Rome-Fiumicino-Leonardo da Vinci

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 event is classified as short landing accident and the cause is mainly due to human factors. The fact that the aircraft contacted the ground took place about 367 meters short of the runway threshold was due to the crew's decision to continue the instrument approach without a declared shared acquisition of the necessary visual references for the completion of the non-precision procedure and of the landing maneuver. The investigation revealed no elements to consider that the incident occurred due to technical factors inherent in the aircraft.
The following contributing factors were identified:
- The poor attitude of those present in the cockpit to use of basics of CRM, particularly with regard to interpersonal and cognitive abilities of each and, overwhelmingly, the commander.
- Deliberate failure to comply with SOP in place which provided, reaching the MDA, to apply the missed approach procedure where adequate visual reference of the runway in use had not been in sight of both pilots.
- Failure to apply, by those present in the cockpit, the operators rules, concerning in particular: the concept of "sterile cockpit"; to do the descent briefing; to make callouts on final approach.
- The routine with the crew, carrying out approaches to Palermo-Punta Raisi Airport, from which the complacency to favor the personalization of the standards set by operator, and by law. The complacency is one of the most insidious aspects in the context of the human factor, as it creeps in individual self-satisfaction of a condition, which generates a lowering of situational awareness, however bringing them to believe they had found the best formula to operate.
- The existence of adverse weather conditions, characterized by the presence of an extreme rainfall, which significantly reduced the overall visibility.
- The "black hole approach" phenomenon, due to adverse weather conditions together with an approach carried out at night, the sea, to a coast characterized by few dimly lit urban settlements.
This created the illusion in the PF of "feeling high" compared to what he saw and believed to be the threshold, with the result to get him to abandon the ideal descent profile, hitherto maintained, to make a correction and the subsequent short landing.
- The decrease of performance of the light beam produced by SLTH in extreme rain conditions; The only bright horizontal reference for the crew consisted of the crossbar of the SALS, probably mistaken for the threshold lights.

The analysis of the technical, operational and organizational context in which the event took place (impact of the end of the right wing of the aircraft, during taxiing, against the rear body of a truck that was parked for work within the protection area of the taxiway that leads from the Bravo connection to the parking area) has allowed to determine the following causes, which are attributable to human and environmental factors.
- Failure to close the Bravo taxiway with the issue of the relative NOTAM of the works in progress.
- Failure of the Torre control to provide the pilots with essential information on the condition of the airport, as provided for by ICAO in ICAO Doc. 4444 PANS-ATM.
- Vertical and horizontal ground signs do not correspond to those specified in ICAO Annex 14.
- Failure to comply with the ENAC circular (APT-11), applicable for the type of work in progress at the airport.
- Insufficient surveillance of the airport area affected by the works by ENAC and the airport management company Aeroporto FVG.
- Lack of an airport Safety Management System .
- Inadequate surveillance of the external space during taxiing by the flight crew, resulting in incorrect assessment of the position of the aircraft with respect to the obstacle.

Failure of the swinging lever of the left main gear due to the presence of fatigue cracks.

Wrong approach configuration on part of the flying crew who decided to continue the descent while the aircraft was unstable and misaligned with the runway. The following contributing factors were reported:
- Failure of the crew to initiate a go-around procedure,
- Unstabilized approach,
- Excessive approach speed,
- Touchdown completed in a nose-down attitude,
- Poor crew coordination,
- Poor weather conditions with thunderstorm activity.