ANSV Investigation of a Boeing 747 Cargo Engine Gondola Contact at Milan Malpensa (I-DAVA)

Incident Overview and Investigation Context On 23 January 2001, at 01:44 UTC (02:44 local time), a serious incident occurred during the landing phase of a Boeing 747-243B Special Freighter, registration I-DEMC, at Milan Malpensa Airport. The aircraft, operating as Alitalia cargo flight AZ 9209 from Chicago, made contact with the runway surface with the lower part of its No. 4 engine gondola, located on the outer side of the right wing. The event was initially classified as an inconvenience by the Italian Civil Aviation Authority (ENAC), which established a technical-operational investigation committee. The National Agency for the Safety of Flight (ANSV) was informed on the same day and requested prompt updates to determine if the event met the criteria for a serious incident. On 9 February 2001, ANSV reclassified the event as a serious incident and opened a formal technical investigation, requesting all relevant documentation from ENAC. However, ENAC only transmitted its incident report and safety recommendation No. 1/2001 to ANSV on 4 April 2001, following multiple requests. ## Aircraft, Crew, and Operational Details The aircraft involved was a Boeing 747-243B Special Freighter, construction number 22.506, built in 1980, with 78,683 flight hours and 13,820 cycles at the time of the incident. It was powered by four General Electric CF6-50E2 engines. The aircraft was operated by Alitalia - Linee Aeree Italiane SpA for public cargo transport. The crew consisted of three Italian nationals: a 54-year-old captain with 8,686 total flight hours (463 on the B747), a 53-year-old first officer with 9,502 total flight hours (7,091 on the B747), and a 52-year-old flight engineer. All crew members held valid licenses and were qualified in Crew Resource Management (CRM); the pilots were also qualified for CAT IIIA operations. ## Airport, Weather, and Flight Description Milan Malpensa Airport (LIMC-MXP) features two parallel runways, each 3,920 by 60 meters, both open to traffic at the time of the incident. The airport was certified for Low Visibility Operations (LVO) up to CAT IIIB, and CAT II LVO procedures were in effect during the approach and incident. Meteorological data from the 01:30 UTC METAR and METEREPORT (observed at 01:20 UTC) indicated calm winds, visibility of 800 meters, rain and fog, and an overcast ceiling at 4,000 feet. The flight departed Chicago at 18:09 UTC on 22 January 2001 and proceeded normally until the incident. During the pre-descent briefing, the first officer, acting as Pilot Flying, announced the intention to conduct an automatic CAT I approach to runway 35R, with a possible transition to manual control before the minimums if actual weather conditions permitted. ## Damage and Investigation Limitations The runway contact damaged the No. 4 engine gondola cowl, the reverse thrust buckets, and the gearbox for the engine and aircraft auxiliary systems. No injuries were reported. The ANSV investigation was based on ENAC's report and a crew hearing held at ANSV headquarters on 18 September 2001. Notably, the Cockpit Voice Recorder (CVR), Performance Maintenance Recorder (PMR), and air-ground radio communications were not collected by ENAC and were therefore unavailable for the ANSV investigation. The Digital Flight Data Recorder (DFDR) data, however, had been downloaded and transcribed by the operator and made available to ENAC.