Investigation into Pilatus PC-12 Crash Near Milan

Casualties unknown • Milano, IT

An ANSV investigation into the crash of a Pilatus PC-12 in Milan has highlighted risks associated with single-pilot operations and the lack of flight data recorders.

What happened

On October 3, 2021, a Pilatus PC-12/47E, registration YR-PDV, was involved in an accident near Milan, Italy. The aircraft was operating in a single-pilot capacity under high-performance airplane (HPA) standards. During the flight, the aircraft encountered challenging environmental conditions, including Instrument Meteorological Conditions (IMC) and potential icing. The sequence of events led to the aircraft impacting the ground, resulting in significant damage to the airframe.

The investigation

The Italian National Agency for Flight Safety (ANSV) conducted a comprehensive investigation into the crash. The inquiry focused on the technical state of the aircraft, the pilot's workload, and the available navigation aids. Investigators examined the wreckage, the flight history, and the cockpit's sophisticated avionics suite. A critical aspect of the investigation was the assessment of the aircraft's recording capabilities. The investigators discovered that the aircraft's Light Data Recorder (LDR) had been non-functional for approximately two years and had not been repaired because there was no regulatory requirement to do so for this specific aircraft category.

Findings

  • The investigation identified that single-pilot operations in complex airspace and demanding environments can lead to task saturation and a breakdown in aeronautical decision-making.
  • The absence of a pilot monitoring role increases the risk of losing situational awareness, especially during manual flight without autopilot assistance.
  • The lack of functional flight recording equipment, specifically the LDR, significantly limited the investigators' ability to access critical flight parameters and cockpit audio, which could have provided vital data for the safety analysis.
  • The aircraft was operating in a high-performance category that requires high levels of proficiency in managing complex avionics and emergency procedures.

Safety action

  • The ANSV has issued several recommendations to EASA, suggesting the implementation of mandatory recurrent training for non-professional pilots in the SET class, specifically focusing on simulator-based training for abnormal and emergency procedures.
  • There is a recommendation to develop and mandate Single Resource Management (SRM) and Unusual Attitude Recovery Training (UPRT) for single-pilot operations in this aircraft class.
  • The agency has recommended to ICAO that regulations should be updated to mandate the use of flight data recorders (FDR or similar) for all turbine-powered aircraft in this category, including those operated by a single pilot, to ensure sufficient data is available for future safety investigations.

Probable cause

The investigation highlights that single-pilot operations in complex environments are highly susceptible to task saturation and loss of situational awareness, exacerbated by the lack of a second pilot to monitor flight parameters.

Frequently asked questions

What happened in the 2021-10-03 Pilatus PC12/47E accident near Milano, IT?

An ANSV investigation into the crash of a Pilatus PC-12 in Milan has highlighted risks associated with single-pilot operations and the lack of flight data recorders.

What aircraft was involved and where did it happen?

The accident on 2021-10-03 involved a Pilatus PC12/47E, registration YR-PDV, at Milano, IT.

What was the probable cause of the accident?

The investigation highlights that single-pilot operations in complex environments are highly susceptible to task saturation and loss of situational awareness, exacerbated by the lack of a second pilot to monitor flight parameters.

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