What happened
On November 5, 2017, an Airbus A319-112, registration ER-AXM, operated by Air Moldova, arrived at Rome Fiumicino (LIRF) from Chișinău. The flight, MLD891, encountered severe weather characterized by intense thunderstorms and cumulonimbus clouds affecting the destination airport.
The crew performed a series of four approach attempts. The first attempt was for runway 16L, followed by a second attempt for runway 34L. During the process, the crew initiated a diversion to Bologna (LIPE), but shortly thereafter declared an emergency due to low fuel levels, stating their intention to return to Rome. A third approach attempt was made for runway 16L, which also resulted in a missed approach. The fourth and final attempt was conducted via a visual circuit, landing on runway 16R. The aircraft landed with fuel quantities below the required final reserve levels.
The investigation
The ANSV investigation examined the flight data, weather reports, and crew performance. The investigation focused on the sequence of missed approaches, the decision-making process regarding fuel management, and the impact of the intense thunderstorm activity at both the destination and the selected alternate airport, Rome Ciampino (LIRA).
Investigators analyzed the cockpit workload and Crew Resource Management (CRM) during the high-stress period. The investigation also reviewed the flight planning, specifically the selection of an alternate airport that was geographically close to the destination and subject to the same severe weather conditions.
Findings
The primary cause of the event was human error, specifically related to the crew's decision-making and flight management under high-pressure conditions. The investigation established that the crew's decision to continue multiple approaches despite severe weather and declining fuel levels led to the emergency.
Contributing factors included:
- Degradation of CRM and flight monitoring: The sudden increase in workload and the stress of the situation led to a breakdown in coordination between the pilot flying and the pilot monitoring. This resulted in flight path deviations, such as exceeding flap speed limits and failing to maintain assigned altitudes during a go-around.
- Inadequate flight planning: The flight plan lacked a contingency plan for arrival during severe weather. Furthermore, the selection of an alternate airport (LIRA) that was experiencing the same thunderstorm activity as the destination left the crew with no viable secondary options.
- Poor in-flight fuel management: The crew's decision-making regarding fuel led to a cycle of repeated approaches that exhausted the available fuel, eventually leaving the aircraft with less than the required final reserve.
- Weather-related risks: The repeated attempts to land in thunderstorm conditions exposed the aircraft to turbulence and windshear, which compromised the stability of the approach and triggered EGPWS warnings.