What happened
On November 10, 2008, a Boeing 737-8AS, registration EI-DYG, was performing an approach to Rome Ciampino Airport. During the final stages of the landing sequence, the aircraft encountered a large flock of birds. Approximately seven seconds before the aircraft was due to touch down, the pilot initiated a go-around maneuver.
During this transition to higher power settings, the aircraft suffered a massive ingestion of birds into both engines. This resulted in an unexpected and simultaneous loss of thrust in both powerplants. The loss of engine performance prevented the crew from successfully completing the go-around procedure, leading to an unstabilized approach and subsequent contact with the runway.
The investigation
The ANSV investigation focused on the sequence of events leading to the engine failure and the crew's response to the bird strike. Investigators examined the flight data recorder (FDR) and cockpit voice recorder (CVR) to reconstruct the flight path and cockpit communications. The investigation also scrutinized the airport's bird control measures and the effectiveness of the crew's training regarding unexpected flight phenomena.
Key areas of examination included the engine performance during the high-power phase of the go-around, the impact of the bird strike on the engine cores, and the psychological impact of the event on the flight crew, specifically regarding the "startle effect."
Findings
- The primary cause of the incident was an unforeseen loss of thrust in both engines caused by a massive bird strike during the go-around maneuver.
- The decision to execute a go-around at such a low altitude, while standard, significantly increased the risk of engine damage because the high power settings required for the maneuver facilitated the ingestion of birds into the engine cores.
- The airport's existing bird control and dispersal measures were found to be inadequately effective at the time of the occurrence.
- The crew's ability to manage the situation was hindered by a lack of specific procedures for handling single or multiple bird strikes during the landing phase.
- The crew was significantly impacted by the "surprise" and "startle" effects, as there was a lack of specific training to mitigate the physiological and cognitive effects of sudden, unexpected engine failures during critical flight phases.