Crash of a Canadair CL-604 Challenger in Birmingham: 5 killed

Date & Time: Jan 4, 2002 at 1207 LT
Type of aircraft:
Operator:
Registration:
N90AG
Flight Phase:
Survivors:
No
Schedule:
Birmingham - Bangor - Duluth
MSN:
5414
YOM:
1999
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
5
Captain / Total flying hours:
10000
Captain / Total hours on type:
800.00
Copilot / Total flying hours:
20000
Copilot / Total hours on type:
800
Aircraft flight hours:
1594
Aircraft flight cycles:
797
Circumstances:
Following ATC clearance, engine start was at 1156 hrs and N90AG was cleared to taxi at 1201 hrs. All radio calls during the accident flight were made by the commander, seated in the right cockpit seat. During taxi, the crew completed their normal Before Takeoff Checks; these included confirmation that the control checks had been completed and that anti-ice might be required immediately after takeoff. Flap 20 had been selected for takeoff and the following speeds had been calculated and briefed by the pilots: V1 137 kt; VR 140 kt; V2 147 kt. By 1206 hrs, the aircraft was cleared to line up on Runway 15. At 1207 hrs, N90AG was cleared for takeoff with a surface wind of 140°/8 kt. The pilot in the left seat was handling the controls. Takeoff appeared normal up to lift-off. Rotation was started at about 146 kt with the elevator position being increased to 8°, in the aircraft nose up sense, resulting in an initial pitch rate of around 4°/second. Lift-off occurred 2 seconds later, at about 153 kt and with a pitch attitude of about 8° nose-up. Once airborne, the elevator position was reduced to 3° aircraft nose-up whilst the pitch rate increased to about 5°/second. Immediately after lift-off, the aircraft started to bank to the left. The rate of bank increased rapidly and 2 seconds after lift-off the bank angle had reached 50°. At that point, the aircraft heading had diverged about 10° to the left. Opposite aileron, followed closely by right rudder, was applied as the aircraft started banking; full right aileron and full right rudder had been applied within 1 second and were maintained until the end of the recording. As the bank angle continued to increase, progressively more aircraft nose-up elevator was applied. Stick-shaker operation initiated 3.5 seconds after lift-off and the recorders ceased 2 seconds later. The aircraft struck the ground, inverted, adjacent to the runway. The last recorded aircraft attitude was approximately 111° left bank and 13° nose-down pitch; the final recorded heading was about 114° (M). The aircraft was destroyed by impact forces and a post crash fire and all five occupants were killed, among them John Shumejda, President of the Massey-Ferguson Group and Ed Swingle, Vice President. The aircraft was leased by AGCO Massey-Ferguson.
Probable cause:
Causal factors:
1. The crew did not ensure that N90AG’s wings were clear of frost prior to takeoff.
2. Reduction of the wing stall angle of attack, due to the surface roughness associated with frost contamination, to below that at which the stall protection system was effective.
3. Possible impairment of crew performance by the combined effects of a non-prescription drug, jet-lag and fatigue.
Final Report:

Crash of a Piper PA-31-350 Navajo Chieftain off Fort Lauderdale: 1 killed

Date & Time: Jan 1, 2002 at 1802 LT
Operator:
Registration:
N3525Y
Survivors:
Yes
Schedule:
North Eleuthera - Fort Lauderdale
MSN:
31-7952127
YOM:
1979
Crew on board:
1
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
2241
Captain / Total hours on type:
72.00
Aircraft flight hours:
7132
Circumstances:
The pilot stated that on the day of the accident he ordered fuel only on the first flight of the day. He said he did not add additional fuel during subsequent flights. He said he flew the accident airplane from Fort Lauderdale Executive Airport, Fort Lauderdale, Florida, to Chubb Cay, Bahamas, to Big Whale Cay, Bahamas, back to the Fort Lauderdale Executive Airport. He said he then departed Fort Lauderdale Executive Airport with his next load of passengers and flew to the North Eleuthera Airport, North Eleuthera, Bahamas, without having refueled, and was returning from North Eleuthera, Bahamas, to the Fort Lauderdale International Airport, when he ditched the airplane off Dania Beach, Florida, in the Atlantic Ocean. When asked whether the fuel on board the airplane had been exhausted, the pilot stated, " the way the engines were acting, it seemed like the airplane ran out of fuel." On scene examination of the airplane, as well as follow on examination of its engines revealed no pre accident anomalies with the airplane or its systems. Information obtained from the FAA showed that at 1757, the pilot contacted FAA Miami Approach Control and advised "minimum fuel, further stating that he was not declaring an emergency at that time. At 1758, the controller responded, passing communications control to the FAA Fort Lauderdale Air Traffic Control Tower (ATCT). In response to the pilot's initial communications call to the Fort Lauderdale ATCT, the pilot was given a clearance to land on runway 09R, and told that he was number one. At 1758:43, the pilot replied, asking if there was any chance of getting runway 27L, and at 1759:17, the controller instructed the pilot to descend at his discretion and remain slightly south of final for landing on runway 27L, and to expect 27L. At 1800:07, the pilot contacted the controller and stated, "two five yankee would like to declare an emergency at this time." At 1800:10, the controller responded, "two five yankee yes sir runway two seven left you are cleared to land the wind zero one zero at six." At 1800:16 the pilot responded acknowledging the wind report, and at 1800:27, the controller asked whether the nature of the emergency was minimum fuel, to which the pilot responded, "exactly two five yankee may be coming in dead stick. At 1800:40, the pilot stated that he had the airport in sight and will try to glide, and at 1801:32, the pilot said "two five yankee I'm going to be short of the shore." At 1802, the pilot ditched the airplane about 300 yards from the Dania Beach shoreline, in the area of John Lloyd State Park, in about 15 feet of water. The occupants of the airplane consisted of the pilot and four passengers. All exited the airplane and one passenger drowned in the Atlantic Ocean when according to the pilot "he was in a state of panic" when he tried to instruct him in the use of the life vest while they was in the water, and subsequently tried to use him for flotation when he tried to help him. All remaining passengers confirmed that the pilot had not given them any pre departure safety related briefing prior to or during the accident flight.
Probable cause:
The pilot's inadequate planning for a Title 14 CFR Part 135 on-demand air taxi flight, and his failure to refuel the airplane, which resulted in fuel exhaustion while en route over the Atlantic Ocean, a power off glide, and ditching in the ocean.
Final Report:

Crash of a Let L-410A near Geti: 6 killed

Date & Time: Dec 14, 2001 at 0845 LT
Type of aircraft:
Operator:
Registration:
5X-CNF
Flight Phase:
Survivors:
No
Site:
Schedule:
Bunia – Beni – Entebbe
MSN:
73 02 08
YOM:
1973
Location:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
4
Pax fatalities:
Other fatalities:
Total fatalities:
6
Circumstances:
En route from Bunia to Beni, while cruising in poor weather conditions, the twin engine airplane crashed in a wooded and hilly terrain located near Geti, some 40 km east of Bunia. All six occupants were killed. The exact cause of the accident remains unknown but the aircraft may have been shot down by Allied Democratic Forces (ADF) rebels fighting the Uganda government.

Crash of a Beechcraft C90 King Air in Toowoomba: 4 killed

Date & Time: Nov 27, 2001 at 0837 LT
Type of aircraft:
Operator:
Registration:
VH-LQH
Flight Phase:
Survivors:
No
Schedule:
Toowoomba – Goondiwindi
MSN:
LJ-644
YOM:
1975
Country:
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
3
Pax fatalities:
Other fatalities:
Total fatalities:
4
Captain / Total flying hours:
3693
Captain / Total hours on type:
385.00
Aircraft flight hours:
6931
Circumstances:
On 25 June 2004, the Australian Transport Safety Bureau released its final investigation report into an accident which occurred on 27 November 2001 at Toowoomba aerodrome, Qld, involving a Beech Aircraft Corporation King Air C90 aircraft, registered VH-LQH, which experienced an engine failure shortly after takeoff. The aircraft was destroyed and all four occupants sustained fatal injuries.
Probable cause:
In light of a further review of the evidence, the ATSB has reconsidered its original finding that the initiating event of the engine failure of VH-LQH was a blade release in the compressor turbine and proposes that an alternative possibility could have been that the initiating event occurred in the power turbine. Notwithstanding this possibility, in either scenario, the remainder of the findings and safety recommendations contained in the original ATSB report are still relevant.
Final Report:

Crash of a Beechcraft H18 off Manila

Date & Time: Nov 21, 2001 at 1715 LT
Type of aircraft:
Registration:
RP-C692
Survivors:
Yes
Schedule:
Taytay – Manila
MSN:
BA-763
YOM:
1969
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Circumstances:
The twin engine aircraft departed Taytay-Sandoval-Cesar Lim Rodriguez Airport on a charter flight to Manila, carrying one passenger and two pilots. While approaching Manila, the left engine failed. The crew informed ATC about his situation and continued the descent to Manila when, shortly later, the right engine lost power. Unable to maintain the assigned altitude, the crew attempted to ditch the aircraft in the bay of Manila, about 3 km offshore. The aircraft floated for few minutes, allowing all three occupants to evacuate the cabin. Few minutes later, the aircraft sank and all three occupants were rescued. The wreckage was not recovered.
Probable cause:
It was reported that white smoke was coming out from the left engine during the descent, forcing the crew to shut it down and feathering its propeller. Due to lack of evidences because the wreckage was not found, the exact cause of the engine failure could not be determined.

Crash of an Ilyushin II-18V near Kalyazin: 27 killed

Date & Time: Nov 19, 2001 at 2119 LT
Type of aircraft:
Operator:
Registration:
RA-75840
Flight Phase:
Survivors:
No
Schedule:
Khatanga - Moscow
MSN:
182 0053 01
YOM:
1962
Flight number:
LDF9602
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
18
Pax fatalities:
Other fatalities:
Total fatalities:
27
Aircraft flight hours:
11617
Aircraft flight cycles:
5582
Circumstances:
En route from Khatanga to Moscow-Domodedovo Airport, while cruising by night at an assigned altitude of 7,800 metres in good weather conditions, the four engine aircraft entered an uncontrolled descent. After it reached an excessive speed of 850 km/h, the aircraft rolled to the left to an angle of 60° and nosed down to an angle of 42°. The aircraft suffered structural failure, lost several elements, partially disintegrated in the air and eventually crashed in a snow covered field located 15 km southeast of Kalyazin. The aircraft was totally destroyed and all 27 occupants were killed.
Probable cause:
Failure of the protection system of the elevator trim, causing a spontaneous deflection of the elevator. This caused the aircraft to enter an uncontrolled descent and the crew was unable to regain control. Violations about aircraft maintenance, flight organization and operational aspects were identified within the operator. Excessive G loads during the descent caused the aircraft to partially disintegrate before final impact.

Crash of a Piper PA-31-350 Navajo Chieftain in Fort Liard: 3 killed

Date & Time: Oct 15, 2001 at 2233 LT
Operator:
Registration:
C-GIPB
Survivors:
Yes
Schedule:
Yellowknife – Fort Liard
MSN:
31-7852170
YOM:
1978
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
5
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
1157
Captain / Total hours on type:
77.00
Aircraft flight hours:
11520
Circumstances:
A Piper PA-31 Navajo Chieftain, C-GIPB, serial number 31-7852170, departed Yellowknife, Northwest Territories, at 2043 mountain daylight time on a night instrument flight rules (IFR) charter flight to Fort Liard. One pilot and five passengers were on board. On arrival at Fort Liard, in conditions of moderate to heavy snow, the pilot initiated a non-directional beacon approach with a circling procedure for Runway 02. At about 2233, the aircraft struck a gravel bar on the west shoreline of the Liard River, 1.3 nautical miles short of the threshold of Runway 02, and 0.3 nautical mile to the left of the runway centreline. The aircraft sustained substantial damage, but no fire ensued. Three passengers were fatally injured, and the pilot and two passengers were seriously injured. The emergency locator transmitter activated and was received by the search and rescue satellite system, and two Canadian Forces aircraft were dispatched to conduct a search. The wreckage was electronically located the following morning, and a civilian helicopter arrived at the accident site approximately 10 hours after the occurrence.
Probable cause:
Findings as to Causes and Contributing Factors:
1. For undetermined reasons, the pilot did not maintain adequate altitude during a night circling approach in IMC and the aircraft struck the ground.
2. The pilot and front seat passenger were not wearing available shoulder harnesses, as required by regulation, which likely contributed to the severity of their injuries.
Findings as to Risk:
1. The aircraft was not fitted with, and was not required to be fitted with, a GPWS or a radio altimeter.
2. The pilot used an unauthorized remote altimeter setting that would have resulted in the cockpit altimeters reading approximately 200 feet higher than the actual altitude.
3. The pilot did not meet the night recency requirements necessary to carry passengers, as specified in CAR 401.05 (2).
4. Risk management responsibilities had been placed almost entirely on the pilot.
5. While the company had taken the voluntary initiative to appoint a safety officer, and appeared to have a safety program in place, the program may not have been directed at the needs.
Other Findings:
1. Approximately 28 hours of flight time that the pilot had logged as multi-engine dual would not have qualified as flight experience for the issue of a higher license.
2. CAR do not define 'flight familiarization', 'flight experience', or 'dual', and therefore do not address flight time 'quality'.
3. Opportunities for local community searchers to identify and access the accident site earlier were hampered by initial inaccurate SARSAT location information, by the time required to locate SAR aircraft to the Fort Liard area, and by darkness and poor weather conditions.
4. The decreased time required to alert the SAR system and the higher degree of accuracy permitted by the utilization of a 406 MHz ELT, particularly one interfaced with the onboard GPS, would have likely permitted rescuers to access the site in a more timely manner.
5. 703 Air Taxi operations continue to have a much higher accident rate than 704 Commuter and 705 Airline operations.
Final Report:

Crash of a Swearingen SA226AT Merlin IVA off Columbretes Islands: 10 killed

Date & Time: Oct 10, 2001 at 1042 LT
Operator:
Registration:
EC-GDV
Flight Phase:
Survivors:
No
Schedule:
Barcelona - Oran
MSN:
AT-043
YOM:
1976
Flight number:
FTL101
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
8
Pax fatalities:
Other fatalities:
Total fatalities:
10
Aircraft flight hours:
11950
Circumstances:
The twin engine airplane departed Barcelona Airport at 1018LT on a charter flight to Oran, Algeria, carrying eight American businessmen and two pilots. En route, while cruising along the Spanish coast, the crew encountered poor weather conditions with thunderstorm activity, and was cleared to deviate from the prescribed flight plan to the east. Shortly later, the aircraft entered an area of heavy turbulences and was presumably struck by lighting, causing the electrical system to fail. The aircraft entered an uncontrolled descent and crashed in the Mediterranean Sea about 18 km northwest of the Columbretes Islands. Few debris were found floating on water and all 10 occupants were killed.
Probable cause:
Although the causes of the accident could not be determined, considering the circumstances in which it occurred and the history of similar events with aircraft of the same type, is considered that the probable cause of the accident was a total loss of the electrical system, caused by a lightning strike in the middle of the storm in which it was flying, without the crew being able to recover. It is possible that the lightning strike produced other damages to the airplane and/or could have induced or produced failures in other systems of the airplane. The set of these circumstances, aggravated by the storm, with strong rains and turbulence and the associated lack of visibility, lead to the impact of the airplane with the sea.
Final Report:

Crash of a De Havilland DHC-2 Beaver in Mollet Lake: 3 killed

Date & Time: Oct 8, 2001 at 1730 LT
Type of aircraft:
Operator:
Registration:
C-GPUO
Survivors:
Yes
Schedule:
Iyachisakus Lake - Mollet Lake
MSN:
810
YOM:
1955
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
6
Pax fatalities:
Other fatalities:
Total fatalities:
3
Captain / Total flying hours:
900
Aircraft flight hours:
13140
Circumstances:
The float-equipped Beaver de Havilland DHC-2 Mk 1, registration C-GPUO, serial number 810, took off at 1710 eastern daylight time from Iyachisakus Lake, Quebec, with the pilot and six passengers on board, for a visual flight rules flight to an outfitter on Mollet Lake, 26 nautical miles (nm) to the east. At about 1730, a witness at the outfitter heard the seaplane flying on an easterly heading to the south of the lake. About 20 minutes later, noting that the aircraft had not arrived at the dock, the manager of the outfitter sent a boat to look for C-GPUO. The Beaver was found 1 nm east of the outfitter. It was lying partly submerged in Mollet Lake near the north shore, with the nose in the water and leaning backward. Four injured occupants who were clinging to the fuselage were rescued. The pilot and two of the passengers were fatally injured.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The seaplane stalled at an altitude that did not allow the pilot time to recover from the stall.
2. The stall occurred in circumstances conducive to illusions created by drift.
Findings as to Risks:
1. The aircraft was not equipped with a stall warning device, which could have alerted the pilot to the onset of a stall.
2. The chances of surviving the impact would have been improved if the front seat occupants had been wearing their shoulder harnesses as prescribed by aviation regulations.
3. Life jackets were available, but the occupants who evacuated the aircraft do not seem to have had time to find, retrieve, and don them.
4. The emergency locator transmitter was not capable of emitting a distress signal because a short circuit occurred when the antenna came into contact with the water.
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: