Ryanair flight RYR9672 was a Boeing B737-800 (EI-DAV) on approach to Rome on 07/09/2005. The event in question was determined by a series of interconnected circumstances, which finally led to the missed approach maneuver at Fiumicino airport in unsafe separation with the ground and with a situation in the cockpit characterised by lack of awareness of the particular present situation.
The cause of the event is to be assigned to the incorrect management of the flight, during the unplanned diversion to Fiumicino, by the flight crew.
Considering the dynamics of the event, it is necessary to take into consideration different factors which, to various degrees, contributed to the event. The particular environmental and meteorological conditions under which the event developed have certainly influenced these dynamics, as well as the flight crew choices/performance and the management of control of the flight by air traffic control.
The co-pilot’s behaviour can be reasonably attributed partly to the lack of complete instructions from the captain and partly to his limited experience
The factors that contributed to the event can be summarised as follows:
– the particular mental state of the captain, whose recent family situation was characterised by the loss of his three months old son;
– the flight crew’s progressive loss of situational awareness;
– the co-pilot’s limited experience;
– the poor flight crew coordination and integration;
– some inappropriate information by air traffic control transmitted using non standard phraseology;
– the not adequate analysis of the weather information by the flight crew;
– the non correct use of the on-board weather radar;
– the lack of readily available weather radar information in the Rome ACC approach radar sector, necessary to be able to provide a more accurate assistance in relation to the weather conditions present in the area of the event;
– the absence in Rome ACC approach radar, of the Minimum Safe Altitude Warning (MSAW) function, able to alert air traffic controllers of an aircraft flying below Minimum Sector Altitudes.