Region
Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Cecina
Date & Time:
May 20, 2017 at 1200 LT
Operator:
Registration:
S5-CEI
Survivors:
Yes
Schedule:
Cecina - Cecina
MSN:
778
YOM:
1977
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The pilot, sole on board, was returning to Cecina Airfield following a skydiving flight in the area. After touchdown on a grassy area, the single engine aircraft veered to the left, impacted a drainage ditch and came to rest. The pilot escaped uninjured and the aircraft was damaged beyond repair.
Crash of a Boeing 737-476 in Bergamo
Date & Time:
Aug 5, 2016 at 0407 LT
Operator:
Registration:
HA-FAX
Survivors:
Yes
Schedule:
Paris-Roissy-CDG - Bergamo
MSN:
24437/2162
YOM:
1991
Flight number:
QY7332
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
2254.00
Copilot / Total hours on type:
86
Aircraft flight hours:
65332
Circumstances:
The aircraft departed Paris-Roissy-Charles de Gaulle Airport at 0254LT on a cargo flight (service QY7332) to Bergamo on behalf of DHL Airways. Upon arrival at Bergamo-Orio al Serio Airport, the crew encountered poor weather conditions with thunderstorm activity, heavy rain falls and strong wind. The aircraft crossed the runway threshold at a speed of 156 knots and landed 18 seconds later, 2,000 metres pas the runway threshold. Unable to stop within the remaining distance (runway 28 is 2,807 metres long), the aircraft overran, went through the perimeter fence, lost its undercarriage and both engines and eventually stopped in a motorway, some 520 metres pas the runway end. Both crew members evacuated safely and the aircraft was destroyed.
Probable cause:
The causes of the accident are mainly due to the human factor. In particular, the accident was caused by the runway overrun during the landing phase, caused by a loss of situational awareness relating to the position of the aircraft with respect to the runway itself. This loss of situational awareness on the part of the crew caused a delay in contact with the runway, which occurred, at a still high speed, in a position too far to allow the aircraft to stop within the remaining distance.
Contributing to the dynamics of the event:
- The commander's prior decision not to carry out a go-around procedure (this decision is of crucial importance in the chain of events that characterized the accident),
- Inadequate maintenance of flight parameters in the final phase of landing,
- Failure of the crew to disconnect the autothrottle prior to landing,
- Poor lighting conditions with the presence of storm cells and heavy rain falls at the time of the event (environmental factor), which may have contributed to the loss of situation awareness,
- The attention paid by the crew during the final phase of the flight, where both pilots were intent to acquire external visual references and did not realize that the aircraft crossed over the runway at high speed for 18 seconds before touchdown,
- The lack of assertiveness of the first officer in questioning the commander's decisions.
Finally, it cannot be excluded that a condition of tiredness and fatigue may have contributed to the accident, even if not perceived by the crew, which may have influenced the cognitive processes, in particular those of the captain, interfering with his correct decision making process.
Contributing to the dynamics of the event:
- The commander's prior decision not to carry out a go-around procedure (this decision is of crucial importance in the chain of events that characterized the accident),
- Inadequate maintenance of flight parameters in the final phase of landing,
- Failure of the crew to disconnect the autothrottle prior to landing,
- Poor lighting conditions with the presence of storm cells and heavy rain falls at the time of the event (environmental factor), which may have contributed to the loss of situation awareness,
- The attention paid by the crew during the final phase of the flight, where both pilots were intent to acquire external visual references and did not realize that the aircraft crossed over the runway at high speed for 18 seconds before touchdown,
- The lack of assertiveness of the first officer in questioning the commander's decisions.
Finally, it cannot be excluded that a condition of tiredness and fatigue may have contributed to the accident, even if not perceived by the crew, which may have influenced the cognitive processes, in particular those of the captain, interfering with his correct decision making process.
Final Report:
Crash of a Pilatus PC-6/B2-H4 Turbo Porter in Cecina: 2 killed
Date & Time:
Jun 11, 2016 at 1230 LT
Operator:
Registration:
S5-CMB
Survivors:
Yes
Schedule:
Cecina - Cecina
MSN:
932
YOM:
2000
Crew on board:
2
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
2
Copilot / Total hours on type:
1700
Aircraft flight hours:
6705
Circumstances:
The aircraft, operated by Skydive Kalifornia (aka Skydive Toscana) was involved in a local skydiving flight from Cecina Airfield. When the aircraft reached the assigned altitude, six of the seven skydivers bailed out. When the seventh skydiver elected to jump, his auxiliary parachute accidentally opened while the skydiver was still in the cabin. He was sucked outside and collided with the right horizontal stabilizer that later detached. The aircraft entered an uncontrolled descent and crashed in a field. The aircraft was destroyed by impact forces and both pilots were killed. There was no fire. All seven skydivers were uninjured.
Probable cause:
The cause of the accident is attributable to the detachment of the horizontal stabilizer following the impact with a skydiver dragged by his auxiliary parachute that accidentally opened while he was still inside the aircraft. This detachment led to the loss of governability of the aircraft.
The following factors contributed to the incident:
- The conformation of the throwing material, with closing flap of the safety flap covering the pin, which, tending to come out of its seat, did not guarantee adequate protection of the locking pin from accidental interference.
- The conformation of the structure of the right front seat, which interferes with the closing system of the auxiliary parachute bag, which determined the opening.
- The non-optimal disposition of the skydivers and the DL on board the aircraft (first skydiver to go out not immediately to the door and DL with his back addressed to the skydiver student).
The following factors contributed to the incident:
- The conformation of the throwing material, with closing flap of the safety flap covering the pin, which, tending to come out of its seat, did not guarantee adequate protection of the locking pin from accidental interference.
- The conformation of the structure of the right front seat, which interferes with the closing system of the auxiliary parachute bag, which determined the opening.
- The non-optimal disposition of the skydivers and the DL on board the aircraft (first skydiver to go out not immediately to the door and DL with his back addressed to the skydiver student).
Final Report:
Crash of a Piaggio P1.HH HammerHead off Levanzo Island
Date & Time:
May 31, 2016 at 1140 LT
Operator:
Registration:
CPX621
Schedule:
Trapani - Trapani
Crew on board:
0
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
Based on a Piaggio P.180 Avanti, the Piaggio P.1HH HammerHead is a drone prototype. Engaged in a series of test as part of the certification program, the twin engine aircraft left Trapani-Vincenzo Florio Airport at 1120LT for a local test flight. About 20 minutes later, the contact was lost with the ground station and the aircraft crashed into the sea about 8 km north of the Levanzo Island. The aircraft was lost.
Crash of a Fokker 50 in Catania
Date & Time:
Apr 30, 2016 at 1135 LT
Operator:
Registration:
SE-LEZ
Survivors:
Yes
Schedule:
Rimini – Catania
MSN:
20128
YOM:
1988
Flight number:
RVL233
Crew on board:
3
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
781.00
Copilot / Total hours on type:
10
Circumstances:
On April 30, 2016, the aircraft Fokker F27 MK50 registration marks SE-LEZ, operating Air Vallee flight number RVL233, took off from Rimini airport at 06.48 hrs with 18 passengers and 3 crew on board. During the final approach to Catania airport, with the aircraft stabilized on ILS Z RWY 08, the crew noticed that the right and left main landing gear lights were green but the nose landing gear light was amber. The crew informed the ATS (Catania APP) that they were in contact with the problem and informed them of their intention to continue the approach to perform a low pass on the runway followed by a standard missed approach procedure, in order to request a visual verification from the control tower of the actual extension of the nose gear. During the low passage, the control tower informed the crew that the nose gear was not extended despite the opening of the nose gear compartment. After the passage, all lights, including the amber light of the nose landing gear, went off. The aircraft proceeded to the INDAX point to perform a holding at an altitude of 3000 feet as agreed with ATS during which the crew applied the abnormal procedures for nose gear unsafe down after selection and alternate down procedures. Both procedures were unsuccessful and the crew declared an "emergency" informing ATS of their intention to perform a final maneuver (leveled 2G turn). The captain of the flight, who had been PNF up to that moment, took the controls as PF and executed the turn: also in this case without any positive outcome. The crew informed ATS of the situation, stating the number of passengers, the amount of fuel on board and the absence of dangerous goods. The crew decided to follow a VOR procedure for RWY26 followed by a visual approach in order to make a last low passage to check the condition of the nose gear. After this second missed approach, the aircraft was instructed to perform an ILS procedure for RWY 08. Landing took place at 09:34 hrs with the main gear properly extracted and locked, the nose gear in "up" position and the doors open. The following is a sequence of pictures taken from a video of the accident, acquired by ANSV through the Catania airport operator, in which the aircraft is seen landing with the nose landing gear not extended and touching the ground only when it reached the speed necessary to sustain it in the absence of nose landing gear support. After completion of the landing run, with the aircraft remaining in the middle of the runway, the engines were shut down and passengers and crew disembarked without further incident. Some of the passengers were transferred to the airport emergency room and subsequently some of them were sent to hospital for further examination; no passenger was reported to have sustained injuries as a result of the event.
Probable cause:
The accident was caused by the failure of the nose landing gear (nose gear up) due to over-extension of the shock absorber which caused interference between the tires and the NLG compartment and locked the NLG in a retracted position. The over-extension was caused by the incorrect installation of some internal components of the shock absorber during the replacement of the internal seals the day before the accident.
The following factors contributed significantly to the improper activity conducted at maintenance:
- the insufficient experience of technical personnel in carrying out the maintenance tasks conducted on the NLG;
- the lack of controls on the operations carried out, deemed unnecessary by the CAMO engineering department;
- the lack of definition of roles and tasks during the planning phase of the maintenance work;
- the operational pressure on maintenance personnel, arising from the need to conclude maintenance operations quickly in order not to penalize the management of the aircraft;
- the insufficient clarity and lack of sensitive information in the maintenance tasks and related figures contained in the AMM, regarding the replacement of internal shock absorber seals, subsequently made clearer by the manufacturer;
- the reported black and white printing of the applied AMM procedures, which could have made the warnings in the manual barely legible.
The following factors contributed significantly to the improper activity conducted at maintenance:
- the insufficient experience of technical personnel in carrying out the maintenance tasks conducted on the NLG;
- the lack of controls on the operations carried out, deemed unnecessary by the CAMO engineering department;
- the lack of definition of roles and tasks during the planning phase of the maintenance work;
- the operational pressure on maintenance personnel, arising from the need to conclude maintenance operations quickly in order not to penalize the management of the aircraft;
- the insufficient clarity and lack of sensitive information in the maintenance tasks and related figures contained in the AMM, regarding the replacement of internal shock absorber seals, subsequently made clearer by the manufacturer;
- the reported black and white printing of the applied AMM procedures, which could have made the warnings in the manual barely legible.
Final Report:
Crash of a Technoavia SMG-92 Turbo Finist in Casale Monferrato
Date & Time:
Aug 29, 2015 at 1430 LT
Operator:
Registration:
HA-YDJ
Survivors:
Yes
Schedule:
Casale Monferrato - Casale Monferrato
MSN:
02-001
YOM:
1993
Crew on board:
1
Crew fatalities:
Pax on board:
10
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
35.00
Aircraft flight hours:
800
Circumstances:
The single engine aircraft departed Casale Monferrato-Francesco Cappa Airfield on a local skydiving mission, the 13th sortie of the day, carrying seven skydivers, three tourists and one pilot). Shortly after rotation from a grassy runway, the pilot encountered engine problems. The aircraft continued in a flat attitude, collided with a hedge and few trees before coming to rest in a wooded area located 300 metres past the runway end. All 11 occupants were injured, some of them seriously. The aircraft was damaged beyond repair.
Probable cause:
The accident is the consequence of an engine failure caused by the loss of connection in the power module between the quill shaft and the PT shaft.
The following contributing factors were identified:
- A control system of the aircraft as part of 'aircraft operator CAMO not sufficiently thorough,
- The inaccurate, non-timely and incorrect reporting by the user of the aircraft of critical parameters for monitoring engine life,
- A national regulation, in force at the time of the accident, relating to the flight activity for launching paratroopers, which did not provide, in fact, adequate surveillance technique by the aeronautical authority on the aircraft used in this activity,
- The absence of adequate retention and safety devices for paratroopers on board the aircraft.
The following contributing factors were identified:
- A control system of the aircraft as part of 'aircraft operator CAMO not sufficiently thorough,
- The inaccurate, non-timely and incorrect reporting by the user of the aircraft of critical parameters for monitoring engine life,
- A national regulation, in force at the time of the accident, relating to the flight activity for launching paratroopers, which did not provide, in fact, adequate surveillance technique by the aeronautical authority on the aircraft used in this activity,
- The absence of adequate retention and safety devices for paratroopers on board the aircraft.
Final Report:
Crash of a Let L-410UVP-E20 in Ancona
Date & Time:
Mar 5, 2015 at 1930 LT
Operator:
Registration:
E7-WDT
Survivors:
Yes
Schedule:
Sarajevo – Ancona
MSN:
91 26 15
YOM:
1991
Flight number:
RAC9002
Crew on board:
3
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Sarajevo Airport on a cargo flight to Ancona, carrying three crew members and a load of various goods. On approach to Ancona-Falconara Airport, the crew encountered strong winds. Upon touchdown on runway 04, the nose gear collapsed. The aircraft skidded for few dozen metres before coming to rest, bursting into flames. All three occupants escaped uninjured while the aircraft was damaged beyond repair due to severe damages in the cockpit area due to fire.
Crash of an ATR72-500 in Rome
Date & Time:
Feb 2, 2013 at 2032 LT
Operator:
Registration:
YR-ATS
Survivors:
Yes
Schedule:
Pisa - Rome
MSN:
533
YOM:
1997
Flight number:
AZ1670
Crew on board:
4
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total hours on type:
3351.00
Copilot / Total hours on type:
14
Aircraft flight hours:
24088
Circumstances:
The Rome-Fiumicino Airport Runway 25 was closed to trafic due to work in progress so the crew was vectored and cleared for a landing on runway 16L. The approach was completed in good visibility with strong crosswinds from 250° at 28 knots gusting to 41 knots and windshear. On the last segment, the aircraft lost height and impacted ground 567 metres short of runway 16L threshold. The aircraft bounced three times, lost its right main gear, slid for few dozen metres and came to rest in a grassy area some 1,780 metres past the runway threshold. All 50 occupants were rescued, among them seven were slightly injured. The aircraft was damaged beyond repair.
Probable cause:
The accident is due to the human factor. In particular, it was caused by an improper conduct of the aircraft by the PF (commander) during landing, not consistent with the provisions of the operator's manuals, in an environmental context characterized by the presence of significant criticality (presence of crosswind with values at the limit/excess those allowed for the ATR 72) and in the absence of an effective CRM.
The following factors may have contributed to the event:
- The failure to carry out the landing briefing, which, in addition to being required by company regulations, would have been an important moment of pooling and acceptance of information fundamental to the safety of operations.
- The maintenance of a V APP significantly higher than expected.
- The conviction of the commander (PF), deriving from his considerable general and specific experience on the aircraft in question, to be able to conduct a safe landing in spite of the presence of critical wind conditions for the type of aircraft.
- The considerable difference in experience between the commander and the first officer, which has reasonably prevented the latter from showing his critical capacity, thus rendering CRM techniques ineffective.
The following factors may have contributed to the event:
- The failure to carry out the landing briefing, which, in addition to being required by company regulations, would have been an important moment of pooling and acceptance of information fundamental to the safety of operations.
- The maintenance of a V APP significantly higher than expected.
- The conviction of the commander (PF), deriving from his considerable general and specific experience on the aircraft in question, to be able to conduct a safe landing in spite of the presence of critical wind conditions for the type of aircraft.
- The considerable difference in experience between the commander and the first officer, which has reasonably prevented the latter from showing his critical capacity, thus rendering CRM techniques ineffective.
Final Report:
Crash of a Cessna 402B in Rome: 2 killed
Date & Time:
Sep 7, 2012 at 1300 LT
Operator:
Registration:
I-ERJA
Survivors:
No
Schedule:
Rome - Brescia
MSN:
402B-0918
YOM:
1975
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.
