Navigational Setting Error During Approach to Venice Airport

Casualties unknown • Wenecja (LIPZ) / Włochy, PL

A crew error involving incorrect ATIS interpretation led to improper flight director settings during an approach to Venice.

What happened

On September 6, 2018, an Embraer 190-200 (195) was operating a commercial international flight from Warsaw (EPWA) to Venice (LIPZ). The flight proceeded normally until the arrival phase at Venice. During the pre-landing procedures, the crew misheard and incorrectly recorded the ATIS information, mistakenly believing that an ILS approach to runway 04R was in effect instead of an LLZ approach to runway 04R.

As a result, the crew prepared the aircraft's navigation settings for an ILS approach. Approximately 10 NM from the runway on the final approach course, the crew realized the actual approach required was the LLZ. They adjusted the decision altitude (DA) to 450 ft. During this period, the monitoring pilot was reading distances to the VOR TES from the chart, while the DME was incorrectly tuned to the ILS VTS frequency.

Believing the aircraft was 600 ft above the glidepath due to the incorrect settings, the crew increased the descent angle to 4.5 degrees. At the decision altitude, the autopilot was disconnected, and the crew continued the approach using visual references. The landing was completed without further incident, and an Air Safety Report (ASR) was filed upon return to Warsaw.

The investigation

The investigation focused on the crew's preparation for the arrival and the subsequent navigation errors. The inquiry examined the discrepancy between the ATIS information received and the actual approach procedures in effect at Venice Airport. The investigation also reviewed the crew's actions following the discovery of the incorrect approach type and the subsequent adjustments made to the flight parameters.

Findings

  • The primary cause of the incident was incorrect navigation settings in the Flight Management System (FMS) resulting from an inadequate approach briefing.
  • A contributing factor was the crew's incorrect belief that they were performing an ILS approach.
  • The pressure of time and the subsequent need to change the approach type contributed to an imprecise briefing process.

Probable cause

The incident was caused by incorrect FMS navigation settings due to an inaccurate approach briefing, compounded by the crew's mistaken assumption regarding the approach type and time pressure.

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Frequently asked questions

What happened in the 2018-09-06 Embraer 190-200 (195) accident near Wenecja (LIPZ) / Włochy, PL?

A crew error involving incorrect ATIS interpretation led to improper flight director settings during an approach to Venice.

What aircraft was involved and where did it happen?

The accident on 2018-09-06 involved a Embraer 190-200 (195), registration SP-LNM, operated by Pilot samolotowy liniowy ATPL, at Wenecja (LIPZ) / Włochy, PL.

What was the probable cause of the accident?

The incident was caused by incorrect FMS navigation settings due to an inaccurate approach briefing, compounded by the crew's mistaken assumption regarding the approach type and time pressure.

Investigation report by the Polish State Commission on Aircraft Accidents Investigation (PKBWL). Original record: https://pkbwl.gov.pl/raporty/2018-3003/. This page is a structured re-presentation; facts and quotes are in the Panstwowa Komisja Badania Wypadkow Lotniczych (PKBWL), Poland.

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