Si Fly Flight 3275

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Location
42°58'00"N
021°03'00"E
Country
 Kosovo
Categories
  • Nature
Rating
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Description

Si Fly Flight 3275 (KSV3275) was a non-scheduled international passenger flight, operated by Italian airline Si Fly using an ATR 42-300 series from Rome Leonardo da Vinci–Fiumicino Airport to Pristina International Airport in Pristina, Kosovo. The flight had been chartered by the United Nations World Food Programme in response to the ongoing war in Kosovo. On 12 November 1999, Flight 3275 struck a mountain during an approach to Pristina Airport on Kosovo's capital. The crash killed all on board.The French Bureau d'Enquêtes et d'Analyses pour la Sécurité de l'Aviation Civile (BEA) investigated the cause of the accident and concluded that poor CRM, aggravated by inclement weather condition in Slakovce at the time, caused the crew to fly the plane into terrain. The BEA subsequently categorized the accident as a Controlled Flight Into Terrain (CFIT), in which an airworthy plane is unintentionally flown into terrain. Several findings revealed that the crew were fatigued and that there was no Ground Proximity Warning System (GPWS) to alert the crew that they were flying into terrain.The accident remains the deadliest plane crash in Kosovo's history. This was the 5th worst plane crash involving an ATR-42 and the worst and only fatal plane crash in Si Fly's history.

Aircraft and crew

The aircraft was an ATR 42-312 with registered as F-OHFV with its first flight in 1986. It has a serial number of 012 with a total airframe hours of 24.930. It was delivered to American Eagle with U.S registration code of N420MQ, later re-registered as N12MQ. It was sold to Si Fly in 1999. When it was delivered to Si Fly, the plane had 25,000 hours of flying time in July.The captain was an unnamed 59-year-old Italian male who received his airline transport pilot license (ATPL) in 1989 and received his type rating on the ATR 42 in 1995. He had 18,000 flight hours, including 5,000 hours on the ATR 42. The first officer was an unnamed 49-year-old Italian male who received his commercial pilot license in 1991 and received his type rating certificate for the ATR 42 in 1998. He received his ATPL in 1999. The first officer had logged 5,000 flight hours, with 1,800 of them on the ATR 42 and was the pilot flying (PF) on the accident flight. Both pilots had previous experience in landing at Pristina and were former Italian Air Force pilots.

Flight

The flight was a daily flight to Pristina carrying UN officials and aid workers to Kosovo. At 08:11 UTC, Flight 3275 departed Rome on 12 November 1999 for Pristina, Kosovo with 3 crew members and 21 passengers. Most of the passengers were diplomats, aid workers and journalists. At 09:57 UTC, the flight was transferred by Skopje air traffic control to the Pristina military air traffic control organization. Pristina military ATC service was being provided in accordance with established procedures in Kosovo at the time of the accident. At 09:59 UTC, the Pristina military air traffic controller requested that KSV 3275 descend initially to 5,200 feet. At 10:03 UTC, the controller asked KSV 3275 to descend to 4,600 feet. 11 minutes later, the aircraft struck the mountain and fell off from the radar.

Search and Rescue

As the aircraft radar plot disappeared from the radar, a search and rescue team assembled by NATO was deployed immediately. Helicopters were assisting the search for Flight 3275 and 500 soldiers had taken part in the search and rescue operation. Flight 3275 was officially declared as missing. Search and rescue team searched the plane overnight with thermal imaging and night-vision equipment. Search and rescue operation was hampered by weather, mountainous terrain, and mines in the area. The wreckage of the plane was found on November 14, 1999 on a steep mountainside, located approximately 7 miles from the town of Mitrovica. There were no signs of life among the wreckage. First responder who arrived first at the scene stated that several charred bodies were found around the wreckage of the plane. Only the tail of the plane was still intact. Dozens of NATO troops cordoned the scene immediately.

Passengers

Most of the passengers were UN officials from the World Food Programme, with several others reported to be journalists and aid workers. The Italian News Agency ANSA reported that at least nine Italians were on board the flight; consecutively - the two pilots, a flight attendant, two doctors, a spokeswoman for the World Food Programme, a volunteer chemist, a police officer and an aid worker. A Canadian official was also on board. Three Britons were also on board the ill-fated flight, with two of them working for The Tearfund relief organisation and had been travelling to Kosovo to join a 15-strong team helping ethnic Albanians rebuild their homes.

Investigation

As the plane was registered and built in France, the French BEA took part in the investigation of the crash. Investigators inspected the wreckage of the plane and both flight recorders. Both recorders were found in good condition. Analysis from the crash site concluded that the plane struck tree tops first before impacting terrain. The first impact occurred 15 metres from the top of a ridge, in a rocky mid-mountain area. During the impact, the fuselage and wing disintegrated, the fuel ignited, and an explosion occurred.The French BEA then collected weather data prior to the crash. From Slovenia to Greece and from Italy to Bulgaria, the winds at altitude were very weak from the north. They were sufficient to create a foehn effect under the mountain winds that left the whole coast and the Adriatic Sea free of cloud. Around 9 o'clock, several meteorological agencies reported that the weather in Kosovo was misty with limited visibility. This was also the case with Skopje, with a visibility of 10 km. A helicopter pilot who was flying in the accident area at noon noticed a compact layer of clouds towards 1,000 m, with all of the peaks covered.Investigators then analysed the contents of the Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR). The BEA realized that before Flight 3275 impacted terrain, the GPWS warning didn't sound at all. When it was delivered, the aircraft was equipped with a GPWS computer. During the check flight conducted by a mixed Aérospatiale/ Si Fly crew, it was noted that the GPWS generated warning alarms during landing. The computer was therefore replaced. During the month of September, Si Fly ordered a GPWS computer from ATR after its old GPWS went faulty. Si Fly informed ATR that despite the replacement of the computer, the GPWS was still not working properly and the "FAULT" indication was still "ON". Suspecting that the failure might originate in the radio altimeter, SI Fly also requested that ATR send them a new radio altimeter. A radio altimeter was sent to Si Fly on 8 October 1999. The faulty GPWS caught investigators' attention. Simulations undertaken during the investigation by both the aircraft manufacturer and the equipment maker showed that the alarms should have been set off during the last thirty seconds of flight. Such alarms might have led the crew to react and avoid a collision with the high ground. Consequently, the aircraft was flying with an inoperative or disconnected GPWS, and the crew must have been aware of this situation.Investigators then checked for another failure on Flight 3275. Further investigation revealed that the flight preparation was rapid and incomplete, indicating a lack of procedural discipline. No safety altitudes were called out by the first officer in the arrival briefing. No questions were asked by the Captain. The large number of flights the crews had made to Pristina could have created a certain sense of routine, more so in that they knew they were, as usual, going to get assistance from the ATC. They may have believed that the radar service provided by the controller was included in the approach control service and that, because of this, the instructions they received ensured that they would clear any obstacles. They could not, however, have been unaware that the military radar unit only provided a limited service. This information was included in their specific instructions, though without any specifics on the nature of the limitation. The crew also failed to check their altitude and their track. Further, the crew prepared an ILS approach without a glide path, a procedure that is not authorised by the airline.The BEA (Bureau of Enquiry and Analysis for Civil Aviation Safety) concluded that the collision of KSV 3275 with high ground was due to: - teamwork that lacked procedural discipline and vigilance during maneuvers in a mountainous region with poor visibility; - the aircraft being kept on its track and then forgotten by a military controller unused to the mountainous environment of the aerodrome and to preventing collisions with high ground, within the framework of the radar service he was providing; - the operator's critical situation as a new company highly dependent on the lease contract, favoring a failure to respect procedures; and - the opening of the aerodrome to civil traffic without an advance evaluation of the operating conditions or of the conditions for distribution of aeronautical information.The following factors contributed to the accident: - Crew fatigue, favoring a lowering of vigilance. - The crew undertaking the flight with an unserviceable or disconnected GPWS (Ground Proximity Warning System).
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