Lazio

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 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.

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.