What happened
On June 1, 2003, a Bombardier Learjet 45, registration I-ERJC, was performing a takeoff from runway 36R at Milan Linate airport, bound for Genoa Sestri. Shortly after rotation, the aircraft struck a flock of pigeons crossing the runway. The crew immediately notified Air Traffic Control of their intention to perform an immediate return to Linate due to the bird strike.
As the aircraft climbed, the pilot flying experienced a stall warning. During the subsequent maneuvers, the pilot significantly reduced engine power, at one point pulling the right engine thrust lever to idle without communicating the action to the first officer. The aircraft entered a right-hand turn to position itself for landing, but the combination of low altitude, improper configuration, and power management led to a loss of control. At 13:25 UTC, the aircraft impacted an industrial warehouse, which subsequently caught fire. Both pilots on board were killed in the impact.
The investigation
The ANSV investigation examined the flight data recorder, cockpit voice recorder, and the wreckage of both engines. Investigators found traces of pigeon feathers in the left engine's fan by-pass stator, confirming the bird strike. While the left engine's N1 indications dropped to 0%, the investigation determined this was due to a disconnected wiring connector caused by vibrations, rather than a total loss of engine function; the engines were likely still producing thrust at the time of impact.
Technical analysis also focused on the crew's actions. The investigation noted that the landing gear remained extended throughout the flight, and the crew failed to follow established procedures for engine failure after V1. The investigation also reviewed the airport's bird mitigation strategies and the crew's training and experience levels.
Findings
- The primary cause of the accident was the loss of control due to an aerodynamic stall during the return to the airport, which could not be recovered due to the insufficient altitude.
- The crew failed to implement the procedures outlined in the Airplane Flight Manual (AFM) for engine malfunctions after V1, specifically regarding maintaining safety altitude, managing thrust levers, and ensuring proper aircraft configuration (flaps and landing gear).
- A significant deterioration in Crew Resource Management (CRM) occurred, particularly during the emergency phase.
- The first officer lacked sufficient experience, as this was his first line training flight on this aircraft type.
- Existing bird control and mitigation measures at the airport were inadequate to prevent the strike.