ASN Wikibase Occurrence # 202471
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| Date: | Sunday 5 November 2017 |
| Time: | 15:10 LT |
| Type: |  Airbus A319-112 |
| Owner/operator: | Air Moldova |
| Registration: | ER-AXM |
| MSN: | 1786 |
| Year of manufacture: | 2002 |
| Engine model: | CFMI CFM56-5B6/P |
| Fatalities: | Fatalities: 0 / Occupants: 131 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Roma-Fiumicino Airport (FCO/LIRF) -
 Italy
|
| Phase: | Landing |
| Nature: | Passenger - Scheduled |
| Departure airport: | Chisinau Airport (KIV/LUKK) |
| Roma-Fiumicino Airport (FCO/LIRF) | |
| Investigating agency: | ANSV |
| Confidence Rating: |  Accident investigation report completed and information captured |
Air Moldova flight 9U891 made a low fuel emergency landing at Rome's Fiumicino Airport, Italy.
The aircraft, an Airbus A319, operated on a scheduled passenger flight from Chisinau, Moldavia. The flight departed at 13:10 hours local time (11:10 UTC). After a flight of just over two hours, the aircraft positioned for an approach to runway 16L. The approach was aborted at 14:20 hours local time (13:20 UTC). The aircraft then positioned for a second approach, this time for runway 34L. This approach was aborted at 14:33. Subsequently, the flight crew decided to divert to Bologna and climbed to FL160. About 14:45 the flight elected to return to Rome, declaring a low fuel emergency.
A third approach, to runway 16L again, was aborted at 14:59 hours. The flight then circled for a visual approach to runway 16R and a normal landing was carried out at 15:10 hours.
CAUSE:
After the first missed approach, the runway change from RWY 16L to RWY 34L undoubtedly increased the workload due to the inclusion of the related procedures in the FMGC. Exceeding the maximum flap speed during aircraft configuration for landing is a possible indicator of deteriorating crew coordination, caused either by workload or pressure to land quickly considering the decreasing fuel quantity.
This urgency also led to a lack of evaluation of the actual weather conditions at the airport before proceeding with the further approach, despite the presence of the thunderstorm.
Consequently, the aircraft passed through an area of turbulence that compromised path stabilization. Recorded data revealed a descent below the glide path, triggering the EGPWS warning.
The absence of a proactive alternate action plan resulted in a diversion attempt, later deemed unfeasible based on calculations at the time. This further expended fuel during the climb and departure from the airport.
The serious incident is attributed to human factors and manifested as a landing with fuel on board below the final reserve fuel, after a series of three missed approaches at LIRF and an initial diversion to LIPE that was subsequently abandoned, while an intense thunderstorm prevailed at the destination airport. These repeated approach attempts in stormy conditions exposed the aircraft to windshear phenomena and risks associated with thunderstorms.
Excitement and sudden increased workload led to a decline in aircraft conduct precision and CRM, with significant deviations from standard flight parameters.
The following factors contributed to the event:
- Inadequate flight planning characterized by the absence of a preventive action plan in case of arrival at the destination concurrent with the thunderstorm.
- Inadequate flight planning in terms of choosing the destination alternate in the presence of a weather condition characterized by predicted (TEMPO) and ongoing thunderstorms at both the destination and alternate airports, which were geographically close to each other in the flight arrival window.
- Insufficient in-flight fuel management decision-making process, resulting in repeated approach attempts at the destination airport despite the presence of a violent thunderstorm, leading to the loss of any alternative option to divert to a suitable alternate airport, as the selected alternate from the flight plan (LIRA), adjacent to LIRF, was also affected by the ongoing thunderstorm.
Weather reported about the time of the incident:
LIRF 051020Z 13018KT 9999 FEW030 SCT050 19/13 Q1012 TEMPO 4000 TSRA SCT014CB
1110Z: Departure from Chisinau
LIRF 051120Z 14023KT 9999 TS SCT014CB SCT030 SCT040 19/12 Q1011 NOSIG
LIRF 051220Z 13017KT 9999 -TSRA SCT014CB SCT030 BKN040 18/12 Q1010 NOSIG
1320Z: First approach aborted
LIRF 051320Z 31013G24KT 280V340 2000 1000N +TSRA SCT007 SCT010CB BKN020 BKN030 13/12 Q1011 NOSIG
1333Z: Second approach aborted
1359Z: Third approach aborted
1410Z: Landing runway 16R
LIRF 051420Z 16006KT 100V200 9999 -RA VCTS FEW005 FEW015CB SCT035 14/14 Q1009 RETSRA 882904// BECMG NSW
LIRF 051520Z 09012KT 9999 FEW005 SCT040 14/13 Q1009 NOSIG
Accident investigation:
 |
|
Sources:
http://www.ansv.it/It/Detail_relazioni.asp?ID=2086
https://www.flightradar24.com/data/aircraft/er-axm#f6f6d2c
Images:
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 03-Dec-2017 15:29 | harro | Added |
| 03-Dec-2017 15:32 | harro | Updated [Narrative] |
| 24-Aug-2023 19:15 | harro | Updated [[Narrative]] |
Corrections or additions? ... Edit this accident description
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