What happened
On 14 January 1969, an aircraft was operating a scheduled international flight from Gatwick to Genoa via Milan. Due to poor weather at the intended destination, the flight diverted to Milan-Linate Airport, arriving at 1430 hours. Following a five-hour delay while waiting for connecting passengers, the crew prepared for the return leg to Gatwick. During the ground period, the crew identified ice on the wings and tail, which was subsequently removed via de-icing procedures.
At approximately 2031 hours, the aircraft was cleared for takeoff from runway 18. As the aircraft accelerated and reached rotation speed, the crew heard a loud, dull thud emanating from the engines. Following this noise, the pilot-in-command observed a temperature increase in the No. 1 engine and instructed the pilot-in-charge to reduce power on that engine. The pilot-in-charge responded by rapidly closing the power lever for the No. 1 engine.
As the aircraft climbed, the crew noticed a significant drop in acceleration. While attempting to manage the emergency, the co-pilot retracted the landing gear, but the aircraft struggled to maintain altitude, reaching a maximum height of only 250 feet. The aircraft eventually made contact with the ground and slid 470 meters along the snow-covered surface before coming to a halt. Although an orange glow was visible through the windows during the slide, no fire occurred. There were 0 fatalities.
Findings
Investigations determined that a segment of the high-pressure turbine seal in the No. 2 engine caused a compressor surge, which the crew misidentified as a major malfunction of the No. 1 engine. The primary cause of the accident was the erroneous reduction of thrust on the No. 1 engine following an incorrect command.
Additional contributing factors included:
- The pilot-in-command's hasty intervention, which may have been influenced by fatigue from a long duty period.
- An inadvertent displacement of the No. 2 engine throttle lever, which further reduced available thrust without the crew realizing it.
- A lack of effective cockpit resource management due to the specific seating arrangement and roles assigned for the flight.