Carpatair AT72 at Rome on Feb 2nd 2013, runway excursion on landing, main and nose gear collapsed

Last Update: December 4, 2015 / 18:25:46 GMT/Zulu time

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Incident Facts

Date of incident
Feb 2, 2013



Aircraft Type
ATR ATR-72-200

ICAO Type Designator

Italy's ANSV released their final report in Italian concluding the probable cause of the accident was:

Human Factors.

In particular the accident was caused by the improper conduct of landing by the aircraft commander (pilot flying) not in line with standard operating procedures as stated in the aircraft operations manual in the presence of challenging/critical environmental conditions and in the absence of effective cockpit resource management.

The following factors contributed to the accident:

- the absence of an approach briefing
- maintaining an approach speed significantly above computed Vapp
- the conviction of the commander that due to his experience and skills he could still manage a safe landing despite critical winds
- the considerable difference of experience between captain and first officer which possibly inhibited the first officer to express criticism rendering cockpit resource management inefficient

Following the accident the execution of the airport's accident response plan highlighted several issues which were not executed timely and prevented an effective search and rescue activity for the aircraft and its occupants.

The ANSV reported that the captain (58, ATPL, 18,522 hours total, 3,351 hours on type) was pilot flying, the captain was also the chief pilot of the airline. The first officer (25, CPL, 624 hours total, 15 hours on type plus 36 hours simulator time) was pilot monitoring.

While descending towards Rome the commander remarked that the landing brief had been done already although no briefing had been conducted.

Tower reported the current winds at 22 knots gusting up to 37 knots from 250 degrees and issued clearance to land on runway 16L. The captain advised he wanted to maintain an approach speed of 130 KIAS, the first officer agreed, the captain invited the first officer to put his hands onto the control column to follow/feel his control inputs for the landing. The landing gear was extended and the flaps were selected to 30 degrees, the approach was stable as the aircraft descended through 1000 feet AGL with the speed being around 130 KIAS fluctuating +/- 10 knots. After the autopilot was disconnected an airspeed of about 125 KIAS was maintained.

The aircraft touched down 2.6 degrees nose down, nose gear first, near the runway center line about 560 meters past the runway threshold in controlled flight but bounced, the captain called out "hop! hop! hop!" upon recognizing the bounce, neither pilot called for a go-around, the captain provided nose down inputs causing the aircraft to sharply touch down a second time nose gear first causing the nose gear to collapse and bounce again, both pilots provided conflicting control inputs thereafter, the captain providing nose down inputs while the first officer provided nose up inputs possibly triggering the interlock to separate left and right control column. Due to the now disconnected flight controls and conflicting control inputs the aircraft rolled slight left and touched down again heavy on the left main gear causing the left main gear to be damaged and bouncing again now with a right bank angle of about 10 degrees, the aircraft touched down a last time causing the collapse of the right main gear. After the last touchdown the aircraft slid for 400 more meters turning around by about 170 degrees until coming to a stop. After the aircraft stopped the two flight attendants initiated an emergency evacuation of the aircraft and collected the passengers outside the aircraft at the lawn.

First emergency vehicles reached the accident site 10 minutes after the aircraft came to a stop. A triage was setup at the site and doctors took care of the injured. 2 crew and 5 passengers received minor injuries. The aircraft was substantially damaged beyond economic repair.

The ANSV analysed that the crew was composed not homogenous due to the extreme difference in experience with the captain's far superior experience. On the other hand, the ANSV argued, the first officer had just completed his type rating and had fresh knowledge.

The ANSV analysed that although the wind data transmitted to the crew exceeded the demonstrated aircraft crosswind capabilities the captain remained confident that he could manage a safe landing nonetheless, reinforced by the fact that other aircraft had managed a safe landing, too. However, in the light of the weather information available the landing should have been aborted in view of the weather conditions being near or above the maximum permissable.

The omission of the landing brief proved fatal - the maximum weather data would have been part of the briefing reminding both crew of the maximum cross wind component they would be able to conduct a safe landing in.

In addition, the omission of the landing brief led to the acceptance of an incorrect approach speed of 130 KIAS by both crew and prevented a discussion between the pilots whether landing in Rome or a diversion to the alternate was advisable. The ANSV stated: "it is reasonable to assume that the first officer had refrained from pointing out the incorrect approach speed given the considerable difference in experience levels."

The ANSV analysed that no technical factors contributed to the accident.

The ANSV analysed that the weather, while not precluding the flight activity, presented significant challenges not to be underestimated in flight preparation and during conduct of the flight. Evidence from the flight data and cockpit voice recorder however made the investigation conclude, that windshear was not involved.

The ANSV analysed that during the descent towards Rome the "Descent" Checklist was read and executed properly by the first officer, however, upon the point "landing briefing" the captain stated that had already been done, a briefing thus did not occur. The briefing however would have been crucial in identifying limits of the approach, e.g. 35 knots maximum demonstrated cross wind, and landing as well as establishing the criteria and procedure for a missed approach. Handling techniques would also have been discussed during that briefing as well as the performance values including Vapp being reviewed.

The ANSV analysis of the landing has already been incorporated in the sequence of events during landing (description of bounces).

The ANSV continued analysis: "From the time tower alerted emergency services it took 10 minutes until the first vehicle of the fire brigades reached the wreckage, although the wreckage was straight in front of the fire station #1 about 400 meters from the station." The accident occurred in night time conditions, the general visibility however was unrestricted. It appeared that the fire fighters were unable to locate taxiway "DE" as identified by tower. Tower on the other hand never mentioned the coordinates according to the grid map laid down in the emergency response plans. As result fire services started a search for the wreckage driving down to the end of the runway, scanning the left hand edge of runway 16L on the way back, turned around and scanning the right hand edge of the runway now spotting the wreckage 10 minutes after the initial alert.
Incident Facts

Date of incident
Feb 2, 2013



Aircraft Type
ATR ATR-72-200

ICAO Type Designator

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