Crash of a Pilatus PC-12/47E in Milan: 8 killed

Date & Time: Oct 3, 2021 at 1307 LT
Type of aircraft:
Registration:
YR-PDV
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Milan - Olbia
MSN:
1532
YOM:
2015
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
8
Captain / Total flying hours:
1025
Captain / Total hours on type:
400.00
Aircraft flight hours:
504
Circumstances:
The single engine aircraft departed Milan-Linate Airport runway 36 at 1304LT, bound to Olbia with 8 people on board, seven passengers and one pilot. Ten seconds after takeoff, the pilot engaged the autopilot and the LNAV mode but both were disengaged about 1 minute and 40 seconds later. Instead of following the Standard Instrument Departure heading 130 after takeoff, the aircraft continued to turn to the west. Milano Area Control Center instructed the pilot to turn left heading 120 but instead, the aircraft turned right again then the altitude was stabilized. At an altitude of 5,300 feet, the aircraft entered an uncontrolled descent and crashed in a vertical attitude on an industrial building under construction and located about 1,8 km southwest of the runway 36 threshold. The aircraft disintegrated on impact and all 8 occupants were killed, among them the Romania businessman Dan Petrescu. The building suffered severe damages as well as few vehicles in the street. There were no injuries on the ground.
Probable cause:
The limitations imposed by the considerable level of destruction of the aircraft and the absence of data recorded by the LDR referable to the accident, did not allow to identify, with incontrovertible certainty, the cause of the event.
For the above reasons, it has not been possible to categorically exclude the occurrence of a failure that may have compromised the controlability of the aircraft; however, such hypothesis, on the basis of the evidence acquired, appears to be the least probable.
The cause of the event is reasonably attributable to the pilot's loss of control of the aircraft, which occurred during the execution of a SID in daytime IMC conditions, with the aircraft manually piloted.
It can be assumed that at the origin of the loss of control, there may have been a saturation of the pilot's cognitive processes, with consequent channeling of attention to the navigation system, which would have likely diverted the pilot's attention from the basic and manual conduct of the aircraft.
It cannot be excluded that a non-catastrophic technical issue may have contributed to this task saturation.
It is believed that a recurring lack of training may have contributed to the failure to control the aircraft, as well as an inadequate handling of a possible non-catastrophic technical failure
Due to the lack of flight data it was not possible to determine if the disengagement was voluntary by the pilot or caused by a failure.
Final Report:

Crash of a Piper PA-31T Cheyenne I in Cassano di Centenaro: 2 killed

Date & Time: Nov 6, 2006 at 0322 LT
Type of aircraft:
Operator:
Registration:
I-POMO
Flight Phase:
Flight Type:
Survivors:
No
Site:
Schedule:
Valetta - Milan
MSN:
31-7904030
YOM:
1979
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
3169
Captain / Total hours on type:
2540.00
Aircraft flight hours:
3122
Circumstances:
The twin engine aircraft departed Valetta Airport, Malta, on a night flight to Milan-Linate Airport, carrying one passenger and one pilot. After passing Elba Island at an altitude of 21,000 feet, over the Gulf of Genoa, the aircraft deviated from the prescribed route to the east while it was supposed to pass over Genoa before descending to Milan. Few minutes later, the aircraft entered an uncontrolled descent and crashed in a wooded and hilly terrain located in Cassano di Centenaro, about 43 km southwest of Piacenza. The aircraft disintegrated on impact and both occupants were killed.
Probable cause:
The pilot lost control of the aircraft, resulting in a collision with the ground. For reasons that investigations have not been able to determine with precision, the twin engine aircraft deviated from its intended course to the east. The lack of visibility caused by night could remain a contributing factor in that the pilot was not able to distinguish the ground and determine his position accurately. The analysis of the flight path and the debris of the aircraft did not make it possible to provide convincing and objective evidence on the possibility of an in-flight structural failure, of a technical failure of the flight controls or any alteration in the psychic or physical abilities of the pilot.
Final Report:

Crash of a Learjet 45 in Milan: 2 killed

Date & Time: Jun 1, 2003 at 1526 LT
Type of aircraft:
Operator:
Registration:
I-ERJC
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
Milan - Genoa - Amsterdam
MSN:
45-093
YOM:
2000
Flight number:
ERJ1570
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
2
Captain / Total flying hours:
1031
Captain / Total hours on type:
544.00
Copilot / Total flying hours:
500
Copilot / Total hours on type:
14
Aircraft flight hours:
931
Aircraft flight cycles:
890
Circumstances:
The aircraft departed Milan-Linate Airport on a positioning flight to Genoa to pick up passengers for Amsterdam. Shortly after takeoff from runway 36R, while in initial climb, the aircraft collided with a flock of pigeons that struck both engines. The crew declared an emergency and reported technical problems without giving any other details. He was cleared for an immediate return and initiated a turn to the east. One minute and 25 seconds after takeoff, the aircraft entered an uncontrolled descent and crashed on a factory located 750 metres southeast from the runway 36R threshold. The aircraft was totally destroyed by impact forces and a post crash fire and both pilots were killed.
Probable cause:
The event, triggered by a multiple impact with birds during take-off, was caused by the loss of control in flight of the aircraft, due to an aerodynamic stall during the return to the departure airport, which could not be recovered due to the reduced altitude available.
The following factors contributed to the event:
- The non-implementation of the procedure provided for in the Flight Manual for engine failure after V1, with particular reference to configuration control (undercarriage and flaps), thrust lever management, definition and achievement of safety altitude, maintenance of expected speeds,
- The lack of CRM, already detectable in the ground procedures phase, but significantly worsened as a result of the emergency,
- The lack of experience of FO, on its first flight of line training on the type of aircraft,
- The inadequacy of the measures and of the bird control activity in the manoeuvring area.
Final Report:

Crash of a Cessna 525A CitationJet Cj2 in Milan: 4 killed

Date & Time: Oct 8, 2001 at 0810 LT
Type of aircraft:
Operator:
Registration:
D-IEVX
Flight Phase:
Survivors:
No
Schedule:
Cologne - Milan - Paris
MSN:
525A-0036
YOM:
2001
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
2
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
5000
Captain / Total hours on type:
2400.00
Copilot / Total flying hours:
12000
Copilot / Total hours on type:
2000
Aircraft flight hours:
28
Aircraft flight cycles:
20
Circumstances:
A brand new Cessna 525A CitationJet 2, D-IEVX, arrived at Milan-Linate following a flight from Köln. The Cessna was to carry out a return flight to Paris-Le Bourget, carrying two pilots, a Cessna sales manager and a prospective customer. The plane arrived at 06:59 and was taxied to the General aviation apron, also known as 'West apron'. It was a foggy morning at Milan and one of the passenger flights parked on the North apron was SAS MD-87 "Lage Viking" which was being prepared for flight SK686 to Copenhagen, scheduled to depart at 07:35. At 07:41, the pilot of the MD-87 contacted Linate Ground Control for his engine start clearance, as the boarding of 104 passengers had been completed. The Ground controller cleared the pilot to start engines and advised that the slot time for takeoff of the flight was at 08:16. Thirteen minutes later flight 686 was cleared to taxi to runway 36R: "Scandinavian 686 taxi to the holding position Cat III, QNH 1013 and please call me back entering the main taxiway." A few minutes later, the Cessna pilot requested permission to start the engines. The ground controller then gave start-up clearance. The ground controller then requested flight 686 to contact the Tower controller. From this moment on the crew of the MD-87 and the crew of the Cessna were tuned on two different radio frequencies. At 08:05 the pilots of the Cessna received taxi clearance: "Delta Victor Xray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the ... main runway extension." The pilot acknowledged by saying: "Roger via Romeo 5 and ... 1013, and call you back before reaching main runway." The Cessna started to taxi from the General Aviation parking position, following the yellow taxi line. After reaching the position where the yellow taxi line splits into two diverging directions, the pilot erroneously took the taxi line to right and entered taxiway R6. At 08:09 the Ground controller cleared the Cessna to continue its taxi on the North apron. At the same time the Tower controller cleared the MD-87 for takeoff: "...Scandinavian 686 Linate, clear for take off 36, the wind is calm report rolling, when airborne squawk ident." The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87 was speeding down the runway, the Cessna crossed the runway holding sign and entered the active runway 18L/36R. At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were extending the shock absorbers but the main wheels were still on the ground at an airspeed of 146 knots (270,5 km/h). At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and reacted with additional large nose-up elevator. At that moment the MD-87 collided with the CitationJet. The right wing of the MD-87 sustained damage at the leading edge and the right hand main landing gear leg broke off. It damaged the right flap and struck the no. 2 engine which then separated from the pylon. The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne for a total of 12 seconds, reaching an estimated height of about 35 feet (11 meters). The left hand engine suffered a noticeable thrust reduction as a result of debris ingestion, which became insufficient to sustain flight. The airspeed had increased up to 166 knots (307,6 km/h), but the MD-87 descended abruptly making contact with the runway with the left hand maingear, the truncated right hand maingear leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust and after ground contact the engine reverse levers were activated and deployed (on the left hand engine only). Maximum available reverse thrust was selected and the brakes applied. The plane skidded past the grass overrun area, across a service road, crashing sideways into a baggage handling building, which partly collapsed. This building was located 20 m/67 feet to the right of the runway, and 460 m/1500 feet from the runway end. Both pilots were German citizens while both passengers were respectively Mr. Stefano Romanello, representative for Cessna Aircraft in Europe and Mr. Luca Fossati, President of the Star food group.
Probable cause:
After analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. The obvious consideration is that the human factor related action of the Cessna crew - during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The following list highlights immediate and systemic causes that led to the accident:
- The visibility was low, between 50 and 100 meters;
- The traffic volume was high;
- The lack of adequate visual aids;
- The Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- The failure to check the Cessna crew qualification;
- The nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- The Cessna crew was not aided properly with correct publications (AIP Italy - Jeppesen), lights (red bar lights and taxiway lights), markings (in deformity with standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- Official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- Operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- Radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- Radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- The ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- Instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
Furthermore:
- The aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognize especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- No functional Safety Management System was in operation;
- The competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- The LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 4976.
The combined effect of these factors, contemporaneously present on the 8th of October 2001 at Milano Linate, have neutralized any possible error corrective action and therefore allowed the accident.
Final Report:

Crash of a McDonnell Douglas MD-87 in Milan: 114 killed

Date & Time: Oct 8, 2001 at 0810 LT
Type of aircraft:
Operator:
Registration:
SE-DMA
Flight Phase:
Survivors:
No
Schedule:
Milan - Copenhagen
MSN:
53009
YOM:
1991
Flight number:
SK686
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
104
Pax fatalities:
Other fatalities:
Total fatalities:
110
Captain / Total flying hours:
5842
Captain / Total hours on type:
232.00
Copilot / Total flying hours:
4355
Copilot / Total hours on type:
1978
Aircraft flight hours:
25573
Aircraft flight cycles:
16562
Circumstances:
A brand new Cessna 525A CitationJet 2, D-IEVX, arrived at Milan-Linate following a flight from Köln. The Cessna was to carry out a return flight to Paris-Le Bourget, carrying two pilots, a Cessna sales manager and a prospective customer. The plane arrived at 06:59 and was taxied to the General aviation apron, also known as 'West apron'. It was a foggy morning at Milan and one of the passenger flights parked on the North apron was SAS MD-87 "Lage Viking" which was being prepared for flight SK686 to Copenhagen, scheduled to depart at 07:35. At 07:41, the pilot of the MD-87 contacted Linate Ground Control for his engine start clearance, as the boarding of 104 passengers had been completed. The Ground controller cleared the pilot to start engines and advised that the slot time for takeoff of the flight was at 08:16. Thirteen minutes later flight 686 was cleared to taxi to runway 36R: "Scandinavian 686 taxi to the holding position Cat III, QNH 1013 and please call me back entering the main taxiway." A few minutes later, the Cessna pilot requested permission to start the engines. The ground controller then gave start-up clearance. The ground controller then requested flight 686 to contact the Tower controller. From this moment on the crew of the MD-87 and the crew of the Cessna were tuned on two different radio frequencies. At 08:05 the pilots of the Cessna received taxi clearance: "Delta Victor Xray taxi north via Romeo 5, QNH 1013, call me back at the stop bar of the ... main runway extension." The pilot acknowledged by saying: "Roger via Romeo 5 and ... 1013, and call you back before reaching main runway." The Cessna started to taxi from the General Aviation parking position, following the yellow taxi line. After reaching the position where the yellow taxi line splits into two diverging directions, the pilot erroneously took the taxi line to right and entered taxiway R6. At 08:09 the Ground controller cleared the Cessna to continue its taxi on the North apron. At the same time the Tower controller cleared the MD-87 for takeoff: "...Scandinavian 686 Linate, clear for take off 36, the wind is calm report rolling, when airborne squawk ident." The pilot advanced the throttles and acknowledged the clearance: "Clear for takeoff 36 at when...airborne squawk ident and we are rolling, Scandinavian 686." When the MD-87 was speeding down the runway, the Cessna crossed the runway holding sign and entered the active runway 18L/36R. At 08.10:21 the nose landing gear of the MD-87 had left the ground and main gears were extending the shock absorbers but the main wheels were still on the ground at an airspeed of 146 knots (270,5 km/h). At that moment the MD-87 crew probably saw a glimpse of the Cessna through the fog and reacted with additional large nose-up elevator. At that moment the MD-87 collided with the CitationJet. The right wing of the MD-87 sustained damage at the leading edge and the right hand main landing gear leg broke off. It damaged the right flap and struck the no. 2 engine which then separated from the pylon. The pilot of the MD-87 gradually advanced the throttles and then the aircraft was airborne for a total of 12 seconds, reaching an estimated height of about 35 feet (11 meters). The left hand engine suffered a noticeable thrust reduction as a result of debris ingestion, which became insufficient to sustain flight. The airspeed had increased up to 166 knots (307,6 km/h), but the MD-87 descended abruptly making contact with the runway with the left hand maingear, the truncated right hand maingear leg and the tip of the right hand wing. Prior to touch down the pilot reduced engine thrust and after ground contact the engine reverse levers were activated and deployed (on the left hand engine only). Maximum available reverse thrust was selected and the brakes applied. The plane skidded past the grass overrun area, across a service road, crashing sideways into a baggage handling building, which partly collapsed. This building was located 20 m/67 feet to the right of the runway, and 460 m/1500 feet from the runway end.
Probable cause:
After analysis of evidence available and information gathered, it can be assumed that the immediate cause for the accident has been the runway incursion in the active runway by the Cessna. The obvious consideration is that the human factor related action of the Cessna crew - during low visibility conditions - must be weighted against the scenario that allowed the course of events that led to the fatal collision; equally it can be stated that the system in place at Milano Linate airport was not geared to trap misunderstandings, let alone inadequate procedures, blatant human errors and faulty airport layout.
The following list highlights immediate and systemic causes that led to the accident:
- The visibility was low, between 50 and 100 meters;
- The traffic volume was high;
- The lack of adequate visual aids;
- The Cessna crew used the wrong taxiway and entered the runway without specific clearance;
- The failure to check the Cessna crew qualification;
- The nature of the flight might have exerted a certain pressure on the Cessna crew to commence the flight despite the prevailing weather conditions;
- The Cessna crew was not aided properly with correct publications (AIP Italy - Jeppesen), lights (red bar lights and taxiway lights), markings (in deformity with standard format and unpublished, S4) and signs (non existing, TWY R6) to enhance their situational awareness;
- Official documentation failing to report the presence of unpublished markings (S4, S5, etc) that were unknown to air traffic controllers, thus preventing the ATC controller from interpreting the unambiguous information from the Cessna crew, a position report mentioning S4;
- Operational procedures allowing high traffic volume (high number of ground movements) in weather conditions as were current the day of the accident (reduced visibility) and in the absence of technical aids;
- Radio communications were not performed using standard phraseology (read back) or were not consistently adhered to (resulting in untraced misunderstandings in relevant radio communications);
- Radio communications were performed in Italian and English language;
- Air Traffic Control (ATC) personnel did not realize that Cessna was on taxiway R6;
- The ground controller issued a taxi clearance towards Main apron although the reported position S4 did not have any meaning to him;
- Instructions, training and the prevailing environmental situation prevented the ATC personnel from having full control over the aircraft movements on ground.
Furthermore:
- The aerodrome standard did not comply with ICAO Annex 14; required markings, lights and signs did either not exist (TWY R6) or were in dismal order and were hard to recognize especially under low visibility conditions (R5-R6), other markings were unknown to operators (S4);
- No functional Safety Management System was in operation;
- The competence maintenance and requirements for recent experience for ATC personnel did not fully comply with ICAO Annex 1;
- The LVO implementation by ENAV (DOP 2/97) did not conform with the requirements provided in the corresponding and referenced ICAO DOC 4976.
The combined effect of these factors, contemporaneously present on the 8th of October 2001 at Milano Linate, have neutralized any possible error corrective action and therefore allowed the accident.
Final Report:

Crash of a Learjet 55 Longhorn in Seville

Date & Time: Apr 4, 1994 at 1517 LT
Type of aircraft:
Operator:
Registration:
I-KILO
Survivors:
Yes
Schedule:
Seville - Milan
MSN:
55-007
YOM:
1981
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11800
Circumstances:
Seven minutes after takeoff from Seville-San Pablo Airport, while climbing, the crew reported technical problems and elected to return. Few minutes later, the situation worsened, the crew declared an emergency and started a rapid descent. The aircraft landed on runway 27 at an excessive speed. Upon touchdown, the right main gear collapsed. The aircraft rolled for about 2 km then veered off runway to the right and came to rest. All 10 occupants escaped uninjured while the aircraft was damaged beyond repair.
Final Report:

Crash of a Dassault Falcon 20C in Kiel: 1 killed

Date & Time: Sep 25, 1991
Type of aircraft:
Operator:
Registration:
I-NLAE
Survivors:
Yes
Schedule:
Milan - Kiel
MSN:
134
YOM:
1968
Country:
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
1
Circumstances:
Following a wrong approach configuration, the twin engine aircraft landed too far down a wet runway. After touchdown, the crew realized he would not be able to stop the airplane within the remaining distance and decided to initiate a go-around procedure. Power was added on both engines and the aircraft took off. After passing over the runway end at low altitude, the aircraft struck trees, stalled and crashed in a wooded area. Nine occupants were injured, some of them seriously, while one pilot was killed.
Probable cause:
Wrong approach configuration on part of the crew who completed the approach at an excessive speed and above the glide. This caused the aircraft to land too far down a runway and the landing distance available was insufficient. After touchdown, the crew failed to identify the situation in due time and the decision to initiate a go-around procedure was taken too late. The following contributing factors were reported:
- Poor crew coordination,
- Poor planned approach and crew decisions,
- Wet runway surface (poor braking coefficient),
- Rain falls.

Crash of a Douglas DC-9-32 in Zurich: 46 killed

Date & Time: Nov 14, 1990 at 2011 LT
Type of aircraft:
Operator:
Registration:
I-ATJA
Survivors:
No
Schedule:
Milan - Zurich
MSN:
47641
YOM:
1974
Flight number:
AZ404
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
40
Pax fatalities:
Other fatalities:
Total fatalities:
46
Captain / Total flying hours:
10193
Captain / Total hours on type:
3194.00
Copilot / Total flying hours:
831
Copilot / Total hours on type:
621
Aircraft flight hours:
43894
Aircraft flight cycles:
43452
Circumstances:
On the 14th November 1990 ALITALIA flight 404, aircraft type DC-9-32 registration I-ATJA, took off from runway 36R at LIN bound for ZRH. The flight was a scheduled commercial flight. The clearance was to the destination airport Zürich, via a CANNE IC departure to Flight Level 120, the transponder code 0302. The PIC assumed the duties of assisting pilot and dealt with the radio-telephony. The First Officer was the handling pilot. The take-off was at 1836 hrs. The standard climb via CANNE towards Airway A9 to the cruising flight level of 200 was trouble free. About 2 minutes after reaching Flight Level 200 the crew listened to Zürich VOLMET. From this they gathered that the surface wind at Zürich was 240/08 kt. This led the PIC forsee a landing on runway 28. Having heard from the ATIS that the landing runway was 14, the crew still discussed a right hand circling approach for a landing on runway 28. The discussion continued considering a left hand circling to runway 28. At 1852.53 hrs, from a QNH of 1019 hPa the crew worked out a QFE of 970 hPa. During the descent, the crew discussed the approach procédure for runway 14, where the Copilot mentioned the Outer Marker height for runway 16. After the discussion about the setting of the navigation aids, they also discussed the procédure to be followed in the event of a communications failure. The crew were instructed that following radar vectors they should fly an ILS approach to runway 14. At 1900.01 hrs the Copilot said "We perform a CAT JJ (approach)". The PIC was in agreement because the navigation equipment had to be checked. Whilst verifying the décision height, it transpired that the Copilot was still Consulting the approach chart for runway 16. Further lengthy discussions about the setting of the required navigation aids followed. As the aircraft passed abeam Zürich descending to Flight Level 90, the PIC noted: "We are by KLOTEN, FL 90. He is bringing us in high". Clearance to descend to Flight Level 60 followed at 1902.28 hrs. At 1902.50 hrs ALITALIA 404 was instructed to fly heading 325. VHF NAV 1 was tuned to Trasadingen VOR (TRA), VHF NAV 2 to Kloten VOR (KLO). To define the fix at EKRON, the course 068 was also set. At 1904.32 hrs the PIC repeated "The outer marker is at 1200 ft (QFE), it can be verified by 3.8 [NM] from Kloten. Rhein (RHI NDB) 5.6 [NM]...". At 1905.15 hrs a new heading was required which the PIC confirmed. The identification of the ILS - 14 was registered on the CVR at 1905.32 hrs. At 1906.20 hrs, together with the approach clearance to runway 14, a new heading of 110, descent to 4000 ft and the QNH of 1019 hPa was given. The PIC confirmed this clearance, however the heading was read back as 120. The incorrect readback of the clearance by the PIC caused the Copilot some uncertainty of the required heading to be flown. The PIC confirmed the approach clearance and the cleared altitude 4000 ft to the COPI, whereby the COPI ordered "RADIO APPROACH...". At this point an altitude of about 5000 ft (QNH) was passed. One of the pilots asked the other whether he had a Glide Path indication. The aircraft position was just before interception of the Localiser passing an altitude of about 4700 ft (QNH) (according to radar and DFDR). It was already about 1300 ft below the Glide Path. Answering the question about the Glide Path, the other pilot replied (hardly understandable) "On 1...I don't have...." Consequently the PIC said: "Good, so let's do it on 1". The COPI then ordered "RADIO 1". The flaps were probably set to 15°. In the meantime, the aircraft had passed through the localiser and was now slightly east of it. About the same time as the PIC said "Capture LOC capture glide path capture - so we are on the localiser, a little off track but..." (translated from Italian) the aircraft descended through 4000 ft (QNH) (about 11.5 NM from the threshold runway 14). It was thus about 1200 ft below the glide path. The QFE 970 hPa was also set by the COPI. About 5 seconds later the Altitude Exit Alert was heard (Descent through 3700 ft [QNH]). The PIC cancelled the warning by setting 5000 ft (Go Around Altitude) on the Altitude Preselect. The PIC said to the COPI: "There is another one (Finnair 863) in front quite close. You can reduce even further to 150 (kt) otherwise we'll end up with a "go around". A discussion followed about possible icing. After this the flaps were set to 25 during which no Landing Gear horn was heard. At this point the aircraft was established on the localiser. The altitude was about 3000 ft QNH - ca. 1200 feet below the glide path. The PIC: "Outer Marker check is at 1250 ft [QFE]". The height was now about 1600 ft QFE. 10 seconds after Flaps 25, the flaps were set to 50. The Outer Marker height of 1250 ft QFE was now passed. The PIC said "Bravo" followed by sounds of switching. At 8 NM final the PIC mentioned "3.8 almost 4 miles". At about 7 NM final, (15 seconds after the PIC's words "Almost 4 miles") the COPI asked "... haven't we passed it?". After a further 12 seconds the COPI asked once again "Didn't we pass the outer marker?" The height was now 670 ft QFE. The PIC's answer was "No no it hasn't changed yet. At 6.6 NM final the PIC said "Oh it shows 7 The crew was now ordered by Zürich ARR to change frequency to Zürich TWR. At 6.25 NM final the pilots conversed as follows: "... That doesn't make sense to me "Nor to me ...". 2 seconds after this conversation the PIC called out "Pull, pull, pull, pull! ". Simultaneously autopilot disconnection could be heard. The position was now about 500 ft AGL overhead Weiach - about 350 ft QFE. 2 seconds later the COPI called out "GO AROUND" the PIC responded with "No no no no ... catch the glide". At this point the DFDR shows a pitch change from -2° [AND] to +5.4° [ANU]. At the same time the thrust was increased from 1.3 to 1.7 EPR. The sink rate decreased from 1100 ft/min. to 190 ft/min. After 11 seconds (the pitch oscillated at +1° [ANU]) the PIC asked "Can you hold it?" to which the COPI replied "Yes". One second after the COPI's answer the Radio Altimeter warning (pip pip pip) indicating 200 ft/AGL could be heard. During this, the PIC said "Hold on let's try to At 1911.18 hrs the aircraft Struck the north em slope of the Stadlerberg at a altitude of 1660 ft QNH. All 46 occupants were killed.
Probable cause:
The accident was caused by:
- False indication of VHF NAV unit No 1 in the aircraft.
- Probable altimeter misreading by the PIC.
- No GPWS warning in the cockpit.
- Pilots not aware of the possibility of incorrect indications in the NAV equipment in use (without flag-alarm).
- Inadequate failure analysis by the pilots.
- Non-compliance by the pilots with basic procédural instructions during the approach.
- Unsuitable cooperation between the pilots during the approach.
- COPI's initiated go-around procédure aborted by the PIC.
- The Approach Controller not observing the leaving of the cleared altitude of 4000 ft QNH before the FAP.
Final Report: