Ansv Relazione Ei-Dav 7-09

FINAL REPORT SERIOUS INCIDENT To B737-800, Registration EI-DAV, On approach to Rome Ciampino and Fiumicino Airports September 7th 2005 AGENZIA NAZIONALE PER LA SICUREZZA DEL VOLO www.ansv.it e-mail: [email protected] TABLE OF CONTENTS TABLE OF CONTENTS. I OBJECTIVE OF THE TECHNICAL INVESTIGATION . III PRELIMINARY REMARKS. IV CHAPTER I - FACTUAL INFORMATION . 1 1. FACTUAL INFORMATION . 1 1.1. HISTORY OF THE FLIGHT . 1 1.2. INJURIES TO PERSONS . 9 1.3. DAMAGE TO THE AIRCRAFT . 9 1.4. OTHER DAMAGE. 9 1.5. PERSONNEL INFORMATION . 9 1.5.1. Flight crew . 9 1.5.2. Flight experience . 9 1.5.3. Air traffic controllers . 10 1.6. AIRCRAFT INFORMATION . 10 1.7. METEOROLOGICAL INFORMATION. 10 1.8. AIDS TO NAVIGATION . 13 1.9. COMMUNICATIONS . 13 1.10. AIRPORT INFORMATION. 13 1.11. FLIGHT RECORDERS . 14 1.12. WRECKAGE INFORMATION. 14 1.13. MEDICAL AND PATHOLOGICAL INFORMATION. 14 1.14. FIRE . 14 1.15. SURVIVAL ASPECTS . 15 1.16. TESTS AND RESEARCH. 15 1.16.1. Weather radar . 15 1.17. ORGANIZATIONAL AND MANAGEMENT INFORMATION. 15 1.17.1. Operations Manual – Part A. 16 I 1.18. ADDITIONAL INFORMATION. 17 1.18.1. NTSB safety alert. 17 1.18.2. Aircraft approaching at Rome Fiumicino (LIRF) . 17 1.18.3. Final approach . 18 1.19. USEFUL OR EFFECTIVE METHODS OF INVESTIGATION . 18 CHAPTER II - ANALYSIS. 19 2. ANALYSIS. 19 2.1. FLIGHT OPERATIONS . 19 2.1.1. Pilots. 19 2.1.2. The flight . 20 2.1.3. Visual approach . 26 2.1.4. Weather conditions . 26 2.1.5. Air Traffic Control . 27 2.1.6. Aids to navigation. 27 2.2. HUMAN FACTOR. 27 2.2.1. Psychological and physiological factors . 27 CHAPTER III - CONCLUSIONS. 33 3. CONCLUSIONS . 33 3.1. GENERAL . 33 3.2. FINDINGS . 33 3.3. CAUSE AND CONTRIBUTORY FACTORS . 34 CHAPTER IV - SAFETY RECOMMENDATIONS . 37 4. RECOMMENDATIONS . 37 4.1. RECOMMENDATION ANSV-23/782-05/1/I/08. 37 LIST OF ATTACHMENTS . 38 ATTACHMENT A . 39 ATTACHMENT B . 40 ATTACHMENT C . 41 APPENDIX Air Accident Investigation Unit - Ireland (AAIU) comments . 42 II OBJECTIVE OF THE TECHNICAL INVESTIGATION The technical investigation relative to the event concerned, as provided for by Art. 827 of the code of navigation, was conducted in conformity with the provisions of Annex 13 to the Convention on International Civil Aviation, agreed in Chicago on December 7th 1944, approved and implemen- ted in Italy by legislative decree no. 616 dated March 6th 1948, ratified by law n. 561 of April 17th 1956. The Agenzia Nazionale per la Sicurezza del Volo (the Italian Air Safety Board) conducts technical investigations within its jurisdiction with “the sole objective of preventing accidents and incidents, excluding any evaluation of blame and liability” (Art. 3, paragraph 1, legislative decree n. 66 of February 25th 1999). For every investigation into an accident the Agenzia Nazionale per la Sicurezza del Volo compiles an accident report while, for every investigation into an incident, it compiles an incident report. The accident and incident reports may contain safety recommendations, aimed at the pre- vention of accidents and incidents (Art. 12, paragraphs 1 and 2, legislative decree n. 66 of February 25th 1999). In accident reports the safeguard of the right to confidentiality of those involved in the event as well as of those who provide information in the course of the investigation is carefully respected; in incident reports also the safeguard of anonymity of those involved in the event, is respected (Art. 12, paragraph 3, legislative decree n. 66 of February 25th 1999). "In no case the concern of accident and incident investigation reports and safety recommendations is to apportion blame or liability" (Art. 12, paragraph 4, legislative decree n. 66 of February 25th 1999). Although great attention has been paid in the translation of the report into the English language, the Italian language version is to be considered as the only official reference text. III PRELIMINARY REMARKS The event occurred on September 7th, 2005, at 12.25 UTC (14.25 local time) in the Rome airports area (Ciampino and Fiumicino) and involved a B737-800 aircraft, registration marks EI-DAV. The event was reported to the ANSV by the equivalent Irish investigation authority (Air Accident Investigation Unit – AAIU) on January 13th, 2006. On January 18th, 2006, after the acquisition of further pertinent information, ANSV proceeded with the institution of a serious incident investigation. The Agenzia Nazionale per la Sicurezza del Volo, under the terms of legislative decree n. 66 of February 25th 1999, conducted the technical investigation in conformity with Annex 13 to the Convention on International Civil Aviation (Chicago, 1944). The AAIU appointed an accredited representative to participate to the technical investigation conducted by ANSV. Note: - All times given within the report are UTC (Coordinated Universal Time) which, at the time of the event, corresponded to local time minus two hours). - Altitudes referred to within the report are taken from the radar recording, the values of which refer to a standard pressu- re of 1013 hPa and are generically referred to as “altitudes”. - Airspeed in the present report should be interpreted as Ground Speed (GS), unless otherwise specified. IV CHAPTER I FACTUAL INFORMATION 1. FACTUAL INFORMATION 1.1. HISTORY OF THE FLIGHT On September 7th 2005 flight RYR 9672, a scheduled flight with 166 passengers on board, departed from Niederrhein airport (Germany) with destination Rome Ciampino airport (here- after referred to as Ciampino). Before the event flight, the same morning the crew had already completed three legs, first take- off was from Ciampino at 04.15 towards Treviso, from Treviso take-off was at 05.55 back to Ciampino and finally from Ciampino at 07.35 towards Niederrhein. The captain stated verbally that, before departure for the event flight from Niederrhein, he had checked Ciampino airport weather reports and that he had requested 8200 kg of fuel, figure that included the minimum fuel quantity necessary for the flight and an additional fuel quantity of 950 kg for any eventual unexpected circumstances, such as particular weather conditions. The first part of the flight was operationally uneventful. The crew declared that when at 80 NM from destination they had observed thunderstorm activity that required a series of deviations from the planned route..

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