Moldova A319 at Rome on Nov 5th 2017, initiated diversion after go arounds, fuel emergency, aborted diversion
Last Update: August 25, 2023 / 16:52:33 GMT/Zulu time
Incident Facts
Date of incident
Nov 5, 2017
Classification
Incident
Airline
Air Moldova
Flight number
9U-891
Departure
Chisinau, Moldova
Destination
Rome Fiumicino, Italy
Aircraft Registration
ER-AXM
Aircraft Type
Airbus A319
ICAO Type Designator
A319
Airport ICAO Code
LIRF
On Dec 1st 2017 Italy's ANSV reported after collecting evidence the occurrence was rated a serious incident, an investigation has been opened. The ANSV reported the aircraft went around twice on approach to Fiumicino Airport due to bad weather, then set course to divert to Bologna but requested to return to Rome where another go around was needed. The crew performed a visual circuit and landed.
The occurrence aircraft remained on the ground for about 3.5 hours, then departed for the return flight.
On Aug 25th 2023 Italy's ANSV released their final report in Italian only (editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, an Italian only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe.)
The report concludes the probable causes of the serious incident were:
The serious incident is attributable to human factors and materialized in a landing that occurred with an amount of fuel remaining less than the required fuel reserve after three missed approaches to Rome Fiumicino, a diversion to Bologna initiated and aborted due to intense thunderstorms.
The repeated approaches while a thunderstorm was in progress exposed the aircraft to windshear and hazards associated with thunderstorms.
The excitement and sudden increase in work load resulted in a lapse of accuracy of aircraft's handling and cockpit resource management, with significant deviations from the standard flight parameters.
The following factors contributed to the serious incident:
- inadequate flight planning, characterized by the lack of precautionary actions in case of arrival in storms
- inadequate flight planning in terms of choice of alternate aerodromes in weather conditions characterized by expected thunderstorms over the destination as well as the alternate aerodromes which all were geographically very close to each other
- a deficient inflight fuel management decision-making process which resulted in the attempt of repeated approaches to the destination aerodrome despite the fact that a violent thunderstorm over the destination (and alternate) aerodromes was in progress resulting in the loss of any alternate possibility to head for a suitable alternate aerodrome.
The ANSV analysed:
The flight proceeded without any major events until the crew established contact initial Rome ACC on descent for FL90 bound for LIRF: the flight's arrival at its destination coincided, in fact, with the onset of the thunderstorm phenomenon.
The initial ILS approach for RWY 16L was being aborted at about 5 NM from THR RWY 16L, due to a component of wind in the tail significant (TWR, when the aircraft was in procedure, had reported a wind coming from 310° with an intensity of 14 knots and gusts up to 29 knots). At that stage, the commander assumed PF duties. The airplane would enter turbulent conditions and there would be a the activation of the master warning for about 20", indicating the activation of the configuration warning due to exceeding the VFE for configuration 1+F. In that phase, the deselection of the TO/GA in the stages following the go around took place by bringing the thrust levers to FLEX/MCT instead of on CLIMB. This caused acceleration, which caused the flaps to momentarily overspeed.
After the go around, ATC cleared MLD891 to 4000 feet, but the aircraft did not level off at that altitude. ATC informed the flight in question to maintain 5000 feet.
The second approach, ILS RWY 34L, took place when, on the field, there was the phenomenon thunderstorm, with heavy showers reducing visibility, variable wind with strong gusts and presence of severe turbulence.
The TWR informed the crew that the wind was coming from 250° with intensity 21 knots and gusts from 18 to 31 knots and that RVR visibility was 1200 m/700 m/900 m, respectively at the head, center and at the end of the runway. Upon flap selection on conf 3, made at a CAS of 190 knots, a red warning was activated, momentarily (1 second), a red warning, likely generated by exceeding the VFE (conf 3 limit at 185 knots).
At a RADALT of 1000 feet, the aircraft entered an area of turbulence and, at 700 feet, the recorded the activation of the master warning resulting from a deviation below the glide slope of 1.3 dot, such that an excessive glideslope deviation warning was generated by the EGPWS (Mode 5). At a distance of about 2 NM from THR RWY 34L the autopilot was disengaged and commanded the second go around.
After the second missed approach, the flight was instructed to climb to 6,000 feet and head to the ESATU point.
Four minutes later, flight MLD891 reported that it had a low amount of fuel and its intention to proceed to LIPE. However, at 13:44'07", the crew of MLD891, while waiting to receive a response from ATC to the request for the latest weather conditions on LIPE, requested the weather conditions on LIRF and declared MAYDAY for "short of fuel." At the time of that declaration, the aircraft was at 8000 feet on climb to FL160, with approximately 2,000 kg of fuel on board. Rome ACC then provided a carrier to direct the aircraft to LIRF. The third approach also took place with the thunderstorm in place over the airport now for 40', with intensity of the phenomenon not yet abating. In the phase of preparation for the third approach, at a distance of about 16 NM from THR RWY 16L, the crew communicated by radio that they were making a 360° right turn to dispose of excess altitude and position themselves for ILS RWY 16L.
The TWR communicated "uniform" weather information, which reported the following: "heavy thunderstorm with rain on the field, wind 270 gusting between 0 and 14 knots"; it then provided a further gust update, specifying up to 27 knots.
At 740 feet RADALT the predictive windshear alert was activated and, at about 2.5 NM from THR, the third go around was commanded at 650 feet RADALT, with thrust lever selection on TO/GA and deselection of the autopilot. The fuel on board amounted to 1518 kg (low level fuel alert).
After the third missed approach, ATC, sensing the criticality of the situation, reminded the pilot of the presence, in the vicinity of LIRF, of Pratica di Mare military airport. The ER-AXM commander, at that stage, was in IMC condition and, therefore, was unable to visually acquire the military airport. He stated that he had 1,200 kg of fuel remaining (this amount represents the final reserve fuel reported on the OFP) and requested carriers for a visual final for RWY 16R (visual pattern), on which he landed with 1077 kg of fuel remaining.
It is possible that the actual fuel figure on landing was lower by at least 100 kg than that computed when analyzing the QAR data, thus consistent with what the crew indicated at shutdown (900 kg) and reported on the ATL. In that case, the landing would have taken place about 100 kg below the final reserve fuel.
Alternate aerodrome selection
The situation on the day was characterized by a forecast of bad weather over central and northern Italy, with a possibility of thunderstorms over the destination airport and alternate (TEMPO).
The choice of the LIRA alternate, with the reported weather conditions, although lawful from the aspect of the requirements of the EU regulations in force at the time of the events (AR AMC-OPS 1.297 Table 4-4. "Application of Aerodrome Forecasts Table"), would, however, appear to be very uncautious due to the proximity of the two airports and the high possibility that both airports could be simultaneously affected by adverse weather conditions.
The other alternates, although not included in the fuel computation, also included windows with the presence of thunderstorms or showers associated with reductions in visibility.
An analysis of the weather situation carried out during the investigation showed that the situation, in the time window considered, was better in the South, as early as Naples Airport (LIRN), which was not considered in the planning phase (TAF LIRN 050500Z 0506/0606 VRB06KT 9999 SCT040 BECMG
0507/0510 19015KT TIME 0515/0524 4000 TSRA BECMG 0600/0603 30010KT).
Fuel Planning
From the analysis of embarked fuel (actual block fuel reported on the ATL equal to 8272 kg) and net of cab (200 kg), trip (4957 kg), alternate considered LIRA (1002 kg rounded to 1010 kg) and minus final reserve fuel (1200 kg), it is derived that the aircraft, by planning, at the destination airport would have had available extra fuel of 655 kg and a contingency of 250 kg. It does not appear that the planning process considered a possible mitigation waiting strategy for the expected transient weather events expected transient, just as it obviously does not appear that any consideration was given to the possibility that the predicted transient thunderstorm phenomenon would would affect, at the same time, the destination airport and the alternate, which are distant from each other
15 NM.
In flight fuel management and decision making (alternate airfield).
The event is characterized by arrival at the destination airport concurrently with the onset of an intense thunderstorm, which also simultaneously affected the alternate airfield due to its proximity. The crew, in the absence of a holding or diversion strategy, then carried out a series of missed approaches, which lasted for about an hour, from 13.10' to about 14.10' and for the duration of the storm, with a fuel consumption of 2600 kg, thus ending up in a committing-to-destination condition over an airport with weather phenomena critical to the flight in progress.
Human factor
The commander, although he had totaled considerable overall flight activity, had, however, limited experience on A320 family aircraft. Moreover, he had served with the operator for only a few months. Even the first officer, in view of the hours totaled overall and on the type, had very limited experience.
Although we do not have the CVR records, what has emerged from the QAR data points to the fact that, due to the excitement of the situation and the sudden increase in workload, there was, in the cockpit, a degradation in the level of CRM, resulting in criticality at the level of the conduct of the aircraft by the PF (commander) and monitoring of parameters and configurations by the by the PM (FO).
It is important to note that the lack of possible alternatives and the increasing psychological pressure due to now necessarily having to land at LIRF (where a severe thunderstorm was looming) made the situation particularly critical.
The missed approach procedure revealed inaccuracies in the aircraft's conduct, notably to improper thrust lever selection (failure to select CLIMB) during the reduction of power after the initial stages of the go around, with corresponding overshooting of the speed limit provided for the flaps in the 1+F configuration and exceeding the assigned altitude of 4000 feet.
After the first missed approach, the change of runway from RWY 16L to RWY 34L certainly generated an increased workload, caused by the inclusion of the relevant procedures into the FMGC. The exceeding of the maximum flap speed limit during configuration of the aircraft for landing is a possible indication of a deterioration in the level of crew coordination, caused either by workload or the pressure of having to land quickly, in view of the gradually decrease.
Such urgency also meant that before proceeding for the further approach there had not had been an assessment of the actual weather conditions present at the airport, considering the presence of the thunderstorm.
Consequently, the aircraft passed through an area of turbulence such that it compromised the stabilization on the path. The recorded data showed a descent below the glide, which generated the EGPWS warning.
The absence of a prior alternate action plan resulted in an attempted diversion, later deemed unfeasible based on the calculations made at the time, resulting, moreover, in an additional expenditure of fuel for the ascent phase and departure from the airport.
Metars:
LIRF 051620Z 10011KT 9999 SCT027 SCT035 14/12 Q1009 NOSIG=
LIRF 051550Z 09011KT 9999 SCT035 14/12 Q1009 NOSIG=
LIRF 051520Z 09012KT 9999 FEW005 SCT040 14/13 Q1009 NOSIG=
LIRF 051450Z 12012KT 9999 FEW005 SCT030 15/14 Q1009 882904// NOSIG=
LIRF 051420Z 16006KT 100V200 9999 -RA VCTS FEW005 FEW015CB SCT035 14/14 Q1009 RETSRA 882904// BECMG NSW=
LIRF 051350Z 20011KT 150V240 1500 0500N +TSRA SCT005 BKN010CB BKN020 13/13 Q1010 NOSIG=
LIRF 051320Z 31013G24KT 280V340 2000 1000N +TSRA SCT007 SCT010CB BKN020 BKN030 13/12 Q1011 NOSIG=
LIRF 051250Z 12013KT 9000 -TSRA SCT014CB SCT030 BKN040 19/13 Q1010 NOSIG=
LIRF 051220Z 13017KT 9999 -TSRA SCT014CB SCT030 BKN040 18/12 Q1010 NOSIG=
LIRF 051150Z 14021G31KT 9999 TS SCT014CB SCT030 BKN040 19/13 Q1011 NOSIG=
LIRF 051120Z 14023KT 9999 TS SCT014CB SCT030 SCT040 19/12 Q1011 NOSIG=
LIRF 051050Z 13022KT 9999 FEW030 SCT050 19/13 Q1011 TEMPO 4000 TSRA SCT014CB=
LIRF 051020Z 13018KT 9999 FEW030 SCT050 19/13 Q1012 TEMPO 4000 TSRA SCT014CB=
LIRF 050950Z 14016KT 9999 FEW030 SCT050 19/13 Q1014 BECMG 4000 TSRA SCT014CB=
Incident Facts
Date of incident
Nov 5, 2017
Classification
Incident
Airline
Air Moldova
Flight number
9U-891
Departure
Chisinau, Moldova
Destination
Rome Fiumicino, Italy
Aircraft Registration
ER-AXM
Aircraft Type
Airbus A319
ICAO Type Designator
A319
Airport ICAO Code
LIRF
This article is published under license from Avherald.com. © of text by Avherald.com.
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