ANSV Investigation Summary: Multiple Aviation Incidents

Casualties unknown • IT

A compilation of safety investigation findings by the ANSV involving various aircraft, ranging from mid-air conflict risks to landing gear failures.

What happened

Several aviation incidents were investigated by the ANSV involving various aircraft types:

  • August 26, 2011: A serious conflict occurred between a McDonnell Douglas DC-9-82, registration I-SMEZ, and an ATR 42-300, registration D-BCRN. While operating in opposite directions near Pantelleria, the aircraft reached the same flight level of FL110. The conflict was resolved by the onboard TCAS systems, which issued a 'Descend' command to I-SMEZ and a 'Climb' command to D-BCRN.
  • May 28, 2015: A Tecnam P92-JS, registration I-PETR, experienced a stall during the final approach to Biella airport. The pilot attempted a go-around with full power, but the aircraft failed to recover speed and struck the ground near the airport perimeter fence, causing substantial damage to the airframe, engine, and landing gear.
  • March 30, 2017: During takeoff from an unpaved airstrip in Sella Valsugana, a Tecnam P92-JS, registration I-GITR, encountered undetected holes in the terrain. The pilot reduced power to avoid them, but the nose gear collapsed upon hitting a depression, causing the aircraft to slide on its nose.
  • March 31, 2017: A Tecnam P92-JS, registration I-LARU, suffered a nose gear collapse at the "La Comina" airstrip. Following a heavy touchdown, the aircraft bounced multiple times; during the third bounce, the nose gear struck the runway with enough force to collapse.
  • March 31, 2017: A Rolladen Schneider LS4 glider, registration OE-5426, performed an off-field landing in Tavernerio. Due to strong downdrafts near Lake Como, the pilot could not reach the home airport and chose a landing in a wooded area, resulting in extensive damage after striking trees.

The investigation

The ANSV examined communication transcripts, radar data, and maintenance records. For the mid-air conflict, investigators reviewed radio exchanges between Pantelleria Tower and Roma ACC. For the I-PETR incident, functional tests of the airspeed indicator and stall warning system were conducted, confirming the systems were operational. For the glider incident, a desk investigation was performed, focusing on the pilot's decision-making regarding meteorological conditions and landing site selection.

Findings

  • The mid-air conflict was caused by a failure in the readback/hearback process, where the crew of D-BCRN incorrectly repeated an assigned altitude, and air traffic controllers failed to correct the error.
  • The I-PETR stall was attributed to inadequate landing management and excessive speed reduction by the pilot.
  • The I-GTIR incident resulted from an inadequate survey of the takeoff surface conditions.
  • The I-LARU gear collapse was caused by the pilot's failure to follow the Aircraft Flight Manual (AFM) procedures for a balked landing after a heavy touchdown.
  • The OE-5426 crash was driven by significant environmental downdrafts and an inadequate assessment of the chosen landing area's obstacles.

Probable cause

The primary causes across these incidents involve human factors, specifically errors in communication/monitoring, inadequate terrain assessment, and improper management of aircraft energy during critical flight phases.

Frequently asked questions

What happened in the 2011-08-26 aircraft accident near IT?

A compilation of safety investigation findings by the ANSV involving various aircraft, ranging from mid-air conflict risks to landing gear failures.

What aircraft was involved and where did it happen?

The accident on 2011-08-26 involved a aircraft, registration I-SMEZ, at IT.

What was the probable cause of the accident?

The primary causes across these incidents involve human factors, specifically errors in communication/monitoring, inadequate terrain assessment, and improper management of aircraft energy during critical flight phases.

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