong approach configuration to the fire area. The following contributing factors were identified:
- Poor decision making in attacking the fire, causing the crew to focus their attention on obstacles (pylons) of power line n°500, without considering the presence of the cable guard line n°550,
- The reduced visibility of obstacles resulting from the smoke of the forest,
- The inadequate reporting of electricity pylons and associated overhead lines,
- Non-activation of the required radio links, so the crew could not receive reports on the presence of obstacles,
- Short and discontinuous experience of the captain in that role, coming from the institution of the "PIC Frozen",
- The combination of to similar qualified pilots ("PIC Frozen") in the cockpit for the operation of a flight, one just rehabilitated to a high command function, the other still employed in the role of co-pilot: This condition could have a negative impact in terms of crew integration, obscuring decision making,
- The existence of criticality in corporate manuals used at the date of the accident,
- Reduced operational capacity of the crew in the last phase of flight, resulting from the strong heat of the fire under the left wing which penetrated the airplane through an opening created by the separation of a porthole.
Final Report:

Crash of a Cessna 500 Citation I near Cagliari: 6 killed

Date & Time: Feb 24, 2004 at 0549 LT
Type of aircraft:
Operator:
Registration:
OE-FAN
Flight Type:
Survivors:
No
Site:
Schedule:
Rome – Cagliari
MSN:
500-0289
YOM:
1976
Flight number:
CIT124
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
6
Captain / Total flying hours:
5472
Captain / Total hours on type:
2709.00
Copilot / Total flying hours:
2300
Copilot / Total hours on type:
1600
Aircraft flight hours:
6471
Aircraft flight cycles:
5618
Circumstances:
The aircraft departed Rome-Ciampino Airport on an ambulance flight to Cagliari, carrying three pilots, three doctors and a cooler containing a heart for a patient. The descent to Cagliari-Elmas Airport was initiated by night under VFR mode. After the crew was cleared to descend to 2,500 feet, ATC reported runway 32 in use and asked the crew to report on short final. About two minutes later, at an altitude of 3,333 feet, the aircraft struck the slope of Mt Su Baccu Malu located 32 km northeast of Cagliari Airport. The aircraft was totally destroyed by impact forces and all six occupants were killed.
Probable cause:
The accident, classified as CFIT, was caused by the conduct of the flight at a height significantly below the Area Minimum Altitude, insufficient to maintain the separation from the ground during a night visual approach in the absence of adequate visual reference.
possible contributory factors that have been identified:
- The aircraft instrumentation did not include a GPWS or TAWS, whose installation is not required by law;
- The erroneous descent by visual flight references, confusing the Elmas runway lights, given that the crew had no special familiarity with the area of Cagliari, the onset of a perspective illusions phenomena, with specific reference to the so-called "black hole approach";
- The misunderstanding by crew members, of the Cagliari Approach controllers instruction to transfer to Elmas TWR ('CIT 124 continue not below 2500 feet, further descent with Elmas TWR 120.6 bye') which may have created the impression, despite the crew had confirmed that they are able to separate themselves from the obstacles that the descent down was free of obstructions;
- Failure to use published procedures and available instruments in a descent to a closer airport and in an unfamiliar area , under conditions of total darkness;
- The anticipation of the deviation from the airway perhaps caused [the crew] to try to speed up the arrival at destination, which determined overflying areas of higher elevation;
- Read errors of the elevations listed in the maps consulted, facilitated by the non representation of the ground color;
- The extended period of wakefulness without adequate rest, which may have contributed to a reduction in the performance of the crew.
Final Report:

Crash of a Learjet 35A in Nuremberg: 3 killed

Date & Time: Feb 8, 2001 at 1540 LT
Type of aircraft:
Registration:
I-MOCO
Flight Type:
Survivors:
No
Schedule:
Nuremberg - Rome
MSN:
35-445
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
2641
Captain / Total hours on type:
54.00
Copilot / Total flying hours:
575
Copilot / Total hours on type:
192
Circumstances:
During an inspection of the right engine a technician found chips in the oil filter. The damage should have been repaired within the next 20 flight hours. Since the maintenance organization in Switzerland, who usually carry out necessary repairs, did not have the spare parts available on time, the task was assigned to an organization in Nuernberg. On 07.02.2001, the airplane was ferried to Nuernberg and repaired in the presence of the chief technician of the operator. The repairs and the replacement of the parts exclusively on the right engine were certified properly. The return flight to Rome was planned for the 8th of February 2001 at about 1530 o’clock. A charter flight from Rome was to be carried out on the following day. Two pilots and the chief technician of the operator were aboard the aircraft. The flight preparation was carried out by phone from the repair facility. A weather briefing and the NOTAM´s for the flight were obtained properly. The check lists for the take-off were read. During the preparation the unbalanced fuel distribution between the right and left-hand tanks, and the fact that the total amount yet was equal on both sides was discussed. Immediately afterwards the second pilot noticed the failure of his gyro instruments. The airplane was taxied via the taxiways "Juliet" and "Foxtrot" to runway 10. Pilot at the controls was the pilot in command while the second pilot carried out the radio communications with the air traffic control. The pilots received the clearance for a departure via the departure route Noerdlingen (NDG 1 M) to Rome. The take-off was at 1531 o'clock. After 5 nautical miles the airplane turned to the south, following the departure route. At 15:33:49 o'clock the left-hand engine failed without a previous warning. The noise of a down running engine was also heard by several witnesses on the ground. Smoke or a fire was not seen by them. The second pilot reported an emergency with the left-hand engine shortly after the occurrence to the control tower and informed them that they wanted to return for a landing on the runway 10. At that time there were visual meteorological conditions, and the runway was continuously to be seen. Since the departure control Nuernber APP wished to coordinate the flight, the frequency was changed for a short time upon request. After the second pilot had declared the emergency once again they switched back to the tower again and continued the approach to runway 10. Up to the final approach the flight was without particular occurrences. The flaps were first set to 8° and later on to 20°, afterwards the landing gear was extended. At this time the airplane was somewhat north of the extended centerline slightly above the glide path for an instrument approach. Approximately one kilometer in front of the runway, when flying over the main road no. 4 near the small town of Buch, the airplane was observed by different witnesses as it made unusual flight maneuvers. The airplane deviated then from the landing direction to the north, and made some reeling movements. Afterwards it seemed for a short
period that the pilot intended to turn right to reach the runway. Immediately afterwards and near the ground the airplane abruptly stalled to the left approximately maintaining its height, then assuming a bank angle of more than 90°, and crashed nearly upside down at 1540 o’clock into a forest north of the runway. The airport fire service, who were in a standby position due to the announced safety landing of the Learjet reached the accident site approximately 4 minutes later and started to extinguish the fire. All three occupants had lost their lives during the impact. The airplane was destroyed.
Probable cause:
The accident was caused by an in-flight failure of the left power plant approximately 3 minutes after take-off and an inadequate conduct of the subsequent single-engine landing procedure so that in short final the airplane stalled and crashed from low height. The failure of the left engine was caused by intergranular fractures of retention posts on the high pressure turbine disk. As a result of incorrect service life recordings the maximum number of cycles had considerably been exceeded.
Final Report:

Crash of an ATR42-312 near Kosovska Mitrovica: 24 killed

Date & Time: Nov 12, 1999 at 1115 LT
Type of aircraft:
Operator:
Registration:
F-OHFV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Rome - Pristina
MSN:
12
YOM:
1986
Flight number:
KSV3275
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
21
Pax fatalities:
Other fatalities:
Total fatalities:
24
Captain / Total flying hours:
18000
Captain / Total hours on type:
5000.00
Copilot / Total flying hours:
5000
Copilot / Total hours on type:
1500
Aircraft flight hours:
24930
Aircraft flight cycles:
32810
Circumstances:
Arriving from Rome, the aircraft chartered by the World Food Program was going to land at Pristina. The meteorological conditions at the aerodrome corresponded to visibility of 4,000 metres with a layer of compact clouds at 3,000 feet. In radar and radio contact with the military air traffic control organisation for an ILS approach, the aircraft, which was outbound to the north at an altitude of 4,600 feet, entered a sector where the minimum safety altitude is 6,900 feet and struck a mountain whose peak is at 4,650 while turning to return towards the airport. The wreckage was found about 15 metres below the summit, some 18 km northeast of Kosovska Mitrovica and 42 km north of Pristina Airport. All 24 occupants were killed.
Probable cause:
The collision of Flight KSV 3275 with high ground was due to:
- Teamwork which lacked procedural discipline and vigilance during maneuvers in a mountainous region with poor visibility,
- The aircraft being kept on its track and then forgotten by a military controller unused to the mountainous environment of the aerodrome and to preventing the risk of collisions with high ground, within the framework of the radar service he was providing,
- The operator's critical situation as a new company highly dependant on the lease contract, favoring a failure to respect procedures,
- The opening of the aerodrome to civil traffic without an advance evaluation of the operating conditions or of the conditions for distribution of aeronautical information.
The following factors contributed to the accident :
- Crew fatigue, favoring a lowering of vigilance,
- Undertaking the flight with an unserviceable or disconnected GPWS.
Final Report:

Crash of a Dassault Falcon 20F in Lugano

Date & Time: Jan 15, 1988 at 0924 LT
Type of aircraft:
Registration:
VR-BJB
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Lugano - Rome
MSN:
244
YOM:
1970
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7618
Captain / Total hours on type:
1574.00
Copilot / Total flying hours:
2747
Copilot / Total hours on type:
1456
Aircraft flight hours:
6569
Aircraft flight cycles:
6410
Circumstances:
During the takeoff roll on runway 21, just before reaching V1 (112 knots), the captain thought that the right engine lost power. He decided to abandon the takeoff maneuver and initiated an emergency braking procedure. Unable to stop within the remaining distance, the aircraft overran at a speed of about 60-70 knots, rolled in a snow covered field and eventually collided with an embankment, coming to rest, broken in two. Both pilots were injured.
Probable cause:
The accident is attributable to a rejected take-off just before reaching the critical speed of decision (V1), due to an alleged loss of power of the right engine.
The following contributing factors were reported:
- The lack of data for the calculation of the accelerate-stop distance in the operating manual (AOM) of the Dassault aircraft for takeoff on wet or contaminated runways;
- Insufficient consideration of the state of the runway, to determine the maximum take-off mass, in regard to the "accelerate-stop" distance;
- Insufficient preparation for takeoff;
- Lack of coordination between the crew at the time of engine failure;
- Insufficient mental preparation of the crew before takeoff;
- The non-inclusion of de-icing system of the engines, in dangerous meteorological conditions with freezing temperatures;
- Insufficient training of the crew on the flight simulator, especially for what concerns the problems and take-off interruption;
- Aquaplaning;
- No airbrakes extended;
- Failure to use the braking parachute.
Final Report: