Narrative:An Airbus A319, registered EI-EDM, suffered substantial damage in a landing accident at Palermo-Punta Raisi Airport (PMO), Italy. Some 34 passengers suffered minor injuries.
|Date:||Friday 24 September 2010|
|C/n / msn:|| 2424|
|First flight:|| 2005-03-04 (5 years 7 months)|
|Total airframe hrs:||15763|
|Engines:|| 2 IAE V2524-A5|
|Crew:||Fatalities: 0 / Occupants: 5|
|Passengers:||Fatalities: 0 / Occupants: 124|
|Total:||Fatalities: 0 / Occupants: 129 |
|Airplane damage:|| Damaged beyond repair|
|Location:||Palermo-Punta Raisi Airport (PMO) ( Italy)
|Phase:|| Landing (LDG)|
|Nature:||Domestic Scheduled Passenger|
|Departure airport:||Roma-Fiumicino Airport (FCO/LIRF), Italy|
|Destination airport:||Palermo-Punta Raisi Airport (PMO/LICJ), Italy|
Windjet flight 243 departed Roma-Fiumicino Airport (FCO) at 19:24 on a domestic service to Palermo on the island of Sicily. The copilot was Pilot Flying.
The en route part of the flight was uneventful.
The flight crew was cleared for a "VOR-Z RWY 07" approach to runway 07. During the descent weather information was passed on to the crew, indicating a visibility of 4 km with few CB clouds at 1800 feet and a windshear warning for runway 20.
At 19:55 another flight reported losing 10 knots in a windshear encounter during the approach to runway 07. While turning to finals the aircraft encountered heavy rainfall. Wind was reported from 020 degrees at 4 knots, gusting to 16 knots.
Both pilots did not have the runway in sight as the aircraft reached MDA. The captain however told the copilot to continue the approach.
At 480 feet both pilots had the runway in sight. At that point the captain took over control from the copilot and became Pilot Flying.
He let the plane deviate significantly from the descent profile. The descent rate reached 1360 ft per minute.
The aircraft then impacted the ground 367 meters before the runway 07 threshold and, after hitting the runway 25 localizer antenna, slid for about 850 meters before stopping on the left side of the runway just after the intersection with runway 02/20.
Probable Cause:PROBABLE CAUSE (translated from Italian):
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.
Numerous factors contributed to the event, including the following.
- 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 on 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.
After the incident, the application of the PEA (airport emergency plan) highlighted a number of serious problems, which made it impossible to carry out a timely and effective research, aid and assistance to the victims of the accident. In particular, the airport organization has not been able, at various levels, to ensure the prompt and effective intervention of the rescue organization, denoting the existence of latent criticality of various types, which have arisen precisely in the incident investigated.
METAR Weather report:
17:50 UTC / 19:50 local time: LICJ 241750Z 06014KT 4000 TSRA FEW018CB SCT022 BKN030 20/18 Q1001 WS RWY 20 RMK VIS MIN 4000=
Wind 060 degrees at 14 knots; Visibility 4000m; Thunderstorm with rain and wind shear; Clouds: broken clouds at 3,000 ft.,scattered clouds at 2,200 ft, few clouds with cumulonimbus 1,800 ft; Temperature: 20°C, dew point 18°C; 1001 hPa; Wind shear runway 20
18:20 UTC / 20:20 local time: LICJ 241820Z 07006KT 4000 TSRA FEW018CB SCT022 BKN030 20/18 Q1000=
18:50 UTC / 20:50 local time: LICJ 241850Z 18010KT 4000 TSRA FEW018CB SCT020 BKN028 20/18 Q1001 RMK VIS MIN 4000=
19:20 UTC / 21:20 local time: LICJ 241920Z 19015KT 9999 SCT022 BKN030 21/18 Q1001=
Official accident investigation report
|investigating agency: ||Agenzia Nazionale per la Sicurezza del Volo (ANSV) - Italy |
|report status: ||Final|
|report number: ||Final report|
|report released:||28 November 2014|
|duration of investigation: ||4 years and 2 months|
|download report: ||
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not
display the exact flight path.
Distance from Roma-Fiumicino Airport to Palermo-Punta Raisi Airport as the crow flies is 407 km (254 miles).