23
December 1978 - Alitalia
4128 |
At about 00.39 a.m. local time DC-9-32 I-DIKQ (named "Isola di
Stromboli"), flight number AZA 4128, flying an extra-flight for
the Christmas season from Rome Fiumicino to Palermo, crashed in the
sea shortly before landing on runway 21 at Punta Raisi airport.
The
aircraft was performing a VOR/DME approach to runway 21. The approach
procedure dictated to establish on the 217 radial inbound of Raisi VOR/DME
(identification PRS) at "Guffy" point, located 16.5 NM north-east
of the VOR at 4000 ft on local QNH, then descend in order to cross the
6 DME fix at 1500 ft, the 4 DME fix at 900 ft, the 3 DME fix at 700
ft. The latter fix is also the Missed Approach Point, where, should
the runway not be in sight, the crew should initiate a go-around, turning
right on a 332 heading, climb to 3000 ft and wait for ATC instructions.
The final part of the approach (about two miles) is to be flown visually,
the crew having to turn left to line up for runway 21, which had a magnetic
heading of 206. The aircraft stopped descent at about 150 ft above the
sea, as if the pilot was trying to locate the final approach area, thinking
to be very close to the runway (this feeling was enhanced by the light
geometry around the airport). For about nine seconds the aircraft flew
almost level with the sea at 150 knots, then the wind helped to loose
the final feet and the right wing impacted water. Twenty-one survivors
were saved by nearby fishing boats.
At that time, Palermo airport was
equipped with a primary radar Plessey ACR430, with an operative range
of no more than 15 miles, usable on the North and West quadrants only
due to high terrain to the East and South, and with no MTI (Moving Target
Indicator) able to suppress the fixed returns, with the consequence
that the inner three miles are almost blind spots to the controller.
Having no secondary radar capability, the equipment is not able to give
transponder answers to the controller (no identification codes and no
altitude reporting), any aircraft appearing just as small unlabelled
target on the screen. Reported weather at time of crash was: wind from
South, variable between South and South-West, up to more than 30 knots,
visibility more than 10 kilometers, scattered cumulus clouds to the
West with distant showers.
Piloting the aircraft was the first officer
(seven years as F/E, just three months as pilot, with 173 hours on the
DC-9). The captain was a senior pilot, with great experience on the
Caravelles, but just 418 hours on the
DC-9.

Transcript of the Cockpit Voice Recorder (CVR)
Legenda:
APP: Palermo Procedural Approach Control
CAPT: Captain
PIL: Co-Pilot
Stw: steward
RDR: Palermo Radar Monitor
C.RAD: radio transmission by the Captain
[...]: phrases included in square brackets are integration for better
clarity.
0:34:00 |
PIL |
Let's say we're leaving Guffy and
four thousand. [position about 17.5 NM from PRS, altitude about
4100 ft, slightly east of the 217 radial] |
|
C.RAD |
Alitalia four one two eight leaving
Guffy and four thousand. |
|
APP |
Roger, leaving Guffy and four thousand
at three-five. Report...twelve miles out. |
|
C.RAD |
Twelve miles out. |
0:35:15 |
APP |
For further, contact Radar 118.6 |
|
C.RAD |
One-eighteen-six. |
|
C.RAD |
Radar, four-one-two-eight, good evening |
|
RDR |
4128, Radar, good evening, go ahead. |
|
C.RAD |
We're leaving three thousand now
and we're thirteen and half miles from Rais [PRS VOR/DME] |
|
RDR |
Roger. Proceed as cleared by the
Approach. Report ten miles from PRS for identification. Radar monitor
service, VOR/DME two approach, runway in use 21. |
|
C.RAD |
Runway 21. VOR/DME two. We'll call
you at ten miles. |
|
PIL |
Uh, if it's a run...we could also
make a straight... |
|
Stw |
Nooo.... |
|
PIL |
Ah... |
|
CAPT |
Mmmh...uh...Straight, there it is.
Straighter than this...we're going straight to the runway. We have
it slightly displaced... |
|
Stw |
Yeah, I've briefly got it. |
|
CAPT |
Me too, but it appears then disappers... |
|
Stw |
...then desappears and we get fucked
! |
|
PIL |
Ten miles now. |
0:37:00 |
C.RAD |
Ten miles, 4128. |
|
RDR |
Identified. Continue [approach].
Slightly to the right, to the right of the 217 [radial]. Report
runway in sight. |
|
C.RAD. |
We'll call you with the runway in
sight. (Sound of radioaltimeter tone, preselected) [Aircraft is
passing 2000 ft radio, about 10.5 NM out, almost perfectly aligned
with the 217 radial, slightly below theoretical descent path] |
|
PIL |
I see the runway. |
|
Stw |
It could be that one... |
|
CAPT |
No, it's better to... |
|
PIL |
Radioaltimeter...our minima here
are seven hundred. |
|
PIL |
He told us we're to the right... |
|
CAPT |
Slightly to the right. |
|
PIL |
I'd say we're to the left. |
|
Stw |
To left for me also. |
|
CAPT |
Uh... |
0:37:30 |
PIL |
The runway, that's it just ahead
of us. So we were slightly to the right and not to the left. [according
to radar recordings, distance is now 7.5 NM from PRS and the aircraft
is diverging from the radial, being slightly to the east, that is
to say right o |
|
RDR |
Seven miles. Aligned now. Continue
and report. |
|
C.RAD. |
We'll report. |
|
CAPT |
Would we put something ? |
|
PIL |
Fifteen ! [flaps are lowered to 15
] |
|
PIL |
Those were other lights. |
|
Stw |
Maybe I was fooled by that one... |
00: 38: 00 |
PIL |
Gear. [landing gear is extended.
The aircrafts is at about 6 DME, approaching 700 ft when altitude
should be 1500 ft, east of the 217 radial] |
|
|
(sound of radioaltimeter tone, 700
ft preselected) |
|
RDR |
4128, now you're going to the left
of radial. Going left of radial, about...one mile. [this information
is correct regarding to the aircraft] |
|
C.RAD. |
We're slightly left of radial. Which
is our position at the moment ? |
|
RDR |
Your position five miles. Five miles
from PRS. |
|
CAPT |
You got this one. But the runway
is that one ! |
|
Stw |
Uh. |
|
PIL |
So he gave us wrong indications. |
|
CAPT |
Yes. |
|
RDR |
4128, Radar. [The pilot initiates
a mild right turn while continuing descent) |
|
C.RAD. |
Go ahead. |
|
RDR |
Four miles, still left of two-one
seven. |
0:38:40 |
|
(sound of radioaltimeter tone, 200
ft, automatic) |
|
CAPT |
Wait a minute... |
|
PIL |
So he gave us wrong indications...
[Descent is stopped] |
|
CAPT |
Let's call Radar... |
|
PIL |
We thought we were to the left...
(noise of crash. End of recording) |
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