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Crash of an ATR72-500 in Rome

Date & Time: Feb 2, 2013 at 2032 LT
Type of aircraft:
Operator:
Registration:
YR-ATS
Survivors:
Yes
Schedule:
Pisa - Rome
MSN:
533
YOM:
1997
Flight number:
AZ1670
Country:
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
46
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
18552
Captain / Total hours on type:
3351.00
Copilot / Total flying hours:
624
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.
Final Report:

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 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.