Atterraggio di emergenza a Catania


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CAUSES
The accident was caused by the failure of the nose landing gear (nose gear up) due to over-extension of the shock absorber which caused interference between the tires and the NLG compartment and locked the NLG in a retracted position.
The over-extension was caused by the incorrect installation of some internal components of the shock absorber during the replacement of the internal seals the day before the accident.

The following factors contributed significantly to the improper activity conducted at maintenance:
- the insufficient experience of technical personnel in carrying out the maintenance tasks conducted on the NLG;
- the lack of controls on the operations carried out, deemed unnecessary by the CAMO engineering department;
- the lack of definition of roles and tasks during the planning phase of the maintenance work;
- the operational pressure on maintenance personnel, arising from the need to conclude maintenance operations quickly in order not to penalize the management of the aircraft;
- the insufficient clarity and lack of sensitive information in the maintenance tasks and related figures contained in the AMM, regarding the replacement of internal shock absorber seals, subsequently made clearer by the manufacturer;
- the reported black and white printing of the applied AMM procedures, which could have made the warnings in the manual barely legible.
 
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Release of the Final Report
6.5 In the interest of accident prevention, the State conducting the investigation of an accident or incident shall release the Final Report as soon as possible.
6.6 Recommendation.— The State conducting the investigation should release the Final Report in the shortest possible time and, if possible, within twelve months of the date of the occurrence. If the report cannot be released within twelve months, the State conducting the investigation should release an interim report on each anniversary of the occurrence, detailing the progress of the investigation and any safety issues raised