Italy

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Technoavia SM-92 Turbo Finist

Schedule:

Rimini – Catania

MSN:

20128

YOM:

1988

Flight number:

RVL233

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

6850

Captain / Total hours on type:

781.00

Copilot / Total flying hours:

2680

Copilot / Total hours on type:

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.

Final Report:

Crash of a Technoavia SMG-92 Turbo Finist in Casale Monferrato

Date & Time: Aug 29, 2015 at 1430 LT

Type of aircraft:

Operator:

Registration:

HA-YDJ

Flight Phase:

Flight Type:

Skydiving / Paratroopers

Survivors:

Site:

Schedule:

Casale Monferrato - Casale Monferrato

MSN:

02-001

YOM:

1993

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

600

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.

Final Report:

Crash of a Let L-410UVP-E20 in Ancona

Date & Time: Mar 5, 2015 at 1930 LT

Type of aircraft:

Let L-410

Operator:

Registration:

E7-WDT

Flight Phase:

Flight Type:

Cargo

Survivors:

Site:

Schedule:

Sarajevo – Ancona

MSN:

91 26 15

YOM:

1991

Flight number:

RAC9002

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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

Type of aircraft:

ATR72-500

Operator:

Registration:

YR-ATS

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Rome-Fiumicino-Leonardo da Vinci

Schedule:

Pisa - Rome

MSN:

533

YOM:

1997

Flight number:

AZ1670

Location:

Lazio

Country:

Italy

Region:

Europe

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

18552

Captain / Total hours on type:

3351.00

Copilot / Total flying hours:

624

Copilot / Total hours on type:

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:

Cessna 402

Operator:

Registration:

I-ERJA

Flight Phase:

Flight Type:

Ferry

Survivors:

Site:

Pilatus PC-6 (Porter & Turbo Porter)

Schedule:

Rome - Brescia

MSN:

402B-0918

YOM:

1975

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

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 Pilatus PC-6/B2-H4 Turbo Porter in Ravenna

Date & Time: Apr 2, 2011 at 1530 LT

Type of aircraft:

Operator:

Registration:

D-FATA

Flight Phase:

Flight Type:

Skydiving / Paratroopers

Survivors:

Site:

Schedule:

Ravenna - Ravenna

MSN:

894

YOM:

1994

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

Pax fatalities:

Other fatalities:

Total fatalities:

Aircraft flight hours:

5797

Circumstances:

The single engine aircraft departed Ravenna-La Spreta Airport on a local skydiving mission, carrying nine skydivers, one child and one pilot. After takeoff from runway 08, while climbing to an altitude of about 50 feet, the aircraft turned to the left then lost height and crashed in an open field located 380 metres from the runway end. All 11 occupants were injured, five of them seriously. The aircraft was destroyed.

Final Report:

Crash of an Airbus A319-132 in Palermo

Date & Time: Sep 24, 2010 at 2007 LT

Type of aircraft:

Airbus A319

Operator:

Registration:

EI-EDM

Flight Phase:

Flight Type:

Scheduled Revenue Flight

Survivors:

Site:

Schedule:

Rome - Palermo

MSN:

2424

YOM:

2005

Flight number:

JET243

Location:

Country:

Region:

Crew on board:

Crew fatalities:

Pax on board:

124

Pax fatalities:

Other fatalities:

Total fatalities:

Captain / Total flying hours:

13860

Captain / Total hours on type:

2918.00

Copilot / Total flying hours:

1182

Copilot / Total hours on type:

937

Aircraft flight hours:

15763

Aircraft flight cycles:

8936

Circumstances:

Following an uneventful flight from Rome-Fiumicino Airport, the crew started a night approach to Palermo-Punta Raisi Airport in poor weather conditions with heavy rain falls, thunderstorm activity and reduced visibility. During the descent, weather information was transmitted to the crew, indicating a visibility of 4 km with few CB's at 1,800 feet and a windshear warning for runway 20. On final approach, at an altitude of 810 feet (100 feet above MDA), following the 'minimum' call, the captain instructed the copilot to continue the approach despite the copilot did not establish a visual contact with the runway. At an altitude of 240 feet, the copilot reported the runway in sight but informed the captain that all four PAPI's lights were red. The captain took over control and continued the approach after the airplane deviated from the descent profile. With an excessive rate of descent of 1,360 feet per minute, the aircraft impacted ground 367 metres short of runway 07 threshold and collided with the runway 25 localizer antenna. Upon impact, both main landing gear were partially torn off. The aircraft slid for about 850 metres before coming to rest on the left of the runway. All 129 occupants were rescued, among them 35 were injured. The aircraft was damaged beyond repair.

Probable cause:

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.

Final Report:

Crash of a Lockheed KC-130J Hercules in Pisa: 5 killed

Date & Time: Nov 23, 2009 at 1410 LT

Type of aircraft:

Lockheed C-130 Hercules

Operator:

Registration:

MM62176

Flight Phase:

Flight Type:

Training

Survivors:

Site: