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.