Incident Overview
On September 26, 2018, an incident occurred involving an Embraer 190-200 aircraft operating a commercial international flight from Warsaw (EPWA) to Venice (LIPZ). The event was classified as an incident by the State Commission for Investigation of Aviation Accidents (PKBWL), with the investigation concluding on March 20, 2019. No fatalities or injuries were reported among the 105 persons on board.
Operational Sequence
During pre-landing procedures at Venice, the flight crew incorrectly transcribed and noted ATIS information. They confused the ILS approach for runway 04R with the LLZ (Localizer) approach for the same runway. Consequently, the crew configured the navigation settings in the Flight Management System (FMS) for an ILS approach. However, at a distance of 10 nautical miles on the final approach course, the crew realized that only the LLZ approach was active.
Contributing Factors and Outcome
The crew adjusted the decision altitude to 450 feet. The monitoring pilot read distances from the map to the VOR TES, while the DME was set to the ILS VTS frequency. Due to this discrepancy, the crew mistakenly believed the aircraft was 600 feet above the glide path and increased the descent angle to 4.5 degrees. At the decision altitude, the autopilot was disengaged, and the approach was continued with visual reference to the runway. The aircraft landed without further incident.
Investigation Findings
The primary cause of the incident was identified as an incorrect NAV SETTING in the FMS during the landing approach, resulting from an imprecisely conducted approach briefing. A contributing factor was the crew's initial assumption that they were flying an ILS approach; the subsequent change to an LLZ approach under time pressure led to the inaccurate briefing and frequency error. The operator, PLL LOT S.A., registered the event in their Safety Management System (SMS) database and distributed a safety alert to all pilots emphasizing the importance of thorough approach briefings.