Airline’s failure to send 737 incident report to Irish authorities delays Italian investigation by four months.

The Italian authorities are launching an investigation into a series of flawed approaches flown into Rome by the crew of a Ryanair Boeing 737-800. The controversial incident has prompted the Irish Airline Pilots Association (IALPA) to question whether Ireland has an adequate safety oversight system in place.

Italian air accident investigation agency ANSV’s decision to investigate comes four months after the 7 September 2005 incident because, it claims, it has only just been handed details by the Irish Air Accident Investigation Unit (AAIU). Read the précis here.

Ryanair’s internal report on the Rome Ciampino airport-bound 737 – the only investigation carried out so far – refers to the crew’s “almost complete loss of situational awareness, both lateral and vertical”, while attempting a diversion to Rome Fiumicino because of storms at Ciampino, ascribing this to high workload in turbulent weather and failure to follow standard operating procedures.

The airline informed the Irish Aviation Authority (IAA) and the AAIU that the event had occurred, but Ryanair chief executive Michael O’Leary admits that the carrier “screwed up” by failing to send them the final draft of its report.
The report says that, when the captain repeatedly failed to capture the instrument landing system on approach to Fiumicino, the co-pilot became concerned. “The first officer repeatedly prompted the captain to ensure he was not suffering some form of partial incapacitation, and when he realised that the aircraft was now in a potentially unsafe situation he urged the aircraft [sic] to perform a go-around, pulled back on the control column and advanced the thrust levers, but he did not assume control from the captain,” it says.

The captain had suffered the death of his young son a few days before the Düsseldorf-Ciampino flight, but had gone back on duty without notifying flight operations. Since then, says the report, existing instructions in the operations manual “for anyone who finds themselves in this situation” have been clarified.

The AAIU has previously reported that on 21 July last year a Ryanair crew carried out “an irrational and inexplicable” steep approach to land at Stockholm Skavsta airport, touching down at 180kt (330km/h) in the wrong configuration (Flight International, 11-17 October 2005). The agency attributed the pilot’s behaviour to stress related to family concerns.

Capt Evan Cullen, head of IALPA, says of the Ryanair Ciampino flight report: “There has been an excessive tendency to criticise the pilots without attempting to understand the situation. The report quotes no information from the flight data recorder [FDR].” O’Leary says the pilots had not “pulled” the data from the FDR at the time, and the report uses information from the aircraft’s operational flight data monitoring unit.

Cullen says: “While not commenting on any particular incident or airline, there is no doubt that the safety margins in Irish aviation have been eroded. The important question is whether we have in place the regulatory oversight system to alert us when the safety margin has been eroded to an unsafe extent.”

The IAA says it “routinely audits Ryanair’s line operations from the flightdeck and training standards, and follows up and investigates reported incidents in a systematic manner”.

DAVID LEARMOUNT / LONDON

Source: Flight International