What happened
On November 20, 2004, at 10:16 UTC, a Piper PA-28R-200 (registration HB-OQH) was performing a VFR flight from Lugano-Agno to Florence Peretla. After receiving authorization to land on runway 23, the aircraft experienced a sudden pitch-up maneuver approximately halfway down the runway. This instability caused the aircraft to drift left of the runway centerline, eventually striking the airport perimeter fence.
The impact occurred near a service road, where the aircraft's nose and engine assembly were torn from the airframe. The left wing struck the ground, causing the aircraft to rotate roughly 180 degrees before the fuselage and right wing slid into the airport fencing. The three occupants—the pilot and two passengers—sustained serious injuries. The aircraft was destroyed, and the airport fence sustained damage.
The investigation
The ANSV investigation examined the aircraft's maintenance records, weather conditions, and the flight crew's qualifications. The investigation noted that the pilot had approximately 100 total flight hours, with only 10 hours of experience on this specific aircraft type. Furthermore, the pilot did not possess the specific qualification required by the AIP Italia for landing on runway 23 at Florence Peretola.
Investigators analyzed the cockpit environment and the sequence of aerodynamic events. Evidence suggested the aircraft was in a full-flap configuration. The investigation also considered the impact of recent heavy aircraft operations at the airport, specifically the jet blast from an Airbus A319 that had departed runway 23 three minutes prior to the incident.
Findings
- Inadequate landing management by the pilot was the primary cause, characterized by an unstable approach and improper control inputs.
- The pilot's limited flight experience, particularly on aircraft with retractable gear and variable-pitch propellers, contributed to the loss of control.
- Poor cockpit resource management occurred between the pilot and the passenger (acting as a co-pilot), leading to uncoordinated actions, such as an inappropriate attempt to increase power which likely exacerbated the leftward yaw.
- The aircraft encountered residual jet blast turbulence from a preceding A310 departure, which likely destabilized the aircraft during the final approach.
- The pilot failed to comply with specific AIP Italia regulations regarding landing requirements for runway 23.
- Environmental factors, including a tailwind component and the displaced threshold of runway 23, complicated the landing maneuver.