What happened
On March 23, 2024, at approximately 10:02 UTC, a Tecnam P2002S, registration I-9681, crashed in the vicinity of Montebelluna, Italy. The aircraft had departed from the Montebelluna airstrip on a recreational flight bound for Udine-Campoformido. Shortly after takeoff, the aircraft began to lose altitude and impacted the ground approximately 300 meters from the end of the runway, striking a private residence's garden near a swimming pool. The impact resulted in two fatalities, involving both the pilot and the passenger.
The investigation
The ANSV investigation focused on the sequence of events following takeoff and the mechanical state of the aircraft. Analysis of flight data from an onboard AvMap device and surveillance footage showed that the engine noise diminished and the engine shut down approximately 25 seconds after the takeoff roll began. This was followed by a rapid loss of airspeed and a left-wing bank that led to an inverted impact.
Investigators examined the engine, a Rotax 912 ULS, and found no mechanical failures, broken components, or issues with the fuel pump or carburetors. Ground tests confirmed that the engine could run for approximately 40 to 43 seconds if the fuel shut-off valves were closed, which matched the timeline of the accident. The investigation also noted that the fuel pressure gauge, located on the co-pilot's side, showed a drop in pressure just before the engine failed, but the pilot had very little time to react.
Findings
- The primary cause of the accident was fuel starvation resulting from the fuel shut-off valves being in the closed position during takeoff.
- The pilot, an experienced aviator, likely closed the valves due to a lack of familiarity with the specific fuel selector logic of the Tecnam P2002S, which differs significantly from the Tecnam P96, an aircraft the pilot had flown extensively.
- On the P96, the fuel selector is in the 'open' position when aligned longitudinally, whereas on the P2002S, the 'closed' position is achieved by turning the lever 90 degrees.
- The lack of a dedicated cockpit warning or alarm for the closed shut-off valves contributed to the error.
- The ergonomic placement of the fuel pressure gauge on the right side of the instrument panel made it difficult for the pilot to monitor fuel delivery effectively during the critical climb phase.
- Potential time pressure due to a morning delay may have led to a rushed pre-takeoff checklist.